Phia GroupPhia Group Mediahttps://www.phiagroup.com/Media/PostsThe Phia Group's 1st Quarter 2024 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1303/the-phia-groups-1st-quarter-2024-newsletterNewslettersThu, 11 Jan 2024 21:06:50 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="0" cellspacing="0" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2024/phiaheader5.png?ver=XOzyzq4h5Bd5ffg65SNvsg%3d%3d" style="width: 650px; height: 451px;" /></td> </tr> <tr> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Q1 2024/block0422lx.png?ver=jvIEOEy4Wj5EcXfYcxjeLQ%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pace3"><img src="/Portals/phiagroup/Newsletters/Q1 2024/block0422rx.png?ver=LONdDU-bRb-KWNypd3DR3g%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> </table> </td> </tr> <tr> <td valign="top" width="47%"> <p><br /> <img src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" style="width: 264px; height: 255px;" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">At industry events, we will frequently ask attendees for a word or quality they attribute to The Phia Group. We then take those words and phrases, and use them to illustrate a “word cloud,” where the more popular answers are larger and the unique responses are smaller. I love seeing what others think of us, and I always print the image and frame it in my office. On a consistent basis, phrases like “Passion,” “Loyalty,” and “Innovative” dominate the image. How wonderful it is to be appreciated for those types of qualities; things that are ingrained in our mentality and personality.</p> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Yet attitude is not enough. You must be able to “put your money where your mouth is.” It’s one thing to be a thought leader. It’s another thing entirely to be an action leader. Passion and loyalty lead us to care about the industry we serve. Caring about this industry in turn leads us to learn. Maybe that’s why my personal Phia Group word cloud features a different word – big, bold, and in the center of the image. That word is “KNOWLEDGE.” Without in-depth understanding of how our industry works, what our clients need, and how the various players interact, all the world’s passion, loyalty, and innovation wouldn’t amount to more than hot air. The Phia Group is knowledge. Yet, like attitude, so too knowledge is not enough.</p> <p class="bodytext" style="text-align: justify;">Whether it is Leonardo da Vinci who said, “I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do…” or, G.I. Joe that reminded us kids that, “Knowing is half the battle,” the real challenge is transforming all of The Phia Group’s knowledge into something tangible, transferable, and useful. Not only is it important to us that we enrich our clients, but even amongst our staff members we seek to deliver knowledge efficiently and effectively. </p> <p class="bodytext" style="text-align: justify;">Thankfully, technology continues to provide tools we can use to package and deliver knowledge. In the past, we would spend hundreds of hours gathering, organizing and updating our internal and industry communication materials and deliverables, but now with artificial intelligence (A/I) so much of the delay between gaining and sharing knowledge has been minimized. Today, every service we offer and every piece of technology we utilize in support of those services leverages technology (like A/I) to improve timing and quality of deliverables. Maybe the inclusion of “innovative” in the word cloud is justifiable after all? Importantly – we don’t view this as a justification for lay-offs or slowing growth. We see technology as a way to make each individual an even more valuable contributor, and at The Phia Group, we can rarely have too much of a great thing. We continue to grow and expand, while also offering much faster turnarounds and reduced costs. In fact, I can argue that because of this focus on leveraging technology to use and distribute knowledge, we have obtained more new business more quickly than ever before. That, in turn, results in more career opportunities for our existing team members, more openings for prospective team members, improved services and deliverables for our clients, and an even larger pool of clients from whom we can all learn. </p> <p class="bodytext" style="text-align: justify;">This year, 2024, will be the year that we take A/I and all of our latest innovations to the marketplace – combining our legal prowess and vast amount of industry expertise with the latest technical tools – in a fashion never seen before. This will in turn result in opportunities for success and growth for all. We are excited about this journey and see 2024 as the year The Phia Group takes it to a new level of breakthroughs. The self-funded health benefits industry has never been bigger, busier, or more complex – let us help you ride the wave and avoid getting soaked. Happy reading!</p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p><img src="/Portals/phiagroup/Newsletter Q2 2017/inthisissue.png?ver=MccyVIGCQMCOF4LSnwUjkQ%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><a href="#pace3">Service Focuses of the Quarter</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2024 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#employ">Employee of the Quarter</a><br /> <a href="#pnews2">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><a name="russo4"></a><strong><br /> Enhancement of the Quarter: SoPhia</strong> </p> <p class="bodytext" style="text-align: justify;">Though it is not yet available directly to ICE users, Phia’s consulting department has begun to use our new artificial intelligence (AI) tool, affectionately named soPhia, to assist with certain tasks and information sharing. </p> <p class="bodytext" style="text-align: justify;">Maybe most importantly, soPhia gives our very own Jennifer McCormick a way to troubleshoot her own Microsoft Excel problems – so our consulting attorneys can spend more time on ICE users’ consulting submissions, and less time fixing Jen’s computer. </p> <p class="bodytext" style="text-align: justify;">We’re excited to keep expanding soPhia’s capabilities and eventually share it with our clients!</p> <a id="pace3" name="pace3"></a> <p class="bodytext"><strong>Service Focus of the Quarter: Unwrapped, BBR & Patient Defense</strong></p> <p class="bodytext" style="text-align: justify;">Through our Phia Unwrapped service – combined with Balance Bill Resolution and Patient Defense – The Phia Group offers a suite of comprehensive end-to-end balance bill resolution services, ensuring that benefit plans and plan participants alike have independent but coordinated advocacy. Phia’s team of over 30 specialists and attorneys, bolstered by in-house medical coding and clinical resources, provides regulatory and legal expertise and over 15 years of reference-based pricing support experience. These services also include plan member legal representation by an external law firm, as well as the Phia “Safeguard,” guaranteeing that groups will not pay more than 200% of Medicare rates. </p> <p class="bodytext" style="text-align: justify;">Clients can enjoy stability, simplified processes, and improved balance bill resolution by working directly with The Phia Group. We offer direct access to our unrivaled team for all balance bill issues at every stage, eliminating the need for complex middlemen arrangements or third-party escalations. </p> <p class="bodytext" style="text-align: justify;">Moreover, existing clients opting for The Phia Group's direct contract in 2024 will continue to enjoy 2023 rates, emphasizing our commitment to providing value and excellent service in the balance bill resolution domain.</p> <p class="bodytext"><strong>Phia Case Study: Hidden Gag Clauses </strong> </p> <p class="bodytext" style="text-align: justify;">A TPA recently engaged Phia to review certain health plan agreements for compliance with the gag clause prohibition. The TPA let us know that their counsel went through them and found nothing problematic, but that they’d appreciate a second set of eyes. </p> <p class="bodytext" style="text-align: justify;">For the most part, we found no prohibited gag clauses; the plan’s vendors had generally done a thorough job of removing any historical gag clauses. In one agreement, however, we found a questionable provision. </p> <p class="bodytext" style="text-align: justify;">Specifically, this provision did not explicitly identify information that constitutes a gag clause such that it was not glaringly obvious, but it did allow the vendor to unilaterally deem any information proprietary and subject to confidentiality at its discretion. Even though this is not an explicit gag clause, it is nonetheless a potential gag clause, which is sufficient to trigger the prohibition, since the vendor could simply decide to make it a gag clause! We pointed it out to the TPA who promptly relayed the information to the vendor, who stated their disagreement with our interpretation. </p> <p class="bodytext" style="text-align: justify;">We suggested that the TPA ask the vendor to simply remove the discretionary nature of the confidentiality clause, and though the vendor was hesitant, its general counsel eventually conceded that while she didn’t personally think it constituted a gag clause, it was “not impossible” that some could hold that opinion (a.k.a. the attorney equivalent of a “you’re right”). The vendor agreed to modify the provision by more clearly delineating what information was confidential and not allowing the vendor to deem information confidential other than what was identified in the agreement. </p> <p class="bodytext" style="text-align: justify;">Within 11 business days of sending us the request, the vendor and plan had signed an amendment, and the health plan was able to attest that that agreement in fact had no gag clauses! </p> <a name="russo55"></a> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Abiding by the No Surprises Act</strong></p> <p class="bodytext" style="text-align: justify;">The No Surprises Act, or NSA, is a sweeping piece of federal legislation that grants and imposes certain rights and responsibilities onto health insurers, medical providers, and individual patients. Given its breadth and the general public’s inability to read Congress’ mind, some parts of this law raise more questions than answers. This quarter’s Fiduciary Burden of the Quarter will focus on one oft-forgotten but incredibly important piece of guidance: the prohibition on applying plan exclusions. </p> <p class="bodytext" style="text-align: justify;">Yes, you read that right. </p> <p class="bodytext" style="text-align: justify;">According to a section of the Public Health Service Act as amended by the NSA <a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2719A">(found here)</a>, a health plan is required to cover an emergency service “without regard to any other term or condition of the coverage, other than” cost-sharing, a permissible waiting period, or “the exclusion or coordination of benefits.” In other words, the plan must cover the emergency claim unless benefits are excluded. That seems intuitive, though, right? Coverage is required unless it’s excluded – the way health plans normally work. That should be simple enough to interpret. </p> <p class="bodytext" style="text-align: justify;">Apparently not. In a publication entitled “Requirements Related to Surprise Billing; Part I” <a href="https://www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-related-to-surprise-billing-part-i">(found here)</a>, the relevant regulatory bodies got together and issued guidance that turns cost-containment on its head. Specifically, this guidance provides that health plans may not “deny benefits for a participant, beneficiary, or enrollee with an emergency medical condition that receives emergency services, based on a general plan exclusion that would apply to items and services other than emergency services.” That would render exclusions like, for instance, those related to illegal acts unenforceable with respect to emergency services. </p> <p class="bodytext" style="text-align: justify;">So there we have it: Congress explicitly wrote that a plan can enforce the “exclusion of benefits” in a given emergency case, but subsequent regulatory guidance interpreted this language as meaning that a “general plan exclusion” cannot be enforced. Where does this leave us? Well, confused, to be honest. Did Congress really intend for health plans to be required to pay for any emergency claim even if the circumstance is clearly subject to a plan exclusion? The regulators say “Yes, patients need to be protected!” To that, we say “But so do health plans!” </p> <p class="bodytext" style="text-align: justify;">For the time being, though – until there’s guidance or a lawsuit to the contrary – we’re left with the regulatory guidance prohibiting health plans from excluding emergency claims based on any exclusion deemed “general” within the plan document – that is, any exclusion that applies regardless of the emergency nature of the claim.</p> <a name="pace3"></a> <hr class="horiz" /><a name="pdef"></a> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On November 15, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/strategizing-for-2024-new-ai-regulations-and-transparency-rules-impacting-healthcare">“Strategizing for 2024: New AI Regulations and Transparency Rules Impacting Healthcare,”</a> in which we discussed technological and legal improvements that are sure to dictate how you survive and thrive in the coming year. </p> <p class="bodytext" style="text-align: justify;">• On October 18, 2023, The Phia Group presented<a href="https://www.phiagroup.com/Media/Posts/cell-and-gene-therapy-industry-and-claim-cost-impact"> “Cell and Gene Therapy: Industry and Claim Cost Impact,”</a> in which we discussed frightening trends in drug costs, defined the risks, and presented solutions you can implement today.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p> <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On December 21, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p178-back-to-december-phias-version">“Back to December (Phia’s Version)”</a> in which our hosts, Kendall Jackson and Corey Crigger, discussed how everything in PGC and Provider Relations has changed in 2023. </p> <p class="bodytext" style="text-align: justify;">• On December 8, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p177-entering-the-danger-zone-cross-plan-offsetting">“Entering the Danger Zone: Cross-Plan Offsetting,”</a> in which our hosts, Jon Jablon and Cindy Merrell, discussed the practice of cross-plan offsetting and the recent settlement between the Department of Labor and EmblemHealth Inc. </p> <p class="bodytext" style="text-align: justify;">• On November 21, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p176-copay-accumulator-programs-take-a-hit-whats-next">“Copay Accumulator Programs Take a Hit: What’s Next?,”</a> in which our hosts, Brady Bizarro and Andrew Silverio, discussed a recent federal court decision that saw drug manufacturers and patients alike score a victory against copay accumulator programs – programs that help maximize the manufacturer assistance available to patients but decline to count those amounts toward deductibles and out-of-pocket maximums. </p> <p class="bodytext" style="text-align: justify;">• On November 9, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/no-surprises-act-brings-more-surprises-other-surprises-for-2024">“No Surprises Act Brings More Surprises & Other Surprises for 2024,”</a> in which our hosts, Brian O’Hara and Kelly Dempsey, discussed a couple lesser-known items hidden in some NSA proposed rules. </p> <p class="bodytext" style="text-align: justify;">• On October 26, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p174-pcori-and-parity-and-lawsuits-oh-my">“PCORI and Parity and Lawsuits, Oh My!,”</a> in which our hosts, Jennifer McCormick and Nick Bonds, discussed some of the scary issues creeping up on health plans: rising PCORI fees, proposed regulations on mental health parity rules, and two fascinating court cases that may have significant implications for ERISA plans going forward. </p> <p class="bodytext" style="text-align: justify;">• On October 12, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p173-gene-y-in-a-bottle-a-magical-overview-of-cell-and-gene-therapy">“Gene-y in a Bottle: A Magical Overview of Cell and Gene Therapy,”</a> in which our hosts, Ron Peck and Corey Crigger, discussed how this emerging treatment can impact self-funded health plans.</p> <p class="bodytext">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a><br />  </p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" style="width: 491px; height: 121px;" /></a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/The_Self-Insured_Health_Plan_Compliance_Clock_Counts_Down_For_2023_by_David_Ostrowsky.pdf">The Self-Insured Health Plan Compliance Clock Counts Down For 2023</a> – December, 2023 </p> <p class="bodytext" style="text-align: justify;">• America’s Benefit Specialist – <a href="https://digitaledition.pub/wc/nahu/Americas-Benefit-Specialist/December-2023/">Dissecting the CAA Gag Clause Prohibition</a> – December, 2023 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/Navigating_Coverage_For_Weight_Loss_Medications_authored_by_Kevin_Brady_Esq.pdf">Navigating Coverage for Weight Loss Medications</a> – October, 2023 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2023/10/25/self-funding-plan-preparation-for-2023/">Self-funding plan preparation for 2024</a> – October, 2023<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1"></span></p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/is-artificial-intelligence-the-new-frontier-for-healthcare">Is Artificial Intelligence the New Frontier for Healthcare?</a> AI is not going anywhere – in the healthcare industry and beyond. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/minor-members-and-third-party-settlements">Minor Members and Third Party Settlements.</a> Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/being-mindful-of-telemedicine-access">Being Mindful of Telemedicine Access.</a> Telemedicine, being such a convenient and effective alternative to traditional in-person care, has helped meet the unprecedented demand for mental health services and more. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/update-on-the-federal-idr-process">Update on the Federal IDR Process.</a> Recently there has been significant discussion about the federal IDR process. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/district-court-strikes-a-blow-to-copay-accumulator-programs">District Court Strikes a Blow to Copay Accumulator Programs.</a> Several patient groups brought a legal challenge against HHS and CMS, challenging the NBPP as unlawful.</p> <p class="bodytext" style="text-align: justify;">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a>The Stacks:</span></p> <p class="bodytext"><strong>The Self-Insured Health Plan Compliance Clock Counts Down For 2023</strong></p> <p class="bodytext">By: David Ostrowsky – December, 2023 – <a href="https://www.sipconline.net/files/The_Self-Insured_Health_Plan_Compliance_Clock_Counts_Down_For_2023_by_David_Ostrowsky.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">For HR professionals, the fourth quarter invariably presents considerable challenges. In addition to handling daily operational work involving employee benefits, HR departments are bracing for the deadline-driven annual open enrollment process—while navigating the upcoming holiday season, no less. With all the looming federal and state deadlines and corresponding action items, it can be overwhelming, if not daunting, when it comes time to review self-funded health plan documents, whether they be summary plan descriptions (SPDs), plan documents (PDs), combined SPD/PDs, wrap documents, cafeteria documents, or SBCs. The following guide outlines several critical compliance deadlines and reminders germane to end-of-year planning, though it should be noted that this is not meant to be a complete and exhaustive list of compliance requirements deadlines.  </p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2023-newsletter">Click here</a> to read the rest of this article</p> <p class="bodytext"><strong>Navigating Coverage for Weight Loss Medications</strong></p> <p class="bodytext">By: Kevin Brady, Esq. – October, 2023 – <a href="https://www.sipconline.net/files/Navigating_Coverage_For_Weight_Loss_Medications_authored_by_Kevin_Brady_Esq.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">In October of 2022, Elon Musk (one of the world’s wealthiest individuals) ignited headlines (a common occurrence for him) when he revealed that he used Wegovy as a primary method for losing weight. Wegovy and other drugs such as Ozempic and Mounjaro instantly became national news and intriguing weight loss options for people across the country. </p> <p class="bodytext" style="text-align: justify;">By all accounts, these drugs seem to show effectiveness in addressing weight loss concerns; however, it's important to note that they come with a significant cost. Specifically, Wegovy, Ozempic, and Mounjaro boast per-treatment list prices of $1,349, $936, and $1,023, respectively.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2024-newsletter">Click here to read the rest of this article</a> </p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2024 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2024 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. </p> <p><span class="bodytext"></span></p> <p class="bodytext"><strong>Thanksgiving Delivery!</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The tradition continues! The night before Thanksgiving, The Phia Group once again had a large contingent of volunteers helping to hand out Thanksgiving meals at the Boys & Girls Clubs of Metro South. Twenty-six families received dinners and each child received a gift from Adam Russo. We hope everyone had a great Thanksgiving!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/bandg.png?ver=1MUTkUpgvkdTKk3WiXMHvQ%3d%3d" style="width: 600px; height: 340px;" /> <p class="bodytext"><strong>Angel Tree at Phia</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our Angel Tree was on display in our Canton office! We are thrilled to share that this marks our 10th consecutive year participating in the Salvation Army Angel Tree program. We had 150 tags on our tree this year, which means that we got to bring joy to 150 children this holiday season. Discover more about this heartwarming initiative that brings us so much joy in the link below: <a href="https://saangeltree.org/">https://saangeltree.org/</a>.</p> <p><br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/angeltree2.png?ver=1sOcyMzWiRqHf0voag5bWg%3d%3d" style="width: 600px; height: 422px;" /></p> <p class="bodytext"><strong>Senior Care Package Corner</strong></p> <p class="bodytext" style="font-weight: normal">Through the Angel Tree Program, The Phia Group spread holiday cheer to dozens of seniors in the Greater Boston area, many of whom do not have families who are local. Thanks to the generosity and dedication of our employees, a Senior Care Package Corner was set up for the collection of basic necessities such as hats and gloves as well as some tasty treats. The Phia Group continues to look forward to making a difference in our local community in the upcoming year.</p>   <p><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/seniorcare.png?ver=nPYAaSgrxmeZ6l_nkd2yOw%3d%3d" style="width: 600px; height: 312px;" /></p> <p class="bodytext"><strong>Santa’s Special Delivery</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">On the evening of Tuesday, December 21, The Phia Group – with CEO Adam Russo serving as Santa, accompanied by a dozen elves – delivered gifts to 150 kids at the Brockton Clubhouse of the Boys & Girls Clubs of Metro South. We hope they enjoyed all of the gifts they received!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/santaelf.png?ver=-_yW7F2b6EpHC1SA5Q6jmA%3d%3d" style="width: 600px; height: 454px;" /> <p><a href="#top">Back to top ^</a></p> <hr class="horiz" /><a id="pnews2" name="pnews2"></a> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Phia News: Ping-Pong Tournament</span></p> <p class="bodytext" style="text-align: justify;">The Phia Group would like to congratulate Tomasz Olszewski on winning Round Two of its inaugural Ping-Pong Tournament. Tomasz is a great ping-pong player and will look to defend his title during the next round of the exciting tourney.</p> <p class="bodytext"> </p> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/pingpong2.png?ver=fPnmmkrBnI0WKETa65vLdg%3d%3d" style="width: 600px; height: 331px;" /></strong> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Stein Holding Challenge</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our arms may have been sore but at least our bellies were full. The Phia Group celebrated Oktoberfest in style with a stein holding challenge (congrats Pete Kotsifas) and barbeque under postcard weather in Canton. What a way to usher in October … even if it didn’t feel like it outside in the Northeast.</p> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/stein.png?ver=LnqbvwOfin5FHYcIP814sg%3d%3d" style="width: 466px; height: 535px;" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Halloween at Phia</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Late in October, many of our employees brought in their children for the annual Halloween extravaganza at our Canton headquarters. Everyone – kids and adults alike – had a blast trick-or-treating around the office and then enjoying a delicious pizza party afterwards! On behalf of everyone here at The Phia Group, we would like to thank all those who made that day so special for the Phia Phamily kids!</p> <br /> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/halloween3.png?ver=-_yW7F2b6EpHC1SA5Q6jmA%3d%3d" style="width: 600px; height: 487px;" /></strong> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/halloween4.png?ver=gsCwemdXUui5kfeSKTj9RA%3d%3d" style="width: 600px; height: 481px;" /> <p class="bodytext"><strong><br /> Halloween Staff Costume Winner – Rebekah McGuire-Dye</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is tradition, Phia held its annual Halloween costume contest. The Phia staff did not disappoint. We could only choose one winner from the group, but the winner was clear. Congratulations to Rebekah McGuire-Dye, who dressed up as Ursula! Check out her amazing costume below.</p> <br /> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/halloweencos.png?ver=ZiV6A_GCmC3PQPz0cOFRGw%3d%3d" style="width: 600px; height: 606px;" /></strong> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Candy Corn Contest</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is tradition, Phia held its annual Candy Corn Contest. The Phia Family made some great guesses, but there was one person who came particularly close to guessing the exact number. Congratulations to Matt Kramp on guessing 801 pieces of candy corn. This was a very close guess, as we had 800 pieces of candy corn in the jar!</p> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/candycorn5.png?ver=3uiqEWECj_D6wpAEHMWGKg%3d%3d" style="width: 354px; height: 460px;" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Ugly Sweater Contest</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Ugly Sweater Contest was in full swing the last week of December, and the Phia family came together to vote one person as the winner of the owner of the ugliest sweater. The winner of the Ugly Sweater Contest was Regina Cattel! Congratulations and wear that sweater proudly!</p> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/uglysweater5.png?ver=OuZvsIOUSuf9xxv-BX0rkQ%3d%3d" style="width: 545px; height: 545px;" /> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong>Get to Know Our Employee of the Quarter: Zach John<strong><a id="employ" name="employ"></a></strong></strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Zach John as The Phia Group’s 2023 Employee of the Year! Here is what someone at Phia had to say about him: “Zach John joined Phia in 2016 and has been a tremendous contributor since day one. We have grown from one enterprise application (TPS) to six different applications on which Phia business is running today. Zach has been enhancing and maintaining all these applications with his team and has been doing it with an excellent attitude. Zach has grown a lot as a leader, and his accountability on getting things done and owning it is phenomenal. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">He is a true Phia idol employee who walks the talk and is appreciated by everyone. There is one thing to do your job, but it is another to do it with patience and empathy. He shows a lot of respect and accountability with business and his team alike. I am proud to have him as part of my team. He has been called the Flash for getting things done so quickly.”</p> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/zach5.png?ver=01NJtYgFD8lKdNe_EW5ycA%3d%3d" style="width: 470px; height: 533px;" /></strong> <p class="bodytext"><br /> Congratulations Zach, and thank you for your many current and future contributions.</p> <p class="bodytext"><strong>Get to Know Our Employee of the Quarter: Daiana Williams</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Explore team has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Daiana Williams as The Phia Group’s 2023 Q4 Employee of the Quarter! </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Here is one person’s comments about Daiana: “Daiana is the rock in the recovery team. Not only is she the go-to for daily questions and stats, but she is the go-to for projects. When new ideas are being brought to the development team, Daiana is heavily involved. Not only does she test the enhancements before they go live, but she also quite literally is writing the guidelines and what is needed for this enhancement to go to development. Daiana works endless hours to get these going and successful for the team, and I don't think she gets enough credit on how appreciative we are for this. In addition to everything else, she is also training new hires and working with them daily to guide them to success.”</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/daiana5.png?ver=rGg99QjkSnsUqe6LkJBsjg%3d%3d" style="width: 447px; height: 558px;" /> <p class="bodytext">Congratulations Daiana, and thank you for your many current and future contributions.</p> <p class="bodytext"><strong>Phia Attending the SIIA National Conference</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Several of Phia’s industry experts will attend SIIA’s 2024 National Conference in Phoenix, Arizona, from September 22nd – 24th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: </p> <p class="bodytext" style="font-weight: normal">Get more details: <a href="https://siiaconferences.org/nationalconference/2024/Index.cfm">https://siiaconferences.org/nationalconference/2024/Index.cfm </a></p>   <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Job Opportunities:</span></p> <p class="bodytext">• Claims Specialist </p> <p class="bodytext">• Client Success Manager </p> <p class="bodytext">• Contract Administrator </p> <p class="bodytext">• Claim and Case Support Analyst </p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• Senior Subrogation Attorney </p> <p class="bodytext">• Sr. Claim Recovery Specialist</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext">• Bill Parlee has been promoted from Case Investigator to Claim Recovery Specialist IV. </p> <p class="bodytext">• Deonte Small has been promoted from Accounting Assistant to Accounting Administrator.</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• David Patrick was hired as a KP Claim Recovery Specialist. </p> <p class="bodytext">• Alex Stoner was hired as a KP Claim Support Analyst. </p> <p class="bodytext">• Matthew McKenzie was hired as a KP Claim Recovery Specialist. </p> <p class="bodytext">• Amy Justice Isaacs was hired as a KP Claim Recovery Specialist. </p> <p class="bodytext">• Shane Kepley was hired as a Claim Specialist. </p> <p class="bodytext">• Whitney Hester was hired as a KP Recovery Manager and Training Specialist. </p> <p class="bodytext">• Kevin Nealon was hired as a Claim and Case Support Analyst. </p> <p class="bodytext">• Ryan Kramer was hired as a Project and Operations Coordinator. </p> <p class="bodytext">• Jackie Ryan was hired as an Accounting Administrator. </p> <p class="bodytext">• Lesly Chavez was hired as a Customer Service Representative. </p> <p class="bodytext">• Chasitie Bryce was hired as a Customer Service Representative. </p> <p class="bodytext">• Roshaun Jones was hired as a Sr. Customer Service Representative. </p> <p class="bodytext">• Neil McCarthy was hired as a Claim Analyst. </p> <p class="bodytext">• Vanessa Leurini was hired as a Case Investigator. </p> <p class="bodytext">• Matthew Robinson was hired as a Director, Recovery Service Onboarding and Support. </p> <p class="bodytext">• John Gullett was hired as a Subrogation Attorney. </p> <p class="bodytext">• Spencer Mahne was hired as an Accounting Admin. </p> <p class="bodytext">• Nikki Wheeler was hired as a Director, Customer Service and Case Evaluation.</p> <a name="story"></a> <hr class="horiz" /> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.<br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter 2018 Q2/footerlogo.png?ver=iYwkNviyLE_yU_0lKTSyJQ%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1303The Stacks – 1st Quarter 2024 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1295/the-stacks-1st-quarter-2024-newsletterNewslettersThu, 14 Dec 2023 17:43:55 GMT<p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:18px;"><span style="color:#0071ce;"><b>Navigating Coverage for Weight Loss Medications</b></span></span><span style="font-size:14px;"></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">By: Kevin Brady, Esq.</span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">In October of 2022, Elon Musk (one of the world’s wealthiest individuals) ignited headlines (a common occurrence for him) when he revealed that he used <i>Wegovy</i> as a primary method for losing weight. <i>Wegovy</i>, and other drugs such as <i>Ozempic</i> and <i>Mounjaro</i>, instantly became national news and an intriguing weight loss option for people across the country. </span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">By all accounts, these drugs seem to show effectiveness in addressing weight loss concerns; however, it's important to note that they come with a significant cost. Specifically, <i>Wegovy</i>, <i>Ozempic</i>, and <i>Mounjaro</i> boast per-treatment list prices of $1,349, $936, and $1,023, respectively.</span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">This scenario often presents a familiar challenge for self-funded group health plans. Employees may express a desire for specific treatments or services to be covered, but the plan may have an understandable reluctance due to the substantial expenses associated with the treatment. Given this situation, group health plans should take a systematic approach:</span></span></p> <ol> <li style="margin-right: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"> <strong>Assess Whether Coverage is Right for Your Plan:</strong> Initially, plan sponsors should thoroughly evaluate whether coverage of weight loss drugs aligns with their overall goals. This entails considering the plan’s overall strategy against the preferences and potential health needs of their members.</span></span></li> <li style="margin-right: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"> <strong>Cost Containment Strategies:</strong> If the decision is made to cover weight loss drugs, plans should explore effective strategies to manage the costs linked to these medications. This might involve proactive conversations with their Pharmacy Benefit Managers (PBM), medical management techniques, or exploring potential alternatives to reduce expenses.</span></span></li> <li style="margin-right: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"> <strong>Update Plan Documents:</strong> To ensure clarity and alignment with revised coverage decisions, plan sponsors should review and update their plan documents accordingly. This includes coverage details and communication to members about the inclusion of weight loss drugs as a covered benefit and any associated medical management techniques.</span></span></li> </ol> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">By methodically addressing these issues, plan sponsors can better navigate the complexities of covering weight loss drugs. This approach promotes informed decision-making, effective cost management, and transparent communication with plan participants.</span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">With a comprehensive understanding of the considerations surrounding the coverage of weight loss drugs such as <i>Wegovy</i>, <i>Ozempic</i> and <i>Mounjaro</i>, let's now delve into each of the three key aspects in greater detail.</span></span></p> <ol> <li style="margin-right: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong>Assess Whether Coverage is Right for Your Plan</strong></span></span></li> </ol> <p style="margin-bottom: 0in; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><b>Pros:</b></span></span></p> <p style="margin-top: 0in; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">The primary argument in favor of covering weight loss drugs is the potential to improve employees' overall health. Obesity is closely linked to a range of health problems, including diabetes, heart disease, and joint issues. By providing access to medications like <i>Ozempic</i> and <i>Wegovy</i>, which are approved by the FDA and have demonstrated effectiveness in aiding weight loss, employers could contribute to reducing these health risks among their workforce. (<i>Wegovy</i> is FDA approved for weight loss while <i>Ozempic</i> is currently only approved for diabetes treatment). </span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">Coverage may also impact <strong><span style="font-weight:normal">employee productivity and morale. Employees that viewed the Elon Musk tweet or heard about these drugs from friends and family may ask about coverage. While this may not be the most important factor in recruiting new employees or retaining current employees, it may give a leg up to employers who offer coverage.  Furthermore, e</span></strong>mployees who are healthier are often more productive. By promoting weight loss through covered medications (and other means), employers may see reduced absenteeism due to health-related issues and increased employee engagement. </span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong><span style="font-weight:normal">Finally, while these drugs are expensive and require upfront costs,</span> </strong>it could lead to long-term savings for employers. Health problems associated with obesity can be expensive to treat, including hospital stays, ongoing medical appointments, and more serious chronic conditions. By investing in weight loss drugs, employers might ultimately mitigate some of these future expenses.</span></span></p> <p style="margin-bottom: 0in; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong>Cons:</strong></span></span></p> <p style="margin-top: 0in; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong><span style="font-weight:normal">The high cost associated with weight loss drugs is the primary argument against coverage.</span></strong> Plan sponsors must evaluate whether the cost of covering these medications aligns with their budget constraints and overall benefits package. Striking a balance between providing valuable benefits and managing costs is always crucial<strong>. </strong><strong><span style="font-weight:normal">As these drugs become more popular, related claim expenses on a group health plan may be significant.</span> </strong>This concern becomes even more significant when considering the necessity for ongoing treatment. To achieve desired results, consistent injections are required. Consequently, discontinuing the drug often leads to weight regain for individuals.<strong></strong></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">Weight loss drugs, while effective for some individuals, do not guarantee long-term success for everyone. Weight loss is a complex process influenced by various factors including genetics, lifestyle, and mental health. There is a risk that employees might not experience the desired results, aside from the emotional impact on the individual, this would essentially result in claim expense that does not effectively treat the underlying condition.</span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">Finally, relying solely on medication for weight loss may discourage employees from adopting healthier lifestyle changes. Sustainable weight management often requires a combination of dietary adjustments, regular physical activity, and behavioral modifications. If an individual relies on the weight loss drug to achieve these results, it may have a net-negative effect on their overall health.</span></span></p> <ol start="2"> <li style="margin-right: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong>Cost Containment Strategies</strong></span></span></li> </ol> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong><span style="font-weight:normal">First, it is imperative to discuss potential options with your PBM. This approach is important to understand the treatment options currently available and whether any generic or lower cost options may be out there. </span></strong></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong><span style="font-weight:normal">Next, imposing medical management techniques such as treatment limitations, established medical necessity criteria, and/or prior authorization requirements will limit coverage and the potential claim exposure to the plan.  </span></strong><b></b></span></span></p> <ol start="3"> <li style="margin-right: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong>Update Plan Documents</strong></span></span></li> </ol> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><strong><span style="font-weight:normal">Once</span> </strong>the decision to cover weight loss drugs is reached, plan sponsors should update their plan documents to clearly outline the details of this coverage. This includes specifying eligible drugs, criteria for coverage, and any associated cost-sharing responsibilities for plan participants. Furthermore, the plan should review the plan document in its entirety to ensure that other language within the plan document does not contradict or otherwise limit coverage on the drugs unintentionally. For example, a general exclusion for “services related to obesity” should be removed from the document entirely or modified to specify that the exclusion does not apply to these drugs.</span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;">Transparent communication with plan participants is essential. Health plans should effectively communicate that coverage is available and provide details on any medical management criteria or techniques that may be relevant for participants. This ensures that members are well-informed and understand their coverage options.</span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><b>Conclusion</b></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%">The decision to cover weight loss drugs is a multi-faceted one that is likely unique for each employer. For example, this decision may be relatively straight forward if plan participants have never heard of Elon Musk or <i>Wegovy</i>. The same can be said for an employer whose workforce does not include individuals battling obesity and its associated health risks. For everyone else, this decision point will likely be relevant for the foreseeable future. As weight loss drugs continue to make headlines across the country, drug coverage, cost containment strategies, and proper plan language will be essential to ensuring that the plan is protected from increasing claim expense and put into the best possible position to provide meaningful benefits to its participants.</span></span></span></p> <hr /> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"></span><span style="font-size:18px;"><strong><span style="color:#0071ce;"><span style="line-height:normal"><span style="background:white"><span style="letter-spacing:.1pt"></span></span></span></span><br /> <span style="color:#0071ce;"><span style="line-height:normal"><span style="background:white"><span style="letter-spacing:.1pt"></span></span><span style="background:white"><span style="letter-spacing:.1pt"></span><span style="letter-spacing:.1pt">Looking Ahead to 2024 </span></span></span></span></strong></span><span style="line-height:normal"><span style="background:white"><span style="letter-spacing:.1pt"></span></span></span><span style="font-size:14px;"></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;">By: David Ostrowsky</span></p> <p><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="line-height:normal"><span style="background:white"><span style="letter-spacing:.1pt"></span></span></span></span></span></p> <p style="margin:0in; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="background:white"><span style="color:black"><span style="letter-spacing:.1pt"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:black"><span style="letter-spacing:.1pt">For HR professionals, the fourth quarter invariably presents considerable challenges. In addition to handling daily operational work involving employee benefits, HR departments are bracing for the deadline-driven annual open enrollment process—while navigating the upcoming holiday season, no less. With all the looming federal and state deadlines and corresponding action items, it can be overwhelming, if not daunting, when it comes time to review </span></span></span></span></span><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">self-funded health plan documents, whether they be summary plan descriptions (SPDs), plan documents (PDs), combined SPD/PDs, wrap documents, cafeteria documents, and SBCs.<span style="background:white"><span style="color:black"><span style="letter-spacing:.1pt"> The following guide outlines several critical compliance deadlines and reminders germane to end-of-year planning, though it should be noted that this is not meant to be a complete and exhaustive list of compliance requirements deadlines.</span></span></span></span></span></span></span></span><br /> <span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:black"><span style="letter-spacing:.1pt"><br /> December 31 - Submit to Centers for Medicare & Medicaid Services (CMS) the Gag Clause Prohibition Attestation (GCPCA).<br /> <br /> Under the Consolidated Appropriations Act of 2021 (CAA), group health plans and health insurance issuers are required to annually submit an attestation that they are in compliance with the gag clause prohibition, a rule that bars plans and issuers from entering into agreements with providers, TPAs, or other service providers who would inhibit either </span></span><span style="color:black">provider-specific cost or quality information sharing with plan members or claims data sharing with plan sponsors as well as their service providers.<br /> <span style="letter-spacing:.1pt"><br /> The first gag clause prohibition attestation is due on December 31, 2023, covering the period starting December 27, 2020, or the effective date of the group health plan coverage (if later), through the attestation date. Subsequent attestations, spanning the period since the last preceding attestation, are due by December 31 of each subsequent year.</span><br /> <br /> The primary burden of responsibility associated with the GCPCA submission falls on issuers and TPAs. As such, it is advisable for plans and issuers to read their service agreements to determine how the GCPCA is covered and to ensure that everything is in line for a submission to be executed by December 31.<br /> <span style="letter-spacing:.1pt"><br /> December 31 - Distribute Annual Women's Health and Cancer Rights Act (WHCRA) Notice.<br /> <br /> The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that gives protection to patients who opt to have breast reconstruction in connection with a mastectomy. By December 31, both ERISA and non-ERISA calendar year plans are required to distribute the annual WHCRA notice to their respective<span style="background:white"> participants (employees and retirees), COBRA enrollees, and other beneficiaries receiving benefits and alternate recipients under QMCSOs. Of note, self-insured state and local government health plans have the ability to opt out. Generally speaking, the WHCRA notice is disseminated during initial enrollment and then annually, before each plan year. Electronic disclosure is allowed, in accordance with the Department of Labor (DOL) guidelines.</span></span></span></span></span></span><br /> <span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="color:black"><br /> It should be mentioned that WHCRA mandates group health plans and health insurance companies (including HMOs) to notify participants about coverage required under the law. Notice regarding the availability of these mastectomy-related benefits must be given:</span></span></span></span></span></span></p> <ol> <li style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">To participants and beneficiaries of a group health plan during enrollment, and to policyholders when an individual health insurance policy is issued; and</span></span></span></span></span></span></span></li> <li style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="color:black"><span style="line-height:normal"><span style="tab-stops:list .5in"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">On a yearly basis to group health plan participants and beneficiaries, and to policyholders of individual policies.</span></span></span></span></span></span></span></li> </ol> <p style="margin:0in; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="background:white"><span style="letter-spacing:.1pt"></span></span></span></span></span></p> <p style="margin:0in; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:black">However, WHCRA does <i>not</i> require group health plans or health insurance issuers to cover mastectomies. If a group health plan or health insurance issuer decides to cover mastectomies, then the plan or issuer is likely subject to WHCRA requirements.<br /> <span style="letter-spacing:.1pt"><br /> December 31 - Distribute Notice of Premium Assistance Under Medicaid or the Children's Health Insurance Program (CHIP).</span></span><span style="letter-spacing:.1pt"></span></span></span></span></p> <p style="margin:0in; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""> <span style="letter-spacing:.1pt"></span></span></span></span></p> <p style="margin:0in; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:black"><span style="letter-spacing:.1pt">By December 31, both ERISA and non-ERISA calendar year plans must distribute the <span style="background:white">notice of premium assistance under Medicaid or the Children's Health Insurance Program (CHIP) to all employees, irrespective of their eligibility or enrollment status, traditionally as a separate document – even if provided in conjunction with enrollment materials. </span>This notice should be provided by the last day of the plan year prior to the year to which the notice relates.<br /> <br /> First Day of Open Enrollment – Distribute the Summary of Benefits and Coverage (SBC).<br /> <br /> <span style="font-family:Arial,Helvetica,sans-serif;">For benefit eligible employees who have to make affirmative benefit elections, the SBC, essentially an overview</span></span></span></span></span></span><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:12pt"><span style="background:white"><span style="color:#040c28"> of a health plan's costs, benefits, covered health care services, and other features that are critical to healthcare consumers</span><span style="background:white"><span style="color:#202124">,</span></span><span style="color:black"><span style="letter-spacing:.1pt"> needs to be provided at the onset of open enrollment. For those employees who do not have to make affirmative benefit elections, the SBC needs to be provided 30 days before the beginning of the plan year. This rule applies to both ERISA and non-ERISA plans. </span></span><span style="letter-spacing:.1pt"></span><span style="line-height:18.0pt"><span style="color:black"><span style="letter-spacing:.1pt"><br /> <br /> First Day of Open Enrollment - Michelle’s Law Notice.</span></span><span style="letter-spacing:.1pt"></span></span></span></span><span style="font-size:11.0pt"><span style="line-height:107%"><br /> <br /> “Michelle's Law” is a piece of federal legislation that extends eligibility for group health benefit plan coverage to a dependent child enrolled in a higher education institution at the start of a medically necessary leave of absence if the leave normally would cause the dependent child to lose eligibility for coverage under the plan due to loss of student status. The extension safeguards eligibility of a sick or injured dependent child for up to one year. <span style="letter-spacing:.1pt">Michelle’s Law Notice has to be provided during open enrollment if the plan covers full-time students beyond age 26. This rule also applies to ERISA and non-ERISA plans.</span></span></span></span></p> <p style="text-align: justify;"> </p> 1295The Phia Group's 4th Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1283/the-phia-groups-4th-quarter-2023-newsletterNewslettersTue, 24 Oct 2023 15:17:08 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="0" cellspacing="0" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q4 2023/newheader4.jpg?ver=4uAdpdrzHX-VFfcTCacEFw%3d%3d" style="width: 650px; height: 451px;" /></td> </tr> <tr> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Q4 2023/block1024l.png?ver=uUKudT90ekikUXs0gMaBbQ%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pace3"><img src="/Portals/phiagroup/Newsletters/Q4 2023/Ignite%20L.png?ver=PzUbhxOf9CSyFVTT_69MFQ%3d%3d" style="width: 325px; height: 218px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> </table> </td> </tr> <tr> <td valign="top" width="47%"> <p><br /> <img height="287" src="/Portals/phiagroup/Q4 2017 Newsletter/adam.jpg?ver=be1bB98lpG0dwmn71Q3oYA%3d%3d" width="297" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">I feel rejuvenated and energized like I haven’t in decades! I know that those of you who have accused me of always being “too” energetic are laughing right now, wondering how I could possibly be even more amped-up, but I honestly feel like I did when I was 26 years old, and just starting this great company. Phia is entering a new stage of its growth and has created a new frontier for our offerings. For you – our loyal readers – I will let you in on a secret. Phia has been developing and will soon be marketing various tools and technology that are tied to, and will enhance, many of our existing services and products. Combined with our unrivaled legal expertise, I know this evolution will truly be a gamechanger.</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Just as I felt back in 2000 – when I was laboring over things that I knew would change the industry – so too today our team is grinding away, developing the “next big things,” fueled by a belief in something – a bigger overall mission and a true sense that we can again change the industry for the better. Make no mistake – The Phia Group isn’t alone in this regard. I've heard a lot of good speeches and read many amazing articles. I've seen parts of our market make drastic positive changes. Employers, plan administrators, and brokers all seem to be more aware and informed when it comes to the benefits of self-funding. They are more willing to be innovative, and not just rehashing the same old things. TPAs and the stop-loss market are likewise using technologies and becoming proactive when it comes to identifying new and emerging ways to reduce overall claim costs. While the industry may not be where it needs to be just yet, and our emphasis on quality metrics still hasn’t caught up to the clamor for “transparent pricing;” a fear of pharmaceutical miracles is blinding some to ways to contain costs with better overall plan designs; we are still in a much better spot overall than we were five years ago. So then … Why do I still have this weird feeling in my gut that, in many instances, our industry is stagnant (or even sliding backwards) despite all of the great things I just said? It is because we are not aligned. We do not all share a clear, and worthy mission! If we could all agree that our overarching goal must be to reduce the overall cost of health benefits by creating healthcare consumer awareness, emphasizing the value of quality outcome metrics, and addressing rising costs rather than trying to avoid them… we could all rise with the tide. In many ways, the fire and passion just isn’t there. My goal is to get that fire burning again; to build a bonfire, light new sparks in places that have been dark, dormant and cold for decades. Instead of just talking the talk, lets walk the walk. Lets not be happy with just 3% of self funded plans doing truly revolutionary and innovative things – Let’s get 100% of the industry wanting to create something special…different… and better. Just wait until you see what we have in store for you; jump on the train and lets go for the ride together.</p> <p class="bodytext"><a name="russo09"></a></p> <p class="bodytext">– Happy reading!</p> <p class="bodytext"> </p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p><img src="/Portals/phiagroup/Newsletter Q2 2017/inthisissue.png?ver=MccyVIGCQMCOF4LSnwUjkQ%3d%3d" style="width: 101px; height: 18px;" /><br /> <a href="#russo4">Service Focuses of the Quarter</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2023 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#EEofQ">Employee of the Quarter</a><br /> <a href="#pnews2">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><a id="russo4" name="russo4"></a></p> <p class="bodytext"><strong>Service Focus of the Quarter: Phia Unwrapped</strong></p> <p class="bodytext" style="text-align: justify;">Borne of The Phia Group’s nearly 25 years of dedicated expertise in managing out-of-network claims with an unwavering commitment to reducing healthcare costs for hard-working Americans, discover the transformative power of Phia Unwrapped. </p> <p class="bodytext" style="text-align: justify;">With the goal of harmonizing plan documents with claims pricing and No Surprises Act requirements, Phia Unwrapped is positioned as an industry front-runner, priding itself on averaging savings of 76% off billed charges thanks to proprietary technologies like the revolutionary Phia Ignite Repricing Engine and our customized PROS case management platform. The claim analysis processes that underly Phia Unwrapped combine considerations such as provider-specific analytics, acuity, quality of care, and applicable law, all culminating with a human touch. </p> <p class="bodytext" style="text-align: justify;">The best-in-class benchmarking data and technology that make up the foundation of Phia Unwrapped represent the convergence of excellence and innovation. What’s more, our team of nurse auditors, claims experts, attorneys, and consultants boasts a combined 200 years of claims settlement experience. Armed with experience, energy, and unmatched passion, Phia Unwrapped, and the team behind it, represents a revolution in healthcare cost-management and patient financial security. </p> <p class="bodytext" style="text-align: justify;">For more information, please contact Garrick Hunt at <a href="mailto:GHunt@phiagroup.com">GHunt@phiagroup.com</a>.</p> <a name="pace3"></a> <p class="bodytext"><strong>Tech Talk: Ignite Pricing Engine </strong> </p> <p class="bodytext" style="text-align: justify;">We’ve recently unveiled this truly revolutionary pricing engine, built with Phia Unwrapped in mind. An AI-powered marvel that's redefining healthcare savings already, even in its infancy, the Phia Ignite Pricing Engine seamlessly navigates the complexities of the No Surprises Act, promising not just savings, but a radical transformation. </p> <p class="bodytext" style="text-align: justify;">Phia Ignite isn’t just tech; it's a mission. CEO Adam Russo declares, "We're ensuring Americans get top-tier care without the top-tier price tag." This is the latest success in Phia’s goal of Empowering Plans.</p> <p class="bodytext" style="text-align: justify;">Ready to experience the future of healthcare? Let the Phia Ignite Repricing Engine power your plans. Join the revolution now, and get a demo of Ignite today! </p> <p class="bodytext" style="text-align: justify;">For more information, please contact Garrick Hunt at <a href="mailto:GHunt@phiagroup.com">GHunt@phiagroup.com</a>.  </p> <a name="russo55"></a> <p class="bodytext"><strong>Phia Case Study</strong></p> <p class="bodytext" style="text-align: justify;">A TPA client of Phia’s Independent Consultation and Evaluation (ICE) service presented the ICE team with a strange situation. A medical provider had administered an expensive experimental treatment to a plan participant. Upon the initial pre-certification request, a clerical error had resulted in pre-certification being granted. The pre-cert letter, as most do, indicated that pre-certification is not a guarantee of benefits.</p> <p class="bodytext" style="text-align: justify;">Upon submission of the finalized claim, the TPA denied it as experimental, which the provider and patient appealed vehemently. One point the provider raised is that though the pre-certification letter had a caveat about not being a guarantee of payment, the plan document itself had no such caveat, and instead indicated that if a service is pre-certified, the plan will cover it. Though the plan of course had an exclusion for experimental services, that exclusion contradicted the language providing for coverage of pre-certified claims. Whoever drafted this plan document overlooked the possibility that a grant of pre-certification may not have been correct, or that circumstances can change – and that oversight caused a questionable situation for this plan. </p> <p class="bodytext" style="text-align: justify;">The TPA represented that another hitch here is that the plan participant in question is the son of a C-suite member, and they were loathe to either deny the claim after the TPA had already pre-certified it or to overturn the denial and pay the claim what they felt would be improperly. The TPA felt it was caught between a rock and a hard place. What’s more is that if the plan did pay this claim, they knew that there was no way stop-loss would reimburse it, since it was, unequivocally, experimental. The plan wasn’t happy, and the TPA was worried about its own liability for the pre-certification error. </p> <p class="bodytext" style="text-align: justify;">Phia sprung into action. Our ICE team tackled the complex plan payment issues, including the risks associated with each potential approach; our Provider Relations team helped the TPA determine a strategy for negotiation (at the group’s request); and our plan drafting team suggested updates to the plan document to add clarity and otherwise update the plan’s payment mechanisms. Ultimately, Phia helped mitigate the provider’s frustration while laying the groundwork for a strong negotiation. Driven by the Ignite Pricing Engine, Phia helped the plan negotiate the claim to approximately 14% of billed charges, which the plan was more than happy to pay to make this go away for this VIP participant. Phia also ensured that the group updated its plan document to make sure this would never happen again. </p> <p class="bodytext" style="text-align: justify;"><u>Plan Exposure</u>: $102,550 </p> <p class="bodytext" style="text-align: justify;"><u>TPA Exposure</u>: Potentially, indemnification for $102,550, and loss of a longtime client group </p> <p class="bodytext" style="text-align: justify;"><u>Phia Intervention Saved</u>: $88,190, the group’s business, and the TPA’s behind</p> <a name="pace3"></a> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Transparency!</strong></p> <p class="bodytext" style="text-align: justify;">ERISA’s claims procedure rules are not always crystal clear in any given situation, but we know that the central theme is transparency and fairness. Health plans are not supposed to be able to game the system; since the ‘70s, federal law has provided broad protection for health plan participants as it relates to the handling of claims and appeals. Transparency is supposed to be at the forefront of a health plan’s claims and appeals adjudication. But is that really enough? There’s much more to health plan operations than how a health plan adjudicates and responds to claims, after all, and much of a health plan’s operational framework has gone virtually unchecked, becoming subject to scrutiny only when a specific complaint arose. </p> <p class="bodytext" style="text-align: justify;">Scratch that. Congress has changed the status quo. In 2020, Congress passed the Consolidated Appropriations Act, 2021, which thrusts transparency and reasonableness into the limelight by prohibiting “gag clauses”, by requiring plan vendors to eliminate opaqueness from their fees, by requiring not just compliance but proactive proof of compliance with the existing mental health parity rules, and, through the No Surprises Act, by protecting patients from balance billing and leveling the playing field of what is “reasonable” payment as far as providers and health plans are concerned. </p> <p class="bodytext" style="text-align: justify;">Transparency isn’t just a buzzword; it's the new norm. Unfortunately, in addition to the inconvenience and resources needed to take the proactive steps necessary to comply with these parts of the Consolidated Appropriations Act, there are still a considerable number of unknowns – and yet enforcement seems to be in full swing! Lest we forget that health plans still need to avoid letting cost-containment falter in the wake of these significant compliance hurdles. </p> <p class="bodytext" style="text-align: justify;">There is no single explanation of how to manage all these complex transparency rules in any given case, but luckily, Phia’s Independent Consultation and Evaluation (ICE) service can be at your disposal to help overcome these and many other obstacles, all for – you guessed it – a transparent flat fee. </p> <p class="bodytext" style="text-align: justify;">For more information, please contact Garrick Hunt at <a href="mailto:GHunt@phiagroup.com">GHunt@phiagroup.com</a>.<br />  </p> <hr class="horiz" /><br /> <a name="pdef"></a> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On August 17, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/a-duty-to-serve-and-protect-the-plan">A Duty to Serve and Protect … the Plan</a>,” in which we discussed strategies applicable to every stage in a claim’s lifecycle, and best practices that will keep you out of the court house. </p> <p class="bodytext" style="text-align: justify;">• On July 11, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/illuminated-by-phia-ignite-leveraging-ai-and-multifaceted-price-and-quality-data">Illuminated by Phia Ignite! Leveraging A/I and Multifaceted Price and Quality Data</a>,” in which we discussed case studies addressing regulatory compliance, claim appeals, and dispute resolution.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p>   <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On September 29, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p172-navigating-the-gag-clause-prohibition">Navigating the Gag Clause Prohibition</a>,” in which our hosts, Jon Jablon and Kendall Jackson, discussed the issue of the gag clause prohibition, a mysterious law that continues to confound the self-funded industry. </p> <p class="bodytext" style="text-align: justify;">• On September 15, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p171-mass-torts-101">Mass Torts 101</a>” in which our hosts, Cindy Merrell and Lisa Hill, discussed the difference between the two types of mass tort cases -- class action and multidistrict litigation (MDL) – while delving into a couple of the larger MDLs making news of late. </p> <p class="bodytext" style="text-align: justify;">• On August 31, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p170-psa-on-the-nsa">PSA on the NSA</a>” in which our hosts, Brian O’Hara and Corey Crigger, discussed a case study highlighting the benefits of the Safeguard Program. </p> <p class="bodytext" style="text-align: justify;">• On August 17, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p169-lets-keep-learning-back-to-law-school">Let’s Keep Learning - Back to (Law) School</a>,” in which our hosts, Kelly Dempsey and Corey Crigger, discussed renewal season preparation items and a variety of late breaking lawsuits that pertain to multiple aspects of the self-funded industry. </p> <p class="bodytext" style="text-align: justify;">• On August 4, 2023, The Phia Group presented ““<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p168-drafting-plan-exclusions">Drafting” Plan Exclusions</a>,” in which our hosts, Andrew Silverio and Kevin Brady, discussed the unanticipated costs of playing pickleball and then “draft” their favorite (and least favorite) plan limitations and exclusions. </p> <p class="bodytext" style="text-align: justify;">• On July 21, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p167-who-is-a-fiduciary-and-does-it-even-matter-lawsuits-abound">Who is a Fiduciary and Does it Even Matter? Lawsuits Abound!</a>” in which our hosts, Ron E. Peck and Jennifer McCormick, discussed recent lawsuits involving self-funded plan sponsors and their third party administrators, and accusations of fiduciary breach on the part of TPAs. </p> <p class="bodytext" style="text-align: justify;">• On July 7, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p166-delving-into-dobbs-one-year-in">Delving Into Dobbs, One Year In</a>,” in which our hosts, Nick Bonds and Kendall Jackson, discussed the changes that have occurred in the past year following the Supreme Court’s decision in Dobbs.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a><br />  </p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" style="width: 491px; height: 121px;" /></a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/3M_Mass_Tort_Settlement_Reminds_Us_That_Subrogation_Matters_by_Ron_E__Peck.pdf">3M Mass Tort Settlement Reminds Us That Subrogation Matters</a> – September, 2023 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2023/08/21/benchmarking-medical-prices-with-payer-transparency-files/">Benchmarking medical prices with payer transparency files</a> – August, 2023<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext" style="text-align: justify;"><span class="heading1"><a id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1"></span><br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/the-first-ten-the-initial-round-of-drugs-subject-to-medicare-price-negotiations">The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiations</a>. Let the negotiations begin! </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-power-dynamics-of-gag-clauses">The Power Dynamics of Gag Clauses</a>. Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/wegovy-the-heart-of-the-matter">Wegovy: The Heart of the Matter</a>. A weight loss drug that has more benefits than simply losing weight. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/idr-entities-still-struggling-with-volume-highlights-from-the-q4-2022-report">IDR Entities Still Struggling with Volume – Highlights from the Q4 2022 Report</a>. The full report is certainly worth reviewing, but here are some noteworthy data points. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/one-year-post-dobbs-decision">One Year Post-Dobbs Decision</a>. It may be a year old now, but the Dobbs case seems as controversial now as it did the week it came out.</p> <p class="bodytext" style="text-align: justify;">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a>The Stacks:</span></p> <p class="bodytext"><strong>3M Mass Tort Settlement Reminds Us That Subrogation Matters</strong></p> <p class="bodytext">By: Ron E. Peck, Esq. – September 2023 – <a href="https://www.sipconline.net/files/3M_Mass_Tort_Settlement_Reminds_Us_That_Subrogation_Matters_by_Ron_E__Peck.pdf">Self-Insurers Publishing Corp</a>. </p> <p class="bodytext" style="text-align: justify;">On Thursday, June 22nd, 3M followed other companies’ example by announcing that it had reached an agreement to settle claims that their polyfluoroalkyl and perfluoroalkyl substances (PFAS), known as “forever chemicals,” had contaminated water supplies in the United States. Specifically, the settlement will see 3M pay up to $10.3 billion over 13 years to municipalities in the U.S. that have detected these chemicals in their drinking water. This is only the most recent in a series of settlements regarding water contamination by PFAS producers, who also announced that they would pay over $1 billion to settle similar lawsuits; with this likely heralding a new series of litigation and settlements, akin to the well-known asbestos proceedings. </p> <p class="bodytext" style="text-align: justify;">Many are familiar with the recent advent of PFAS testing conducted by municipal water authorities, and the resultant identification of unacceptable PFAS levels in drinking water. This in turn led to various lengthy and costly remediation procedures, to remove the offending chemicals from public drinking water. The aforementioned settlement is primarily meant to address abatement claims, compensating municipalities for damage suffered to property and costs incurred in said remediation projects.  </p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2023-newsletter">Click here</a> to read the rest of this article.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2023 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2023 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. </p> <p style="text-align: justify;"><span class="bodytext"></span></p> <p class="bodytext" style="text-align: justify;"><strong>Backpack & School Supply Drive</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our friends from the Boys & Girls Club of Metro South are going back to school, and the Phia Family wanted to send them some school supplies to go back to school with. The Phia family donated over $5,000 in school supplies! The kids were able to pick out a backpack, markers, glue sticks, pens, pencils, notepads, and so much more to help them succeed in school. In addition to the school supplies, Phia sent in a check for $10,000 to make sure any school supplies that the kids needed, they had. We hope all of the amazing children are enjoying their new school supplies!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q4 2023/backpacks.png?ver=2Qr-r5o4bquqZ6MaXQyKeA%3d%3d" style="width: 500px; height: 340px;" /><br />   <p class="bodytext"><strong>The Boys & Girls Club of Kentuckiana</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our Louisville team was out and about this past summer, volunteering at The Boys & Girls Club of Kentuckiana. They hosted a Water Wonderland event for the kids that included face painting, a water slide, sprinklers, water balloon/cannon games, and more. We hope you all had a great time and can’t wait to do it all again next year!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q4 2023/slide2.png?ver=plEFA2E6NeAPX_0e1UMLgg%3d%3d" style="width: 430px; height: 464px;" /> <p><a href="#top">Back to top ^</a></p> <hr class="horiz" /><a name="pnews2"></a> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Phia News: Phia Made the Top Workplace USA 2023 List</span></p> <p class="bodytext" style="text-align: justify;">This award celebrates nationally recognized companies that make the world a better place to work together by prioritizing a people-centered culture and giving employees a voice. The Top Workplaces USA award is based entirely on feedback from an employee engagement survey completed by the employees of participating workplaces.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Q4 2023/award2.png?ver=4uAdpdrzHX-VFfcTCacEFw%3d%3d" style="width: 490px; height: 420px;" /></p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>A Picture Worth a Thousand Words</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group has well over 200 employees, many of whom have unique talents they exercise outside of work. One such employee is Facilities Coordinator Richard Hunt who this past August crafted a montage that brilliantly depicts our company’s different homes, both past and present. In a sense, Phia’s transition from being headquartered in the basement of CEO Adam V. Russo’s Quincy home to eventually settling in a massive Greater Boston office building mirrors the company’s upward trajectory in developing into a leader in the healthcare cost containment space. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is readily apparent from the accompanying image, Richard is, quite simply, an exceptionally gifted painter who is blessed with unparalleled attention to detail and creative sensibility. Because Richard’s masterpiece so perfectly chronicles our company’s history over the past quarter century, it now greets employees and visitors upon their arrival at our Canton, MA, office. While the elegance of the work is undeniable, its deeper message – how Phia has transformed and expanded its reach through the years – is masterfully conveyed. We are so proud of Richard’s crowning achievement and eternally grateful to have his artwork serve as a reminder of our unique history for all to see.</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q4 2023/phiayears2.png?ver=ABGB6Iz2eidirN3dHkbqcA%3d%3d" style="width: 539px; height: 628px;" /><a name="employ"></a><br /> <a id="EEofQ" name="EEofQ"></a> <p class="bodytext"><strong><br /> Get to Know Our Employee of the Quarter: Amanda Watts</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Explore team has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Amanda Watts as The Phia Group’s 2023 Q3 Employee of the Quarter! </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Here is one person’s comments about Amanda: “Amanda has gone above and beyond facilitating client referral emails. Amanda has acted very professionally in time-sensitive, client-focused situations. She is the point person for CH, DSG, and CST. It is very intense as most of these cases are settling the moment we get the referral, so they are extremely time-sensitive. A large employer group was so impressed by our handling of another matter, they specifically reached out and asked us to handle another file. Amanda made this file a priority and had CS get the information, DSG check the pass file, and notified me (the CH) the case was ready to be worked. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">She did all of this extremely fast and with a smile. Her work facilitated a fast turnaround for an important group and client. This team member always goes above and beyond. We are extremely lucky to have her as a teammate.”</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q4 2023/amanda2.png?ver=66rLupeHM8ZXKJMWS39yzw%3d%3d" style="width: 470px; height: 320px;" /> <p class="bodytext"><br /> Congratulations Amanda, and thank you for your many current and future contributions.</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Job Opportunities:</span></p> <p class="bodytext">• Customer Care Representative </p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• Claim Analyst • Claim Recovery Specialist </p> <p class="bodytext">• Claim and Case Support Analyst </p> <p class="bodytext">• Subrogation Attorney</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext" style="text-align: justify;">• Ethan Forrest has been promoted from Claim Investigator to Claim recovery Specialist IV </p> <p class="bodytext" style="text-align: justify;">• Lauren Pellegrino has been promoted from Claims Specialist to CRS Coverage, Training & Auditing Specialist</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Chantelle Andrade-Browne was hired as a Claims Specialist. </p> <p class="bodytext">• Ben Nix was hired as a Client Success Account Executive. </p> <p class="bodytext">• Ralitsa Vega was hired as a Project Coordinator. </p> <p class="bodytext">• Rebecca Garfield was hired as a Claims Specialist. </p> <p class="bodytext">• Ivan Monteiro was hired as a Customer Service Rep. </p> <p class="bodytext">• Nancy Henderson was hired as a Sr. Project Manager. </p> <p class="bodytext">• Daniel Vital was hired as a Claim and Case Support Analyst. </p> <p class="bodytext">• John Gresh was hired as an Attorney. </p> <p class="bodytext">• Chloe Henderson was hired as a Plan Drafter. </p> <p class="bodytext">• Matt Kramp was hired as a Sr. Project Manager Data Services. </p> <p class="bodytext">• Matt Sanborn was hired as a Customer Service Representative. </p> <p class="bodytext">• Hannah Gray was hired as a Sr. Claim Recovery Specialist.</p> <p class="boldtext">Phia Attended the 2023 SIIA National Conference</p> <p class="bodytext" style="font-weight: normal">Several of Phia’s industry experts attended SIIA’s National Conference in Phoenix, Arizona, from October 8th – 10th. If you are interested in learning more about SIIA’s National Conference, visit their website today: <a href="https://siiaconferences.org/nationalconference/2023/index.cfm">https://siiaconferences.org/nationalconference/2023/index.cfm</a>. </p> <a name="story"></a> <p class="boldtext"> </p> <hr class="horiz" /> <p class="bodytext" style="text-align: justify;"><strong><br /> The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.</p> <p class="bodytext" style="text-align: justify;"><strong></strong><br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter 2018 Q2/footerlogo.png?ver=iYwkNviyLE_yU_0lKTSyJQ%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1283The Stacks – 4th Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1282/the-stacks-4th-quarter-2023-newsletterNewslettersTue, 24 Oct 2023 14:33:56 GMT<p style="margin: 0in; text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#0071ce;"><span calibri="">3M Mass Tort Settlement Reminds Us that Subrogation Matters</span></span></strong></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">By: Ron E. Peck, Esq.</span></span><br /> <span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><br /> On Thursday, June 22<sup>nd</sup>, 3M followed other companies’ example by announcing that it had reached an agreement to settle claims that<b> </b>their<b> </b>polyfluoroalkyl and perfluoroalkyl substances (PFAS), known as “forever chemicals,” had contaminated water supplies in the<b> </b>United States.<b> </b> Specifically, the settlement will see 3M pay up to $10.3 billion over 13 years to municipalities in the U.S. that have detected these chemicals in their drinking water.  This is only the most recent in a series of settlements regarding water contamination by PFAS producers, who also announced that they would pay over $1 billion to settle similar lawsuits; with this likely heralding a new series of litigation and settlements, akin to the well-known asbestos proceedings.<br /> <br /> Many are familiar with the recent advent of PFAS testing conducted by municipal water authorities, and the resultant identification of unacceptable PFAS levels in drinking water.  This in turn led to various lengthy and costly remediation procedures, to remove the offending chemicals from public drinking water.  The aforementioned settlement is primarily meant to address abatement claims, compensating municipalities for damage suffered to property and costs incurred in said remediation projects. <br /> <br /> As entities funding and/or servicing self-funded health benefit plans, the importance and relevance of this news to our industry cannot be overstated.  That is because these settlements are not focused on potential illness caused by exposure to and consumption of PFAS chemicals, nor do they resolve what promises to be a substantial number of medical claims.  The lawsuits and settlements we are witnessing now are more likely than not just the tip of the iceberg.  That is why it is so important for health benefit plans to act now, and assert their and their participants’ rights – at the beginning of what promises to be a long process.</span></span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><br /> Furthermore, this type of lawsuit – and opportunity – is not unique.  Class actions, and the lesser-known toxic tort and mass tort cases, represent substantial chances for health benefit plans to recoup funds they had previously paid – sometimes years prior – through specialized subrogation.<br /> <br /> As a refresher, whenever a third party causes – or potentially causes – an illness or injury to a participant of a health benefit plan, and that plan pays to treat those illnesses or injuries, subrogation enables the aforementioned benefit plan to either “step into the shoes” of the injured participant – and pursue a claim against the liable third party – or, seek to recoup what the plan paid from the plan participant; (after that participant has recovered from a liable third party funds that are meant to pay for illness or injuries that are deemed to be the liable third party’s responsibility, but were already paid by the plan).<br /> <span style="color:#140028"><br /> Subrogation is a legal concept grounded in fairness.  It is one of those few rights, supported by both statute and equity, that has repeatedly withstood judicial review at every level.  The reason why subrogation is so durable is because society recognizes the justice inherent in ensuring parties pay for the damages they cause; guaranteeing that victims and their health benefit plans are not left paying for damages caused by someone else.  The most common and recognizable “type” of subrogation case usually involves one victim, one liable party, and one incident.  These often take the form of a car accident, slip and fall at a place of business, or injury at one’s place of employment… resulting in subrogation against automobile insurance carriers, businesses, and workers’ compensation.<br /> <br /> There exist other types of subrogation cases which, despite being far less common, represent a massive opportunity for health benefit plans and their participants to recoup substantial funds.  These cases are often called class action, toxic tort, or mass tort cases, and they occur when a substantial entity – such as 3M – is deemed to be responsible (or avoids liability through settlement) for injuries or illnesses caused to a large population over a meaningful period.  These lawsuits usually occur in Federal Court, following consolidation into multi-district litigation (“MDL”) by the judicial panel on multidistrict litigation (“JPML”).  As a result, there are many plaintiffs involved, at least one – but sometimes more than one – sizeable defendant organization, and a lot of money at stake.    </span><br /> <br /> Identifying such subrogation opportunities is no easy feat.  Unlike a motor vehicle accident – where the accident, injury, and treatment all occur within days (if not hours) of each other – with mass torts, exposure to the hazard, development of the illness or injury, identification of the link between the two, and filing of the case can take years or even decades to unfold.  That means plans and their service providers must remain aware of developing cases, know which conditions are deemed to be caused by the accused tortfeasors, and exercise a capacity to audit old claims to flag treatments that are indicative of said conditions, before investigating whether the affected participants encountered the accused tortfeasors’ substance or device in question.<br /> <br /> Is it worth the effort?  Absolutely.  Setting aside the tremendous plan funds at stake, consider also every plan administrator’s fiduciary duty to prudently manage plan assets and enforce the terms of the plan.  As such, it is arguably every plan administrator’s duty to investigate and pursue such cases.  Admittedly, it requires more sophistication than most plan sponsors and even third-party administrators may possess; but fortunately, fiduciaries can satisfy their duty by utilizing agents acting on their behalf.<br /> <br /> How much is at stake, and what do these cases look like?<br /> <br /> In June of 2012, the FDA announced a voluntary recall of Stryker Orthopedics’ Rejuvenate Modular-Neck and ABG II Modular-Neck Hip Stems.  Litigation ensued, and a subsequent settlement followed.  In total, the proceedings only addressed an estimated 20% of the failed devices, meaning an estimated 80% of the episodes were not addressed.  This is particularly worrisome, given that just the revision surgeries associated with the removal of the recalled devices cost health plans approximately $45,000.00 per procedure.  Similarly, another case involved the Exactech knee replacement systems.  Like Stryker, Exactech launched a recall in February of 2022 of more than 140,000 Optetrak, Optetrak Logic and Truliant knee replacement systems, after it discovered a defect in its packaging that exposed a polyethylene insert component to oxygen.  A lawsuit was filed, with 27 complaints pending in 11 different federal district courts – as well as a motion to centralize the cases.  Again, this represents only a fraction of the estimated patients and health plans that expended money to pay for procedures that should be funded by Exactech.  Likewise, in 2002, a study suggested that the long-term use of Wyeth Pharmaceuticals’ Prempro (a hormone therapy drug used to treat menopausal symptoms) significantly increased the likelihood of developing breast cancer.  After several years of litigation, a settlement was reached to pay patients who developed hormone-receptor positive breast cancer<a href="#_ftn1" name="_ftnref1" title=""><sup><sup><span style="font-size:11.0pt"><span calibri="" style="font-family:">[1]</span></span></sup></sup></a>, however, only about 10,000 individuals<a href="#_ftn2" name="_ftnref2" title=""><sup><sup><span style="font-size:11.0pt"><span calibri="" style="font-family:">[2]</span></span></sup></sup></a><sup> </sup>(a mere 5% of the estimated 200,000 women who developed this type of breast cancer), ever asserted a claim.  The average cost in these instances is estimated to be $50,000,<a href="#_ftn3" name="_ftnref3" title=""><sup><sup><span style="font-size:11.0pt"><span calibri="" style="font-family:">[3]</span></span></sup></sup></a> meaning that the unrecovered medical expenses associated with treating breast cancers caused by Prempro and similar drugs – payments made by health plans – are estimated to exceed $9.5 billion.  These, along with other examples – such as the Chantix recall, Paragard IUDs lawsuits, and Elmiron MDL – represent billions of dollars spent by health plans, and only a fraction in reimbursement being paid back. <br /> <br /> Finally, many readers are likely familiar with the recent lawsuits involving RoundUp.  In 2015 the World Health Organization’s (WHO) International Agency for Research on Cancer classified glyphosate – a key component of RoundUp – as a probable cancer-causing agent.  Additional research over the years subsequently suggested that RoundUp exposure increases the risk of developing Non-Hodgkin’s Lymphoma and other cancers.  As with the other examples of mass tort described herein, here too the matter became an MDL, instituted by the Federal Courts.  Some claims have settled, whilst many others remain open.  Specifically, as of December 2022, Bayer reached an agreement to settle about 100,000 cases, with $10.9 billion being paid out.<br /> <br /> These are just a few examples of mass tort cases.  Looking again at the recent claims involving PFAS, chemical seepage into drinking water may not be the only target for mass tort consideration.  PFAS that is present in household items may soon also become a subject of litigation, including items which may more easily introduce potentially harmful substances into human bodies – such as feminine hygiene products and baby wipes.  Likewise, extensive use of PFAS chemicals by airports, firefighters, and all divisions of the military, promises to result in more claims and more damages arising from this issue.  The amount of potential recovery health benefit plans could be pursuing are substantial and meaningful.  These assets, once returned to the plan, could be used to fund other claims and simultaneously prevent contribution, co-pay, and deductible increases.  It therefore behooves all self-funded plans, administrators, and fiduciaries to investigate what their plans are doing to identify and manage these types of claims.<br /> <br /> How does this impact self-funded health benefit plans, and the entities that service them?  Great question.  In a word: money.  These types of cases almost always impact numerous participants, and result in a lot of funds changing hands.  Self-funded benefit plans almost certainly have spent substantial amounts of plan assets on treatments about which these cases relate.  Every plan administrator has a fiduciary duty to identify opportunities to recoup such funds for their plan.  The question, then, is how to do it.  With traditional subrogation and third party liability work, the process is fairy straightforward.  You monitor claims as they come in, and flag those that – based on a diagnosis code – tend to relate to an accident or injury which, more often than not, entails third party liability.  In other words, if claims arrive for a broken bone, an ambulance, whip lash, facial injuries, and other similar trauma codes – all within the same 24 to 48 hour period – it’s a safe bet that these injuries all relate to one accident for which a third party may be responsible.  With mass tort claims, however, it’s much less straightforward.  In 2015, a plan member may have incurred $200,000 in claims for the treatment of Non-Hodgkin’s Lymphoma.  In 2015, there was no reason to think these claims relate in any way to third party liability.  Then, in 2020, someone proves that the use of a chemical herbicide causes Non-Hodgkin’s Lymphoma.  Then, in 2022, a lawsuit is filed against the producer of said herbicide.  To maximize this opportunity, self-funded plans must themselves – or with a partner – monitor instances like this; where some substance or product is tied to an illness or injury.  When instances like this arise, the plan – or their partners – must then identify the illness or injury caused by the substance or product, and audit their historical claims to identify if and when participants treated for (and the plan paid for) such illness or injury.  Then, they must communicate with the impacted participant, or their family, to identify if that patient came in contact with the substance or product in question.  Then (phew) the plan or the plan’s partner must work with the attorney’s managing the mass tort case, to assert the plan – and if at the patient’s behest, the patient’s – rights.  It’s not easy, but with the right process and partners in place, it is more than worth it.</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 calibri="" style="font-family:"><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 calibri="" style="font-family:">[1]</span></span></span></span></a> <span calibri="" class="fontstyle01" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:normal">Feeley, Jef, </span></span></span></span><span calibri="" class="fontstyle21" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:italic">Pfizer Paid $896 Million in Prempro Settlement, </span></span></span></span><span calibri="" class="fontstyle01" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:normal">Bloomberg Business, June 19, 2012</span></span></span></span></span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[2]</span></span></span></span></a> Id.</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[3]</span></span></span></span></a> <span calibri="" class="fontstyle01" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:normal">See e.g. Campbell, J.D. and Ramsey, S.D. </span></span></span></span><span calibri="" class="fontstyle21" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:italic">The Costs of Treating Breast Cancer in the US: a Synthesis of Published</span></span></span></span><i><span style="color:black"><br /> <span calibri="" class="fontstyle21" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:italic">Evidence, </span></span></span></span></span></i><span calibri="" class="fontstyle01" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:normal">Pharmacoeconomics 2009 27(3): 199-209. (“</span></span></span></span><span arial="" class="fontstyle31" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:normal">The estimates of lifetime per-patient costs of breast</span></span></span></span><span arial="" style="font-family:"><span style="color:black"><br /> <span arial="" class="fontstyle31" style="font-family:"><span style="color:black"><span style="font-weight:normal"><span style="font-style:normal">cancer ranged from $US20 000 to $US100 000.”)</span></span></span></span></span></span></span></span></p> </div> </div> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> 1282The Stacks – 3rd Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1258/the-stacks-3rd-quarter-2023-newsletterNewslettersFri, 07 Jul 2023 17:59:05 GMT<p style="text-align: justify;"><span style="font-size:11.0pt"><span calibri="" style="font-family:"><b><span style="color:#0071ce;"><span style="font-size:16px;">Gene and Cell Therapy: Where Compassion and Cost Collide</span></span></b><br /> Jen McCormick, Esq.<br /> <br /> As advancements in how individuals consume healthcare have drastically and rapidly improved (i.e., the prevalence of virtual patient care, online pharmacies where treatments can be received and delivered to the home, etc.) face-to-face communication between providers and patients has often been supplanted by virtual interactions that expedite processes. The result is faster and easier access to healthcare.<br /> <br /> Improved access is certainly a step forward, but is it enough? For patients diagnosed with a rare or life-threatening condition where the only treatment is difficult to obtain, the answer is probably not. Availability is a challenge for patients seeking gene and cell therapy as treatment can cost millions to obtain. Cost is a factor and has the potential to impact the availability of treatment for patients.  Access and availability are not always in parity when it comes to patient care.<br /> <br /> Research shows and common sense would suggest that providing healthcare services for patients to maintain or restore their physical, mental, or emotional well-being is best when the patient care is embedded with empathy and kindness; it greatly enhances the healing process. Compassion is important for healthcare providers, and for employers with self-funded healthcare benefit plans.<br /> <br /> Gene and cell therapies are quickly evolving, and employers need to understand the potential impact. Employers face the tall order of exuding empathy while relating to employees contemplating the multi-million-dollar treatment that is gene and cell therapy. Even the most compassionate of such professionals find it difficult to strike the delicate balance of weighing costs to their respective plans with the natural inclination to provide coverage for potentially lifesaving or life-altering therapy.<br /> <br /> Knowledge and a solid game plan for how to manage gene and cell therapy within their plan design, however, will allow employers to confidently focus their energy on the employee facing life-threatening circumstances instead of being blindsided by the economics of the situation. By understanding the nuances and limitations, plan sponsors should be well-positioned to employ a strategy that uniquely balances compassion and cost.<br /> <br /> The following discussion highlights some of the plan administration and documentation considerations for employers navigating the evolving gene and cell therapy landscape.<br /> <b><br /> Gene and Cell Therapy Background</b><br /> <br /> According to the FDA, <i>gene therapy</i> is a method that modifies a person’s genes to treat or cure disease, while the American Society of Gene + Cell Therapy (ASGCT) defines <i>cell therapy</i> as the transfer of live cells into a patient to treat or cure a disease -- i.e., a blood or marrow transplant is a type of cellular therapy.<b>  </b><br /> <br /> Undoubtedly, accessibility and attainability are challenges for patients and plan sponsors as they learn more about cell and gene therapies, which has been a very hot topic in recent years. The response to these innovative treatments has been mixed: The medical community is advocating the new treatments for patients hoping to find a cure for their respective rare diseases while health plans remain concerned about potential costs.<br /> <br /> In the past couple years, the pipeline of both pending and U.S. Food & Drug Administration (FDA) approved treatments has grown. In fact, in January 2019 FDA Commissioner Scott Gottlieb noted the surge in cell and gene therapy products entering early development and predicted that the FDA would be approving 10 to 20 cell and gene therapy products a year by 2025 based on the assessment of the current pipeline and clinical success rates. Flash forward to the present day and as of April 2023, the FDA has (according to fda.gov) approved over 25 cell and gene therapy products. Furthermore, according to the Alliance for Regenerative Medicine (ARM), there could be as many as 13 brand new cell or gene therapies approved in the United States, Europe, or both by the end of 2023, and there is a large queue of various clinical trials for gene and cell therapies listed on the ClinicalTrials.gov website.<br /> <br /> Why is there so much excitement over these developments? Gene and cell therapies potentially offer a new avenue for treatment in cases where there were otherwise limited options for such rare and life-jeopardizing diseases. Indeed, some of the FDA approved cell and gene therapy treatments on the market have yielded curative changes with a one-time treatment. Long term metrics and results are still being examined, but as the interest in and education about these types of treatments increases, employers who sponsor self-funded health plans should take the opportunity to decide how to address such coverage within their plan designs.<br /> <b><br /> Plan Language Considerations</b><br /> <br /> Many factors should be considered by employers as they navigate this new landscape. For example, if a treatment is approved for use in Europe, but not in the United States, would such benefit be eligible for coverage under the current plan design (if the individual travels to Europe) or is there an exclusion for foreign travel (i.e., benefits received outside the United States if travel is for the sole purpose of obtaining medical services)? Even if plans have the strictest language possible for international medical tourism, how does the plan currently address gene and cell therapy? Is there an exclusion? Is there a benefit? Are there limits? Is the plan silent?<br /> <br /> This is an important conversation as cutting-edge science and technology continue driving forward the current state of medicine in the United States, and the queue for more FDA approved gene and cell therapies is rapidly growing. While it’s undeniable that these advancements in treatment options can come with an overwhelming price tag, the conversation becomes more nuanced when further questions are considered:  What if covering the one-time treatment could potentially cure the condition and offset the need for other expensive ongoing or life-long care? Further, if the plan did cover such benefits would they be reimbursable by the plan’s stop loss carrier?  Are there alternative payment options?<br /> <br /> Plans, however, are still permitted (and should) ensure benefits are covered subject to the appropriate medical management techniques. For example, plans should have a strong definition and policy for how medical necessity is determined. The plan should also review the definition of experimental and investigational to ensure the language is in line with its expectations. Other plan options may include pre-certification or prior authorization requirements on the benefits.<br /> <b><br /> Compliance Considerations</b><br /> <br /> A key question plans may be asking is what they are required to cover. The Affordable Care Act (ACA) prohibits plans from imposing dollar limitations on any of the 10 categories of essential health benefits (EHB). To the extent the plan covers an EHB, no dollar limitations may apply to that benefit. Self-funded plans should have identified a particular state benchmark to which they determine and classify EHBs under the plan design.  In 2022, HHS released the 2023 final payment rules which provide that for plan years beginning on or after January 1, 2023, an EHB plan design should be clinically based, among other factors. Further, in late 2022, HHS published a request for information (RFI) asking for public comment by January 31, 2023, regarding a variety of topics, but including the description of EHBs and questions involving the barriers to accessing services due to cost, coverage and whether EHBs needed to be updated to account for changes in medical evidence or scientific advancements.<br /> <br /> The timing for plan design changes should be considered as well. Plan design modifications should comply with the ACA and ERISA timing requirements and may be best incorporated at plan renewal to mitigate discrimination concerns.<br /> <br /> Consequently, coverage and access issues remain pressing issues.  Plans should be mindful when it comes to their decision-making surrounding how and whether to extend (or limit) coverage for gene and cell therapy. These are tough choices for employers and plan sponsors, and they need support as they weigh the various factors and considerations to make an educated decision.<br /> <b><br /> Define a Strategy</b><br /> <br /> As gene and cell therapies develop so too are the options for plan sponsors when it comes to potential payment methodologies. Traditional health plans were not structured to handle one-shot, high-cost treatments so alternative options are important to consider. For example, new reinsurance programs are emerging to offer options for plans hoping to cover gene and cell therapies. Each of these programs is unique and should be reviewed against the existing plan materials to ensure the program aligns with the intentions of the plan sponsor and the terms of the plan document/summary plan description.  Patient support programs where patients receive support for cell and gene therapy may also be available. Unlike traditional drug patient assistance programs, these programs may offer psychosocial, economic, and caregiver assistance to the patients and their families. The support programs may be individualized to address clinical issues and matters involving logistical and transportation related support, financial support, and nurse navigation support.  Other payment strategies could include multiple year payment plans, reimbursement based on meaningful outcomes or performance-based measures for the treatment, payment model where the price reflects the value, or a methodology that includes a warranty (where a refund may be issued if the treatment fails after a certain time).<br /> <br /> In adopting a strategy for coverage (or exclusion, or limited coverage) of gene and cell therapies, plan sponsors should balance the various factors. While there may not be a perfect solution, plans need a strategy that is clearly consistent with plan materials so there is no confusion among plan participants (or between other contracts held by the plan sponsor). For example, in navigating this evolving area of benefits, plan sponsors should ensure the plan document/summary plan description aligns with their coverage decision; the stop loss policy provisions are free from conflict with the underlying plan materials; review any potential supplement programs that may assist in the coverage of these gene and cell therapy benefits; continually monitor the regulations as state and federal laws regarding price transparency and drug pricing pass to ensure ongoing compliance; and keep abreast of the pipeline of pending and newly approved FDA therapies.<br /> <br /> New (and costly) gene and cell therapy treatments are on the horizon. As a result, it will be important for employers to have the appropriate balance between tight controls to ensure patients see the value and benefit of these high-cost treatments. Having a strategy that successfully connects employees and plan members with life-changing treatments and mitigates the financial impact, while demonstrating compassion, is critical. </span></span></p> <hr /> <p style="margin-bottom:0in; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><br /> <strong><span style="color:#0071ce;"><span style="font-size:18px;">Eli Lilly Caps Insulin Cost</span></span></strong></span></span></span></span></span></p> <p style="margin-bottom:0in; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><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; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">By: David Ostrowsky</span></span></span></span></span></p> <p style="margin-bottom:0in; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">During his State of the Union speech last month, President Joe Biden called for the out-of-pocket cost for insulin to be capped at $35. </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 calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">It turns out that at least one drugmaker was listening. </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 calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">On March 1, Eli Lilly, a pharmaceutical company with vast global reach, announced that it was indeed </span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#2a2a2a">capping the out-of-pocket cost of<strong> </strong>its insulin at $35 a month—in addition to slashing the price of its two highest-selling insulin products, Humalog and Humulin, by 70%—</span></span></span></span><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">and thus falling in line with a provision in the recently passed Inflation Reduction Act, which ensured that seniors enrolled in Medicare pay no more than $35 per month for insulin. Eli Lilly’s announcement made for above the fold news because now some individuals with private insurance—and not just Medicare recipients—would reap the considerable benefits of a $35 cap. For those without insurance, they too can pay just $35 per month by downloading Eli Lilly’s Insulin Value Program savings card. </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 calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The costs of insulin, a lifesaving drug for millions of Americans (the American Diabetes Association estimates that 8.4 million Americans who are diabetic rely on insulin), remain exorbitantly high, at least compared to the medication’s price tag in other countries </span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#363636">where their respective governments negotiate prices directly with drug manufacturers</span></span></span></span><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">. </span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#141414">Case in point: a 2020 Rand study revealed that the average price per vial of insulin in the US was over $98 in 2018; in Australia, Canada, and the UK, the prices for a vial of insulin were approximately $7, $12, and $8, respectively. </span></span></span></span><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Hopefully, Eli Lilly taking the initiative to help rectify this systemic problem will motivate America’s two other primary insulin manufacturers, </span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#2a2a2a">Novo Nordisk and Sanofi, to follow a similar course of action. </span></span></span></span><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#212121"></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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#212121">“While the current healthcare system provides access to insulin for most people with diabetes, it still does not provide affordable insulin for everyone and that needs to change,” remarked </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#2a2a2a">Eli Lilly’s Chair and CEO </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#212121">David A. Ricks in a company-issued press release.</span></span></span></span> <span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#212121">“The aggressive price cuts we're announcing today should make a real difference for Americans with diabetes.</span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#2a2a2a"> . . . </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#212121">For the past century, </span></span></span></span><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Lilly<span style="background:white"><span style="color:#212121"> has focused on inventing new and improved insulins and other medicines that address the impact of diabetes and improve patient outcomes. Our work to discover new and better treatments is far from over. We won't stop until all people with diabetes are in control of their disease and can get the insulin they need.”</span></span><span style="background:white"><span style="color:#2a2a2a"></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 calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Tragically, for decades now, millions haven’t been able to get the requisite amounts of insulin they need because of the runaway prices charged for the medication that in its absence can lead to death or, at the very least, severe health consequences including kidney failure and amputation. In fact, for many Americans living with diabetes, the annual cost to obtain life-saving insulin can well exceed $1,000. As such, it comes as little surprise that, per a report released earlier this month by “PBS News Hour,” among the millions of diabetic Americans, approximately 1.3 million are either uninsured or have subpar insurance and are thus forced to ration their insulin in order to pay other bills … ultimately to jeopardize their ability to survive. </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 calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Undoubtedly, Eli Lilly has been a chief culprit behind such escalating prices, as evidenced by the fact that for the past nearly 30 years, the publicly traded company has increased the list price of its most popular insulin product, Humalog, by more than tenfold. And while the announcement that Eli Lilly will not only enact the $35 price cap but also plans to lower the list prices of Humalog and Humulin by 70 percent in the last quarter of 2023 and reduce its generic lispro’s list price from $126 to $25 per vial appears promising, diabetic Americans and lobbyists clamoring for price regulation still face significant headwinds in their campaign to reduce costs for an </span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#363636">injection that millions take to stabilize their blood sugar levels. </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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#363636"></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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#363636">For one, the reduced list prices, which will take effect over the course of 2023, are only applicable to Lilly’s older insulin products. (One of the company’s newer Humalog products, a prefilled insulin pen, will still cost $530 while its long-acting insulin product, Basaglar, first approved in 2015, will not become more affordable.) Meanwhile, Lilly’s new list price for a vial of Humalog ($66) still exceeds triple the amount which the company charged for the product when it was brought to market in 1996. And perhaps most significantly, Lilly’s </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:#222222">list-price cuts won’t necessarily translate to all diabetic patients enjoying a corresponding reduction in their out-of-pocket costs for insulin as many insured people pay fixed monthly copays that will continue to be static.</span></span></span></span><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></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 new="" roman="" style="font-family:" times=""><span style="color:black">As </span><span style="color:black">Elizabeth Pfiester, who has diabetes and is the executive director of T1International, a group that has been advocating for a federal ceiling on insulin list prices, told the <i>New York Times</i>,</span> <span style="color:black">Lilly’s announcement “does not mean that the situation is fixed or everything is solved” while adding, “this is good news for some, but we need regulation to make sure that the companies can’t change their mind again and decide to raise the price.”</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 new="" roman="" style="font-family:" times=""><span style="color:black">Indeed, the recent Eli Lilly development can’t be perceived as a panacea for all Americans who suffer from diabetes because there are still the two other drug manufacturing companies, </span><span style="background:white"><span style="color:#2a2a2a">Novo Nordisk and Sanofi, that have a significant foothold in the market. For patients whose health insurers are contracted with these two behemoth manufacturers, which in other words is approximately seven out of ten Americans, there may not be such relief at the pharmacy counter. This stands in stark contrast to the situation involving government-mandated insulin price caps: the firm $35 cap on insulin out-of-pocket costs for Medicare-eligible Americans, included in last year’s Congressional approved Inflation Reduction Act, is in effect irrespective of the company manufacturing the insulin.   </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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The bottom line is that for the majority of diabetic Americans, the prices of insulin will continue to present a significant financial burden—at least in the short term. Which means for self-insured employers, ones who traditionally </span></span><span style="font-size:12.0pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="color:black">contract with pharmacy benefit managers (PBMs) who design drug formularies and negotiate prices with drug manufacturers on their behalf, it becomes even more critical to seek out generic versions of a branded product as well as less costly alternatives. This is easier said than done. Unfortunately, the complex relationship that many self-funded employers have with PBMs often leaves many employers unaware that reclassifying certain drugs as generic (or branded) can drive up costs tremendously or that their employees have been directed to utilize pricey drugs when more reasonably priced generics are available. The end results are often the overutilization of overpriced drugs, higher patient cost sharing, and excessive employer spending on drugs. Although self-insured group health plans do not have full discretionary authority to include or exclude expensive prescription drugs, they do have some latitude to pursue prescription drugs that are more cost effective, a reality of which plan administrators should be very well aware. </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">From a broader perspective, diabetes, itself, remains a pressing concern among the American population. CNN recently reported that </span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:black"><span style="letter-spacing:.3pt">in the US alone, the number of adults with diabetes has doubled over the past two decades while the US Centers for Disease Control and Prevention estimate that over 37.3 million now have it. As if these numbers weren’t sobering enough, tens of millions of more Americans are prediabetic. </span></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 new="" roman="" style="font-family:" times=""><span style="color:black"><span style="letter-spacing:.3pt">A measure to lower the cost of a live-saving product for the masses suffering from the malady? No wonder President Biden heralded the Lilly announcement as “a big deal.” </span></span></span></span></span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> 1258The Phia Group's 2nd Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1238/the-phia-groups-2nd-quarter-2023-newsletterNewslettersThu, 13 Apr 2023 14:59:37 GMT<meta charset="utf-8" data_liveedit_tagid="6421148928644923" ><meta http-equiv="Content-Type" content="text/html; charset=UTF-8" data_liveedit_tagid="0x00007f91ff780020" /> <title data_liveedit_tagid="0x00007f921422b950"></title> <style data_liveedit_tagid="0x00007f91ff7811d0" type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="0" cellspacing="0" data_liveedit_tagid="0x00007f91ff746760" width="650"> <tbody> <tr data_liveedit_tagid="0x00007f91ff746890"> <td bgcolor="#4a85d3" colspan="2" data_liveedit_tagid="0x00007f91ff77fc90"> <table border="0" cellpadding="0" cellspacing="0" data_liveedit_tagid="0x00007f91ff77ed40" width="90%"> <tbody> <tr data_liveedit_tagid="0x00007f91ff77d250"> <td bgcolor="#4a85d3" class="whitetext" data_liveedit_tagid="0x00007f91ff77d6d0" style="text-align: right" valign="bottom"> <p data_liveedit_tagid="0x00007f91ff77c410"><br data_liveedit_tagid="0x00007f91ff77f200" /> Phone: 781-535-5600 | <a class="whitetext" data_liveedit_tagid="0x00007f91ff77ba90" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr data_liveedit_tagid="0x00007f91ff77b700"> <td colspan="2" data_liveedit_tagid="0x00007f91ff7798f0"><img data_liveedit_tagid="0x00007f91ff77e180" src="/Portals/phiagroup/Newsletters/Q2 2023/newheader3.jpg?ver=0rzouXXydknfnXxIzzp4kw%3d%3d" style="width: 650px; height: 451px;" /></td> </tr> <tr data_liveedit_tagid="0x00007f91ff779a20"> </tr> <tr data_liveedit_tagid="0x00007f91ff778230"> <td data_liveedit_tagid="0x00007f91ff777c40" valign="top" width="312"><a data_liveedit_tagid="0x00007f91ff775260" href="#russo4"><img data_liveedit_tagid="0x00007f91ff77aed0" src="/Portals/phiagroup/Newsletters/Q2 2023/block0422l.png?ver=QzxOCNrPRY7XLxR2EvsCFA%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td data_liveedit_tagid="0x00007f92147be650" valign="top" width="323"><a data_liveedit_tagid="0x00007f92147b7250" href="#pace3"><img data_liveedit_tagid="0x00007f91ff77a710" src="/Portals/phiagroup/Newsletters/Q2 2023/block0422r.png?ver=RYzovi58oc_zFfzcCG7aAA%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr data_liveedit_tagid="0x00007f92147b74b0"> <td colspan="2" data_liveedit_tagid="0x00007f92147cdcb0"> <table border="0" cellpadding="0" cellspacing="2" data_liveedit_tagid="0x00007f92147ccd60" width="100%"> </table> </td> </tr> <tr data_liveedit_tagid="0x00007f91ff7590d0"> <td data_liveedit_tagid="0x00007f91ff75b0c0" valign="top" width="47%"> <p data_liveedit_tagid="0x00007f91ff757ce0"><br data_liveedit_tagid="0x00007f91ff778ab0" /> <img data_liveedit_tagid="0x00007f91ff7762e0" height="277" src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" width="286" /></p> </td> <td data_liveedit_tagid="0x00007f92147c8c70" valign="top" width="53%"> <p class="bodytext" data_liveedit_tagid="0x00007f92147c7d60"><span class="heading1" data_liveedit_tagid="0x00007f92147c6360" style="font-size: 14px; font-weight: bold;">The Book of Russo: </span></p> <p class="bodytext" data_liveedit_tagid="0x00007f92147bfe40" style="text-align: justify;">I love April. Between the New England winter finally loosening its grip, my birthday, Easter (including hiding easter eggs around my yard at 4 a.m. when it’s 35 degrees outside), and yes…OPENING DAY FOR THE CLEVELAND GUARDIANS (and some other teams, I guess) – in my opinion, you can’t beat this month! It’s also the beginning of conference season. In fact, I just got back from SIIA’s event in Orlando, where we saw not only the largest crowd since the pandemic began – but perhaps the best attendance I can remember, period. The industry is changing for the better, as TPAs realize that certain technology and member communication are the keys to ensure the self-insured industry enjoys growth and expansion, now – and in the future.</p> <table border="0" cellpadding="0" cellspacing="0" data_liveedit_tagid="0x00007f92147bf370" width="100%"> </table> </td> </tr> <tr data_liveedit_tagid="0x00007f921497cca0"> <td colspan="2" data_liveedit_tagid="0x00007f9214971ee0" valign="top"> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7ae7d0" style="text-align: justify;">I have never seen such proactive measures and such an upbeat attitude about our work, and what our future can bring. There are, however, risks all around us. Whether it’s a random gap between plan coverage and the applicable stop-loss policy, groups forcing products or vendors upon administrators that can’t coordinate with them, services being advertised to witless employers one way whilst the reality is far different, rigid contracts and processes eliminating customization, and beyond… there are pitfalls around every corner. This is a major reason why The Phia Group is here for the industry. We love looking at new technologies and offerings that promise to reduce overall cost and increase quality outcomes, while remaining wary of cracks in the armor; ensuring a seamless implementation process that’s is never as easy as it seems. As always, we celebrate what is great about this industry, but continue to be on the lookout for threats. With that in mind, I hope you enjoy this newsletter, and the great insight from our staff.</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88fb90">– Happy reading!</p> </td> </tr> <tr data_liveedit_tagid="0x00007f91ed88a8b0"> <td bgcolor="#eeeeee" class="toc" colspan="2" data_liveedit_tagid="0x00007f91ed88a3f0" valign="top"> <table border="0" cellpadding="5" cellspacing="10" data_liveedit_tagid="0x00007f91ed889390" width="100%"> <tbody> <tr data_liveedit_tagid="0x00007f91ed884f70"> <td data_liveedit_tagid="0x00007f9214353840"> <p data_liveedit_tagid="0x00007f9214353090"><img data_liveedit_tagid="0x00007f92147c5680" src="/Portals/phiagroup/Newsletter 2018 Q2/inthisissue.png?ver=4_c-EncNsuJUxrT1QINLVg%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd" data_liveedit_tagid="0x00007f9214351ff0"><a data_liveedit_tagid="0x00007f921434ff70" href="#russo09">Service Focuses of the Quarter</a><br data_liveedit_tagid="0x00007f92147c21e0" /> <a data_liveedit_tagid="0x00007f921434f350" href="#pftp">Phia Fit to Print</a><br data_liveedit_tagid="0x00007f92147c0780" /> <a data_liveedit_tagid="0x00007f921434cf40" href="#pblog">From the Blogosphere</a><br data_liveedit_tagid="0x00007f91ff795f70" /> <a data_liveedit_tagid="0x00007f921434d2d0" href="#pwebinars">Webinars</a><br data_liveedit_tagid="0x00007f91ff7a6740" /> <a data_liveedit_tagid="0x00007f92147ddf30" href="#ppodcast">Podcasts</a><br data_liveedit_tagid="0x00007f91ff7a6040" /> <a data_liveedit_tagid="0x00007f92147dd5d0" href="#pcharity">The Phia Group’s 2023 Charity</a><br data_liveedit_tagid="0x00007f91ff7a5710" /> <a data_liveedit_tagid="0x00007f92147db840" href="#pstacks">The Stacks</a><br data_liveedit_tagid="0x00007f91ff7625c0" /> <a data_liveedit_tagid="0x00007f92147dcb20" href="#pemployee">Employee of the Quarter</a><br data_liveedit_tagid="0x00007f91ff75fda0" /> <a data_liveedit_tagid="0x00007f92147b5460" href="#pemployee">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr data_liveedit_tagid="0x00007f92147b6410"> <td colspan="2" data_liveedit_tagid="0x00007f92147d3140" valign="top"> <p class="bodytext" data_liveedit_tagid="0x00007f91ff745400"><strong data_liveedit_tagid="0x00007f91ff742d00"><a id="russo09" name="russo09"></a><br /> Service Focuses of the Quarter: Subrogation & Phia Unwrapped</strong> </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff743c70"><strong data_liveedit_tagid="0x00007f91ff7ae440">Subrogation </strong> </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147c1f80" style="text-align: justify;">At The Phia Group, we recognize that being prudent with plan assets entails recovering them whenever possible. Thus, we offer comprehensive subrogation recovery services that help our clients maximize recoveries, protect their plans’ best interests, and, most importantly, keep costs down. Our team of specialized recovery professionals, including attorneys, is widely considered to be the most experienced in the self-funded industry. Having vast industry experience even outside of subrogation and expertly crafted plan language that reflects the current state of the law and this ever-changing industry allows us to review existing plans and customize subrogation rights and other language to fit our clients' needs. </p> <p class="bodytext" data_liveedit_tagid="0x00007f9214980410" style="text-align: justify;">Our subrogation services involve ordinary third-party accident cases (such as car accidents, slip and falls, etc.) and mass tort cases (such as products liability, toxic torts, etc.), and we place all high-dollar cases in our attorneys’ hands for optimal settlements. Our state-of-the-art analytics and advanced algorithms ensure robust case identification, and our case management process promotes efficiency. We also provide specialized reporting so our clients can manage their business. We understand what a comprehensive, optimally performing subrogation service is because we've built one. Let us help you maximize your recoveries and protect your plan's best interests.</p> <p class="bodytext" data_liveedit_tagid="0x00007f92147db970"><strong data_liveedit_tagid="0x00007f92149729a0">Phia Unwrapped </strong> </p> <p class="bodytext" data_liveedit_tagid="0x00007f921436dd60" style="text-align: justify;">Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited rights. With Phia Unwrapped, we replace wrap network access and modify non-network payment methodologies, securing payable amounts based upon fair market parameters that are unbeatably low.</p> <p class="bodytext" data_liveedit_tagid="0x00007f921422a190" style="text-align: justify;">Phia Unwrapped places no minimum threshold on claims to be repriced or potential balance billing to be negotiated, and The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed889000" style="text-align: justify;">Phia Unwrapped implementation entails setting up an EDI feed with the claims administrator, so claims are flagged, transferred, and repriced automatically. Phia Unwrapped is billed based on a percentage of actual savings, leading to fair rates and no excessive costs for unprecedented savings – and if there’s pushback or balance-billing, our Provider Relations team will handle it. </p> <p class="bodytext" data_liveedit_tagid="0x00007f921436bfc0" style="text-align: justify;">Out-of-network claims that run through Phia Unwrapped yield a whopping average savings of 74% off billed charges (three times the average wrap discount). On average, The Phia Group sees roughly 2% of claims result in balance-billing; these results are similar throughout different plan types and locations, proving that this program and these results can be replicated nationwide. </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147badc0" style="text-align: justify;">Per our data, Phia Unwrapped has yielded significantly better savings than wrap networks. Can you and your clients afford to maintain the status quo given such results? </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147bb020" style="text-align: justify;">Contact Garrick Hunt, at <a data_liveedit_tagid="0x00007f92147bb280" href=" mailto:GHunt@phiagroup.com">GHunt@phiagroup.com</a> to learn more about The Phia Group’s Subrogation and Phia Unwrapped services. </p> <a data_liveedit_tagid="0x00007f91ff7a4e10" name="russo4"></a> <p class="bodytext" data_liveedit_tagid="0x00007f92147dbf40"><strong data_liveedit_tagid="0x00007f92147d56e0">Phia Case Study: Gag Clause Attestations</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff75ae60" style="text-align: justify;">The Consolidated Appropriations Act made many changes for health plans, including prohibiting so-called gag clauses, which are contractual provisions prohibiting a plan from disclosing information involving cost of healthcare services or availability of lower-cost alternatives. This prohibition is intended to increase healthcare transparency and empower patients to make more informed decisions – but, ironically, the law applies to health plans. In other words, while providers suggest gag clauses, health plans are prohibited from agreeing to them, resulting in a strange contractual dynamic. </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147b0430" style="text-align: justify;">A TPA utilizing Phia’s ICE service approached the consulting team hoping to receive an affirmation of its current process regarding the relatively new requirement for health plans to submit “gag clause” attestations. Specifically, although the requirement applies to the plan itself, the TPA tried to make things easier for its plans and offered to submit gag clause attestations for its clients for a nominal fee. When we asked how the TPA verifies the lack of gag clauses, we were told that they do not, and affirmations are submitted on a given plan’s request, even without asking the plan to prove or even verify it! </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147c0520" style="text-align: justify;">;We immediately cautioned against that practice, because although the TPA’s ASA had a broad indemnification provision, we know from experience that when a regulatory body finds fault with a particular plan’s operations, it also often takes a deep dive into the TPA’s operations on a larger scale as well, under the theory that the TPA’s actions often facilitate or promote the plan’s actions. We’ve seen this lately, particularly regarding mental health parity. If a TPA submits a gag clause attestation on behalf of a health plan and that attestation is ultimately imperfect, the TPA may be indemnified by the plan, but it’s a better idea for the TPA to at least confirm that the attestation is correct prior to submitting it. Furthermore, an audit of the TPA’s processes is burdensome. </p> <p class="bodytext" data_liveedit_tagid="0x00007f921422ab10" style="text-align: justify;">Proactively verifying accuracy of a gag clause attestation may be slightly more work, but anecdotally, protecting yourself is worth it! (Of course, Phia can help review contracts if necessary.)</p> <a data_liveedit_tagid="0x00007f92147bf980" name="pace3"></a> <p class="bodytext" data_liveedit_tagid="0x00007f9214229cd0"><strong data_liveedit_tagid="0x00007f92147c6490">Fiduciary Burden of the Quarter: Mental Health Parity – Past and Future</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff744f80" style="text-align: justify;">It’s old news that health plans subject to Mental Health Parity and Addiction Equity Act must perform a nonquantitative treatment limitations analysis, intended to document a plan’s compliance with the law’s parity aspects. This has become an important plan function, and plan administrators must disclose the report per normal plan disclosures. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7ad100" style="text-align: justify;">There are many nuances involved in performing an NQTL analysis, which many readers may have experienced; for example, while plans are struggling to comply with mental health parity, they are updating documents and processes in the normal course of business and in response to unearthed parity concerns – but to perform a given analysis, the plan must travel back in time and report on what was the case, rather than what is now the case. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff75a020" style="text-align: justify;">The result? Many health plans want to have their NQTL analyses performed after they have updated their SPDs to change or remove noncompliant provisions. The logic makes sense: once a compliance issue was discovered and fixed, why would the plan want to perform an analysis of a version that is now old and defunct?! After all, plans understandably want to do whatever possible to get a “passing” grade on the analysis report.</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed887bf0" style="text-align: justify;">Unfortunately, though, that’s not what regulators look for, and not what health plans have been directed to do. An analysis is specifically designed to review the plan’s historical compliance, which is bolstered by the idea that analysis must also include data regarding the plan’s operational compliance. Updating SPDs is always good, but an NQTL analysis can’t scrutinize a new plan document that didn’t exist during the testing period, just as the analysis can’t inspect future operational data, since by definition it doesn’t exist at any given time either. When an SPD is updated, it’s updated for the future, not for the past, so the NQTL analysis needs to rely on the SPD that was in place in the past. The report can certainly document what changes were made after the testing period, which goes a long way if there’s an audit, but the report must nonetheless discuss the past.</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7425e0"> </p> <hr class="horiz" data_liveedit_tagid="0x00007f91ff75ee00" /> _<br data_liveedit_tagid="0x00007f91ff755720" /> <a data_liveedit_tagid="0x00007f9214351c60" name="pdef"></a> <p class="heading1" data_liveedit_tagid="0x00007f91ff742820"><a id="p5" name="p5"></a><a data_liveedit_tagid="0x00007f92147d9720" id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff775830" style="text-align: justify;">• On February 15, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff742e30" href="https://www.phiagroup.com/Media/Posts/love-is-in-the-healthcare">“Love is in the (Health)Care!,”</a> in which we discussed important issues, best practices, and case studies. From disputes with providers, to subrogation, to regulatory updates, and beyond. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff744be0" style="text-align: justify;">• On January 19, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff744e20" href="https://www.phiagroup.com/Media/Posts/an-omnibus-edition-to-kick-off-2023">“An Omnibus Edition to Kick Off 2023,”</a> in which we discussed The Consolidated Appropriations Act of 2023, its inclusion of protections for pregnant and nursing mothers, regulatory updates regarding the No Surprises Act, and manufacturer assistance programs.</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7451c0" style="text-align: justify;">Be sure to check out all of our <a data_liveedit_tagid="0x00007f91ff745850" href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p>   <hr class="horiz" data_liveedit_tagid="0x00007f91ed890750" /> <p class="heading1" data_liveedit_tagid="0x00007f91ff7461b0"><a data_liveedit_tagid="0x00007f91ff7463f0" id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center data_liveedit_tagid="0x00007f91ff746630"> <p class="heading1" data_liveedit_tagid="0x00007f91ff744830">Empowering Plans</p> </center> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7444c0" style="text-align: justify;">• On March 31, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff744390" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p159-putting-the-patient-first-challenges-to-common-tpa-operations">“Putting the Patient First: Challenges to Common TPA Operations,”</a> in which our hosts, Katie Malkin and Jon Jablon, discussed three aspects of TPA operations designed to try to make the TPA's job more manageable. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed885b50" style="text-align: justify;">• On March 17, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff744260" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p158-seek-and-ye-shall-find">“Seek and Ye Shall Find,”</a> in which our hosts, Chris Aguiar and Cindy Merrell, discussed how, particularly regarding auto accidents involving participants with substandard coverage, there is greater need to capitalize on opportunities for plans to recover funds. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff744130" style="text-align: justify;">• On March 3, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff744000" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p157-new-tpa-liabilities-section-1557">“New TPA Liabilities – Section 1557,”</a> in which our hosts, Brady Bizarro and Andrew Silverio, discussed a recent federal court case whereby a TPA was found liable for violations of ACA’s Section 1557. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7469c0" style="text-align: justify;">• On February 16, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff746d30" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p156-accommodating-reasonably-navigating-the-ada-and-pwfa-in-2023">“Accommodating Reasonably: Navigating the ADA and PWFA in 2023,”</a> in which our hosts, Kelly Dempsey and Kevin Brady, discussed the reasonable accommodation process under ADA and PWFA. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff746c00" style="text-align: justify;">• On February 10, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff746f90" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p155-the-state-of-the-union-2023-phias-take">“The State of the Union 2023: Phia’s Take,”</a> in which our hosts, Ron Peck and Brady Bizarro, discussed the president’s speech, providing you with their reaction and analysis, and explained what you should be watching this year. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7470c0" style="text-align: justify;">• On February 3, 2023, The Phia Group presented<a data_liveedit_tagid="0x00007f91ff746e60" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p154-no-ordinary-time-in-healthcare"> “No Ordinary Time in Healthcare,” </a>in which our hosts, Corey Crigger and Nick Bonds, discussed the ever-changing world of healthcare. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff747340" style="text-align: justify;">• On January 20, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff747800" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p153-living-up-to-expectations">“Living Up To Expectations,”</a> in which our hosts, Jen McCormick and Jon Jablon, discussed past predictions, their predictions for 2023, and what the best health plans need to do to stay ahead of the game this year! </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff747470" style="text-align: justify;">• On January 5, 2023, The Phia Group presented <a data_liveedit_tagid="0x00007f91ff747930" href="https://www.phiagroup.com/Media/Posts/empowering-plans-p152-the-contemporary-fiduciary-emerging-law-on-an-old-topic">“The Contemporary Fiduciary: Emerging Law on an Old Topic,”</a> in which our hosts, Katie MacLeod and Jon Jablon, discussed fiduciary status, both traditionally and in the new age of self-funding.</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff747cc0">Be sure to check out all of <a data_liveedit_tagid="0x00007f91ff747df0" href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff748510"><a data_liveedit_tagid="0x00007f91ff748640" href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" data_liveedit_tagid="0x00007f91ed890640" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" style="width: 491px; height: 121px;" /></a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7489d0"><br data_liveedit_tagid="0x00007f91ed88ead0" /> <a data_liveedit_tagid="0x00007f91ff748770" href="#top">Back to top ^</a></p> <hr class="horiz" data_liveedit_tagid="0x00007f91ed88da70" /> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7488a0"><span class="heading1" data_liveedit_tagid="0x00007f91ff748b00"><a data_liveedit_tagid="0x00007f91ff748c30" id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff748d60" style="text-align: justify;">• BenefitsPro – <a data_liveedit_tagid="0x00007f91ff749220" href="https://www.benefitspro.com/2023/03/22/the-relevance-of-network-reimbursement-rates-to-mental-health-parity-compliance/">The relevance of network reimbursement rates to mental health parity compliance</a> – March 22, 2023 </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff749480" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a data_liveedit_tagid="0x00007f91ff749e80" href="https://www.sipconline.net/files/Extended_Telehealth_Relief_For_HSA_Plans_by_Andrew_Silverio%2C_Esq.pdf">Extended Telehealth Relief For HSA Plans</a> – February 5, 2023 </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff74a470">• BenefitsPro – <a data_liveedit_tagid="0x00007f91ff7496e0" href="https://www.benefitspro.com/2023/01/11/health-care-2022-challenges-and-opportunities-in-the-years-ahead/">Health care 2022: Challenges and opportunities in the years ahead</a> – January 11, 2023<br data_liveedit_tagid="0x00007f91ed88d590" /> <br data_liveedit_tagid="0x00007f91ed88d350" /> <a data_liveedit_tagid="0x00007f91ff74c400" href="#top">Back to top ^</a></p> <hr class="horiz" data_liveedit_tagid="0x00007f91ed88ad70" /> <p class="bodytext" data_liveedit_tagid="0x00007f91ff74b730"><span class="heading1" data_liveedit_tagid="0x00007f91ff74b270"><a data_liveedit_tagid="0x00007f91ff74d6a0" id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1" data_liveedit_tagid="0x00007f91ff74d570"></span><br data_liveedit_tagid="0x00007f91ed889f50" />  </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff74e350" style="text-align: justify;">• <a data_liveedit_tagid="0x00007f92147cfe20" href="https://www.phiagroup.com/Media/Posts/price-transparency-a-chief-concern-at-siias-recent-kanas-city-forum">Price Transparency: A Chief Concern at SIIA’s Recent Kanas City Forum</a>. A look into SIIA’s Price Transparency Forum. </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147d2900" style="text-align: justify;">• <a data_liveedit_tagid="0x00007f92147b5b80" href="https://www.phiagroup.com/Media/Posts/the-state-of-paid-fmla-thirteen-states-and-counting">The State of Paid FMLA: Thirteen States and Counting</a>. Thirteen states and the District of Columbia have enacted paid family leave. </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147b5cb0" style="text-align: justify;">• <a data_liveedit_tagid="0x00007f92147b5de0" href="https://www.phiagroup.com/Media/Posts/no-matter-the-remedy-no-language-no-luck">No Matter the Remedy – No Language, No Luck!</a> If your language is lacking, so too will your remedies. </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147d62a0" style="text-align: justify;">• <a data_liveedit_tagid="0x00007f92147d6170" href="https://www.phiagroup.com/Media/Posts/accommodating-pregnant-workers-enhanced-protections-under-new-legislation">Accommodating Pregnant Workers: Enhanced Protections Under New Legislation</a>. How much do you know about the Consolidated Appropriations Act of 2023? </p> <p class="bodytext" data_liveedit_tagid="0x00007f92147d7560" style="text-align: justify;">• <a data_liveedit_tagid="0x00007f92147d71b0" href="https://www.phiagroup.com/Media/Posts/new-year-new-rules-but-dont-forget-about-the-old-ones">New Year, New Rules – But Don’t Forget About the Old Ones.</a> Go into the new year knowledgeable about new rules.</p> <p class="bodytext" data_liveedit_tagid="0x00007f92147deed0">To stay up to date on other industry news, please <a data_liveedit_tagid="0x00007f92147d9150" href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br data_liveedit_tagid="0x00007f91ed888e90" /> <br data_liveedit_tagid="0x00007f91ed888b20" /> <a data_liveedit_tagid="0x00007f92147deb40" href="#top">Back to top ^</a><span class="heading1" data_liveedit_tagid="0x00007f9214346d80"><a data_liveedit_tagid="0x00007f9214346310" id="pstacks" name="pstacks"></a></span></p> <hr class="horiz" data_liveedit_tagid="0x00007f91ed888310" /> <p class="bodytext" data_liveedit_tagid="0x00007f9214346440"><span class="heading1" data_liveedit_tagid="0x00007f9214346d80">The Stacks:</span></p> <p class="bodytext" data_liveedit_tagid="0x00007f92143481a0"><strong data_liveedit_tagid="0x00007f9214347bb0">Extended Telehealth Relief for HSA Plans</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f9214349370" style="text-align: justify;">By: Andrew Silverio, Esq. – February 2023 – <a data_liveedit_tagid="0x00007f9214349f50" href="https://www.sipconline.net/files/Extended_Telehealth_Relief_For_HSA_Plans_by_Andrew_Silverio%2C_Esq.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" data_liveedit_tagid="0x00007f9214349110" style="text-align: justify;">The COVID-19 pandemic has led to many practical and regulatory challenges for self-funded plans and those serving them. Most of these regulatory changes create important protections for plan participants but create significant burdens and potential exposure for plans – including significant expansions to COBRA rights under the American Rescue Plan Act of 2021, vaccine and testing mandates under the FFCRA and CARES Act, and extension of plan deadlines relating to claim submission, appeals, enrollment, and COBRA.  </p> <p class="bodytext" data_liveedit_tagid="0x00007f921434a7a0"><a data_liveedit_tagid="0x00007f921434ac60" href="https://www.phiagroup.com/Media/Posts/the-stacks-2nd-quarter-2023-newsletter">Click here</a> to read the rest of this article<br data_liveedit_tagid="0x00007f9214352250" /> <br data_liveedit_tagid="0x00007f9214350690" /> <a data_liveedit_tagid="0x00007f921434b7a0" href="#top">Back to top ^</a><span class="heading1" data_liveedit_tagid="0x00007f921434ca80"><a data_liveedit_tagid="0x00007f921434d840" id="pcharity" name="pcharity"></a></span></p> <hr class="horiz" data_liveedit_tagid="0x00007f921434eb40" /> <p class="bodytext" data_liveedit_tagid="0x00007f921434ba00"><span class="heading1" data_liveedit_tagid="0x00007f921434ca80">The Phia Group's 2023 Charity</span></p> <p class="bodytext" data_liveedit_tagid="0x00007f921434dd00" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" data_liveedit_tagid="0x00007f921434e7b0" style="font-weight: normal; text-align: justify;">The Phia Group's 2023 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" data_liveedit_tagid="0x00007f921434e1c0" style="font-weight: normal; text-align: justify;"><img alt="" data_liveedit_tagid="0x00007f921434c840" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br data_liveedit_tagid="0x00007f9214346900" /> <br data_liveedit_tagid="0x00007f9214345f90" /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" data_liveedit_tagid="0x00007f921434daa0" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" data_liveedit_tagid="0x00007f921434e420" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. </p> <p data_liveedit_tagid="0x00007f921434f0f0" style="text-align: justify;"><span class="bodytext"></span></p> <p class="bodytext" data_liveedit_tagid="0x00007f9214350560" style="text-align: justify;"><strong data_liveedit_tagid="0x00007f9214350b30">The Leukemia and Lymphoma Society</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f9214351470" style="font-weight: normal; text-align: justify;">The Phia Group’s Louisville-based employees, Rebekah McGuire-Dye, Cindy Merrell, and Corey Crigger, and their wonderful relatives, represented our company with style at The Leukemia and Lymphoma Society (LLS)’s Student Visionaries of the Year Grand Finale Celebration, held at the Kentucky Derby Museum. The Phia Group is heavily invested in LLS and looks forward to continue supporting the noble organization by participating in the upcoming “Big Climb” event and fundraiser (May 13 at 1 Beacon St., Boston). Please see the following link to learn more about how LLS performs lifesaving blood cancer research for patients worldwide.</p> <img alt="" data_liveedit_tagid="0x00007f92147c2fa0" src="/Portals/phiagroup/Newsletters/Q2 2023/lym3.jpg?ver=QSpaObu_Xf9_4VGHIN-9EA%3d%3d" style="width: 372px; height: 464px;" /><span class="heading1" data_liveedit_tagid="0x00007f91ed886930"><a id="pemployee" name="pemployee"></a></span> <p data_liveedit_tagid="0x00007f91ed884850"><a data_liveedit_tagid="0x00007f9214352f60" href="#top">Back to top ^</a></p> <hr class="horiz" data_liveedit_tagid="0x00007f92147afcf0" /> <p class="bodytext" data_liveedit_tagid="0x00007f91ed885ee0"><span class="heading1" data_liveedit_tagid="0x00007f91ed886930">Phia News: Get to Know Our Employee of the Quarter:<br data_liveedit_tagid="0x00007f92147b0190" /> Emily Rodriguez</span></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed887180" style="text-align: justify;">Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed8866d0" style="text-align: justify;">The Phia Explore team has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Emily Rodriguez as The Phia Group’s 2023 Q1 Employee of the Quarter! </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed8878a0" style="text-align: justify;">Here is one person’s comments about Emily: “Above and beyond is the first thing that comes to mind when I think of Emily's work ethic. She will always put the success of the company over anything else - she has met with clients off-business hours, accepts every role and request thrown in the direction of PGC, and all the while acts as a mentor for her team. No matter what happens, she will always be understanding of every situation. She will always bring a friendly "can-do" attitude and swiftly assess how to solve any matter at hand. As she is the point of contact for many clients under PGC, I can think of nobody more suited to act as the face of Phia.”</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed886f20"><img alt="" data_liveedit_tagid="0x00007f92147cf720" src="/Portals/phiagroup/Newsletters/Q2 2023/emily3.jpg?ver=f8Il_19D6XCZ5bF2jSnu9A%3d%3d" style="width: 490px; height: 420px;" /></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed887f80"> </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed887640">Congratulations Emily, and thank you for your many current and future contributions.</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed8895f0"><span class="heading1" data_liveedit_tagid="0x00007f91ed889980"><a data_liveedit_tagid="0x00007f91ed889ab0" id="p11" name="p11"></a></span></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88a9e0"><strong data_liveedit_tagid="0x00007f91ed88b320">Valentine’s Day at Phia</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88b450" style="font-weight: normal; text-align: justify;">The Phia Family celebrated Valentine’s Day by hosting a contest to see who could guess how many candy hearts were in the jar below; one person submitted a very close guess. The jar had 737 candy hearts, and Irene Yalch guessed 732 candy hearts.</p> <img alt="" data_liveedit_tagid="0x00007f91ff74a6d0" src="/Portals/phiagroup/Newsletters/Q2 2023/hearts3.jpg?ver=7cwbN61lIWfnZ5lIRUIQrQ%3d%3d" style="width: 539px; height: 628px;" /> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88b7e0"><strong data_liveedit_tagid="0x00007f91ed88ba40">Saint Patrick’s Day at Phia</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88cc70" style="font-weight: normal; text-align: justify;">The Phia Family celebrated Saint Patrick’s Day by hosting a contest to see who had the best luck of the Irish! Employees guessed how many M&M’s were in the jar below, and one lucky person submitted a guess that was one off. The jar had 947 M&M’s, and Matthew Painten guessed 946 M&M’s.</p> <img alt="" data_liveedit_tagid="0x00007f91ff746af0" src="/Portals/phiagroup/Newsletters/Q2 2023/stpats3.jpg?ver=0rzouXXydknfnXxIzzp4kw%3d%3d" style="width: 521px; height: 570px;" /><span class="heading1" data_liveedit_tagid="0x00007f91ed88e740"><a data_liveedit_tagid="0x00007f91ff7adf80" id="pnews" name="pnews"></a></span> <hr class="horiz" data_liveedit_tagid="0x00007f91ff746520" /> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88c1c0"><span class="heading1" data_liveedit_tagid="0x00007f91ed88e740">Job Opportunities:</span></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88df10">• Claim and Case Support Analyst </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88f5a0">• Human Resources Generalist </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed88ff20">• Customer Service Representative </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed890f60">• EDI Data Engineer</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed890510">See the latest job opportunities, here: <a data_liveedit_tagid="0x00007f91ed891f30" href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a8e30"><a data_liveedit_tagid="0x00007f91ff7a9090" id="pcert" name="pcert"></a></p> <span class="boldtext" data_liveedit_tagid="0x00007f91ed892d30">Promotions</span> <p class="bodytext" data_liveedit_tagid="0x00007f91ed892e60" style="text-align: justify;">• Lisa Hill has been promoted from Senior Subrogation Attorney to Managing Attorney, Subrogation Services. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed893ce0" style="text-align: justify;">• Kaycee O’Toole has been promoted from Case Investigator to Claim Recovery Specialist IV. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ed893820" style="text-align: justify;">• Elizabeth Pels has been promoted from Subrogation Implementation Specialist, Recovery Services to Manager, Recovery Service Onboard & Support. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7582f0" style="text-align: justify;">• Olesya Avramenko has been promoted from Health Benefit Plan Consultant II to Health Benefit Plan Consultant III. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff755000" style="text-align: justify;">• Corrie Cripps has been promoted from Health Benefit Plan Consultant II to Health Benefit Plan Consultant III. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff75b300" style="text-align: justify;">• Ulyana Bevilacqua has been promoted from Manager, Drafting Services to Senior Manager, Drafting Services. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7581c0" style="text-align: justify;">• Sarah Ingle has been promoted from Claim Recovery Specialist IV to Sr. Claim Recovery Specialist. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff75ccc0" style="text-align: justify;">• Skyla Mrosk has been promoted from Claim Analyst to Senior Claim Analyst. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff75c470" style="text-align: justify;">• Emily King has been promoted from Customer Care Representative to Claim Analyst.</p> <p class="bodytext" data_liveedit_tagid="0x00007f921498bff0"><strong data_liveedit_tagid="0x00007f91ff75e6e0">New Hires</strong></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff75d640">• Ania Russo was hired as Specialist Projects Coordinator. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff761fd0">• Joanie Verinder was hired as Director, Service Strategist. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7611c0">• Denise Aubrey was hired as Director, Subrogation Implementation. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff763ed0">• Ernestine Cherubin was hired as Accounting Temp. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff762230">• Harman Singh was hired as Sr. Software Engineer. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a63b0">• Joanna Marden was hired as Customer Service Rep. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a64e0">• Richard Harrison was hired as Sr. Accountant. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a6cf0">• Saheed Yussuff was hired as Accounting Administrator. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a5de0">• Deonte Small was hired as Accounting Assistant. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a9b20">• Bharat Bogelli was hired as Business Analyst. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a8250">• Kendall Jackson was hired as Health Benefit Plan Consulting Attorney. </p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7abbe0">• Nicholas Walsh was hired as Case Investigator.</p> <p class="boldtext" data_liveedit_tagid="0x00007f91ff7afdc0">Phia Attending the SIIA National Conference</p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7b1150" style="font-weight: normal">Several of Phia’s industry experts will attend SIIA’s National Conference in Phoenix, Arizona, from October 8th – 10th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: <a data_liveedit_tagid="0x00007f91ff7b3fa0" href="https://siiaconferences.org/nationalconference/2023/index.cfm">https://siiaconferences.org/nationalconference/2023/index.cfm</a>. </p> <a name="story"></a><a name="story"></a> <hr class="horiz" data_liveedit_tagid="0x00007f91ff745d10" /> <a name="story"> </a> <a name="story"> </a> <p class="bodytext" data_liveedit_tagid="0x00007f91ff796670" style="text-align: justify;"><a name="story"><span style="color:#000000;"><strong data_liveedit_tagid="0x00007f91ff796a00">The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong></span><br data_liveedit_tagid="0x00007f91ff7450b0" /> <br data_liveedit_tagid="0x00007f91ff744d10" /> <span style="color:#000000;">At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements. </span></a><span style="color:#000000;"></span></p> <p style="text-align: justify;"><span style="color:#000000;"> </span><a name="story"><span style="color:#000000;"> </span></a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7962e0" style="text-align: justify;"><a name="story"><span style="color:#000000;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. </span></a></p> <p style="text-align: justify;"><span style="color:#000000;"> </span><a name="story"><span style="color:#000000;"> </span></a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff7975e0" style="text-align: justify;"><a name="story"><span style="color:#000000;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality. </span></a></p> <p style="text-align: justify;"><span style="color:#000000;"> </span><a name="story"><span style="color:#000000;"> </span></a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff797e10" style="text-align: justify;"><a name="story"><span style="color:#000000;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion. </span></a></p> <a name="story"> </a> <p class="bodytext" data_liveedit_tagid="0x00007f91ff798970"><a name="story"><strong data_liveedit_tagid="0x00007f91ff799420"></strong></a></p> <a name="story"> </a> <p class="bodytext" data_liveedit_tagid="0x00007f91ff799e70"><a name="story"></a><br data_liveedit_tagid="0x00007f91ff742710" /> <a data_liveedit_tagid="0x00007f91ff79c320" href="#top">Back to top ^</a></p> <p class="bodytext" data_liveedit_tagid="0x00007f91ff79b020" style="text-align: center"><img data_liveedit_tagid="0x00007f9214980c60" src="/Portals/phiagroup/Q4 2017 Newsletter/footerlogo.png?ver=4DNYnYNm_73szM3RBRt7Qw%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr data_liveedit_tagid="0x00007f91ff79be60"> <td bgcolor="#4a85d3" colspan="2" data_liveedit_tagid="0x00007f91ff79ca20"> <table border="0" cellpadding="5" cellspacing="5" data_liveedit_tagid="0x00007f91ff79c6b0" width="100%"> <tbody> <tr data_liveedit_tagid="0x00007f91ff79d010"> <td class="whitetext" data_liveedit_tagid="0x00007f91ff79e1e0"><a class="whitetext" data_liveedit_tagid="0x00007f91ff7a24e0" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br data_liveedit_tagid="0x00007f92147cd350" /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <dw-container-div> <script src="/static/files/deviceClientScript.js"></script> <script src="/static/files/IOSScrolling.js"></script> <script src="/static/files/HTMLDOMDiff.js"></script> <script src="/static/files/HTMLSimpleDOM.js"></script> <script src="/static/files/HTMLTokenizer.js"></script> <script src="/static/files/murmurhash3_gc.js"></script> <script src="/static/files/RemoteFunctions.js"></script> <script src="/static/files/LiveUpdateTools.js"></script> <script>$dwJQuery = window.parent.$; window.DevicePreview_RenderSuccess = true; DW_LiveEdit_SetupDoc('<!DOCTYPE html PUBLIC "-\/\/W3C\/\/DTD XHTML 1.0 Transitional\/\/EN" "http:\/\/www.w3.org\/TR\/xhtml1\/DTD\/xhtml1-transitional.dtd">\n<html xmlns="http:\/\/www.w3.org\/1999\/xhtml" data_liveedit_tagid="0x00007f92147db250">\n<head data_liveedit_tagid="0x00007f91ff79ff40">\n<meta http-equiv="Content-Type" content="text\/html; charset=UTF-8" data_liveedit_tagid="0x00007f91ff780020" \/>\n<title data_liveedit_tagid="0x00007f921422b950">Phia Group Newsletter 4th Quarter<\/title>\n<style type="text\/css" data_liveedit_tagid="0x00007f91ff7811d0">\n.header {\n font-family: Verdana, Geneva, sans-serif;\n font-weight: normal;\n color: #FFF;\n}\na:link {\n color: #2d67a1;\n}a:visited {\n color: #2d67a1;\n}\na:hover, a:active {\n color: #2d67a1;\n}\n.bodytext {\n font-size: 10px;\n}\n.bodytext {\n font-size: 12px;\n}\n.bodytext {\n font-family: Verdana, Geneva, sans-serif;\n}\n.heading1 {\n font-family: Verdana, Geneva, sans-serif;\n font-size: 18px;\n}\nhr.style1{\n border-top-width: 4px;\n border-top-style: solid;\n border-top-color: #2d67a1;\n}\n.horiz {\n}\n\n.toc {\n font-family: Verdana, Geneva, sans-serif;\n color: #039;\n line-height: 24px;\n text-decoration: underline;\n}\n.whitetext {\n font-family: Verdana, Geneva, sans-serif;\n font-size: 12px;\n color: #FFF;\n}\n.horiz {\n border-top-width: 4px;\n border-top-style: solid;\n border-right-style: none;\n border-bottom-style: none;\n border-left-style: none;\n border-top-color: #2d67a1;\n border-right-color: #2d67a1;\n border-bottom-color: #2d67a1;\n border-left-color: #2d67a1;\n}\n.tocbkgd {\n background-attachment: scroll;\n background-image: url(images\/tocbkgd.png);\n background-repeat: no-repeat;\n background-position: center center;\n}\n.boldtext {\n font-family: Verdana, Geneva, sans-serif;\n font-size: 12px;\n font-weight: bold;\n}\n.bodytextsm {\n font-size: 10px;\n}\n.fealinks {\n font-size: 16px;\n font-family: Verdana, Geneva, sans-serif;\n color: #FFF;\n text-decoration: none;\n}\n<\/style>\n<\/head>\n\n<body data_liveedit_tagid="0x00007f91ff781430">\n<table width="650" border="0" align="center" cellpadding="0" cellspacing="0" data_liveedit_tagid="0x00007f91ff746760">\n <tr data_liveedit_tagid="0x00007f91ff746890">\n <td colspan="2" bgcolor="#4a85d3" data_liveedit_tagid="0x00007f91ff77fc90"><table width="90%" border="0" cellspacing="0" cellpadding="0" data_liveedit_tagid="0x00007f91ff77ed40">\n <tr data_liveedit_tagid="0x00007f91ff77d250">\n <td valign="bottom" bgcolor="#4a85d3" class="whitetext" style="text-align: right" data_liveedit_tagid="0x00007f91ff77d6d0"><p data_liveedit_tagid="0x00007f91ff77c410"><br data_liveedit_tagid="0x00007f91ff77f200" \/>\n Phone: 781-535-5600 | <a href="http:\/\/www.phiagroup.com" class="whitetext" style="color: #FFFFFF" data_liveedit_tagid="0x00007f91ff77ba90">www.phiagroup.com<\/a><br data_liveedit_tagid="0x00007f91ff77e620" \/>\n <\/p><\/td>\n <\/tr>\n <\/table><\/td>\n <\/tr>\n <tr data_liveedit_tagid="0x00007f91ff77b700">\n <td colspan="2" data_liveedit_tagid="0x00007f91ff7798f0"><img src="images\/newheader3.jpg" width="650" height="451" data_liveedit_tagid="0x00007f91ff77e180" \/><\/td>\n <\/tr>\n <tr data_liveedit_tagid="0x00007f91ff779a20"> <\/tr>\n <tr data_liveedit_tagid="0x00007f91ff778230">\n <td width="312" valign="top" data_liveedit_tagid="0x00007f91ff777c40"><a href="#russo4" data_liveedit_tagid="0x00007f91ff775260"><img src="images\/block0422l.png" width="325" height="216" data_liveedit_tagid="0x00007f91ff77aed0" \/><\/a><\/td>\n <td width="323" valign="top" data_liveedit_tagid="0x00007f92147be650"><a href="#pace3" data_liveedit_tagid="0x00007f92147b7250"><img src="images\/block0422r.png" width="325" height="216" data_liveedit_tagid="0x00007f91ff77a710" \/><\/a><\/td>\n <\/tr>\n <tr data_liveedit_tagid="0x00007f92147b74b0">\n <td colspan="2" data_liveedit_tagid="0x00007f92147cdcb0"><table width="100%" border="0" cellspacing="2" cellpadding="0" data_liveedit_tagid="0x00007f92147ccd60"><\/table>\n <tr data_liveedit_tagid="0x00007f91ff7590d0">\n <td width="47%" valign="top" data_liveedit_tagid="0x00007f91ff75b0c0">\n <p data_liveedit_tagid="0x00007f91ff757ce0"><br data_liveedit_tagid="0x00007f91ff778ab0">\n <img src="images\/adam.jpg" width="264" height="255" data_liveedit_tagid="0x00007f91ff7762e0" \/><\/p>\n <\/td>\n <td width="53%" valign="top" data_liveedit_tagid="0x00007f92147c8c70"><p class="bodytext" data_liveedit_tagid="0x00007f92147c81e0"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147c7d60"><span class="heading1" style="font-size: 14px; font-weight: bold;" data_liveedit_tagid="0x00007f92147c6360">The Book of Russo: <br data_liveedit_tagid="0x00007f92147c8da0">\n <\/span><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147bfe40">I love April. Between the New England winter finally loosening its grip, my birthday, Easter (including hiding easter eggs around my yard at 4 a.m. when it’s 35 degrees outside), and yes…OPENING DAY FOR THE CLEVELAND GUARDIANS (and some other teams, I guess) – in my opinion, you can’t beat this month! It’s also the beginning of conference season. In fact, I just got back from SIIA’s event in Orlando, where we saw not only the largest crowd since the pandemic began – but perhaps the best attendance I can remember, period. The industry is changing for the better, as TPAs realize that certain technology and member communication are the keys to ensure the self-insured industry enjoys growth and expansion, now – and in the future. <br data_liveedit_tagid="0x00007f92147c79f0" \/>\n <table width="100%" border="0" cellspacing="0" cellpadding="0" data_liveedit_tagid="0x00007f92147bf370">\n \n <\/table>\n \n <tr data_liveedit_tagid="0x00007f921497cca0">\n <td colspan="2" valign="top" data_liveedit_tagid="0x00007f9214971ee0">\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7ae7d0">I have never seen such proactive measures and such an upbeat attitude about our work, and what our future can bring. There are, however, risks all around us. Whether it’s a random gap between plan coverage and the applicable stop-loss policy, groups forcing products or vendors upon administrators that can’t coordinate with them, services being advertised to witless employers one way whilst the reality is far different, rigid contracts and processes eliminating customization, and beyond… there are pitfalls around every corner. This is a major reason why The Phia Group is here for the industry. We love looking at new technologies and offerings that promise to reduce overall cost and increase quality outcomes, while remaining wary of cracks in the armor; ensuring a seamless implementation process that’s is never as easy as it seems. As always, we celebrate what is great about this industry, but continue to be on the lookout for threats. With that in mind, I hope you enjoy this newsletter, and the great insight from our staff. <\/p>\n \n<p class="bodytext" data_liveedit_tagid="0x00007f91ff7ad4d0">\n \n <a name="russo09" data_liveedit_tagid="0x00007f91ff762490"><\/a>\n <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ed88fb90">– Happy reading!<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88f470"> <\/p>\n \n\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88f6d0"> <\/p>\n <\/td>\n <tr data_liveedit_tagid="0x00007f91ed88a8b0">\n \n <td colspan="2" valign="top" bgcolor="#eeeeee" class="toc" data_liveedit_tagid="0x00007f91ed88a3f0"><table width="100%" border="0" cellspacing="10" cellpadding="5" data_liveedit_tagid="0x00007f91ed889390">\n <tr data_liveedit_tagid="0x00007f91ed884f70">\n <td data_liveedit_tagid="0x00007f9214353840"><p data_liveedit_tagid="0x00007f9214353090"><img src="images\/inthisissue.png" width="101" height="18" data_liveedit_tagid="0x00007f92147c5680" \/><\/p>\n <p class="tocbkgd" data_liveedit_tagid="0x00007f9214351ff0"><br data_liveedit_tagid="0x00007f92147c2c50" \/>\n <a href="#p1" data_liveedit_tagid="0x00007f921434ff70">Service Focuses of the Quarter<\/a><br data_liveedit_tagid="0x00007f92147c21e0" \/>\n <a href="#pftp" data_liveedit_tagid="0x00007f921434f350">Phia Fit to Print<\/a> <br data_liveedit_tagid="0x00007f92147c0780" \/>\n <a href="#pblog" data_liveedit_tagid="0x00007f921434cf40">From the Blogosphere<\/a><br data_liveedit_tagid="0x00007f91ff795f70" \/>\n <a href="#pwebinars" data_liveedit_tagid="0x00007f921434d2d0">Webinars<\/a><br data_liveedit_tagid="0x00007f91ff7a6740" \/>\n <a href="#ppodcast" data_liveedit_tagid="0x00007f92147ddf30">Podcasts<\/a><br data_liveedit_tagid="0x00007f91ff7a6040" \/>\n <a href="#pcharity" data_liveedit_tagid="0x00007f92147dd5d0">The Phia Group’s 2023 Charity<\/a><br data_liveedit_tagid="0x00007f91ff7a5710" \/>\n <a href="#pstacks" data_liveedit_tagid="0x00007f92147db840">The Stacks<\/a><br data_liveedit_tagid="0x00007f91ff7625c0" \/>\n <a href="#pemployee" data_liveedit_tagid="0x00007f92147dcb20">Employee of the Quarter<\/a><br data_liveedit_tagid="0x00007f91ff75fda0" \/>\n <a href="#pnews" data_liveedit_tagid="0x00007f92147b5460">Phia News<\/a><\/p><\/td>\n <\/tr>\n <\/table><\/td>\n <\/tr>\n <tr data_liveedit_tagid="0x00007f92147b6410">\n <td colspan="2" valign="top" data_liveedit_tagid="0x00007f92147d3140">\n \n <p class="heading1" data_liveedit_tagid="0x00007f91ff74cd20"><br data_liveedit_tagid="0x00007f91ff75f6a0" \/><\/a>\n \n \n \n \n \n<p class="bodytext" data_liveedit_tagid="0x00007f91ff745400"><strong data_liveedit_tagid="0x00007f91ff742d00">Service Focuses of the Quarter: Subrogation & Phia Unwrapped<\/strong> <\/p><p class="bodytext" data_liveedit_tagid="0x00007f91ff743c70"><strong data_liveedit_tagid="0x00007f91ff7ae440">Subrogation <\/strong> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147c1f80">At The Phia Group, we recognize that being prudent with plan assets entails recovering them whenever possible. Thus, we offer comprehensive subrogation recovery services that help our clients maximize recoveries, protect their plans’ best interests, and, most importantly, keep costs down. Our team of specialized recovery professionals, including attorneys, is widely considered to be the most experienced in the self-funded industry. Having vast industry experience even outside of subrogation and expertly crafted plan language that reflects the current state of the law and this ever-changing industry allows us to review existing plans and customize subrogation rights and other language to fit our clients\' needs. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f9214980410">Our subrogation services involve ordinary third-party accident cases (such as car accidents, slip and falls, etc.) and mass tort cases (such as products liability, toxic torts, etc.), and we place all high-dollar cases in our attorneys’ hands for optimal settlements. Our state-of-the-art analytics and advanced algorithms ensure robust case identification, and our case management process promotes efficiency. We also provide specialized reporting so our clients can manage their business. We understand what a comprehensive, optimally performing subrogation service is because we\'ve built one. Let us help you maximize your recoveries and protect your plan\'s best interests.\n \n <p class="bodytext" data_liveedit_tagid="0x00007f92147db970"><strong data_liveedit_tagid="0x00007f92149729a0">Phia Unwrapped <\/strong> <\/p>\n \n <p class="bodytext" data_liveedit_tagid="0x00007f921436dd60">Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited rights. With Phia Unwrapped, we replace wrap network access and modify non-network payment methodologies, securing payable amounts based upon fair market parameters that are unbeatably low.<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f921422a190">Phia Unwrapped places no minimum threshold on claims to be repriced or potential balance billing to be negotiated, and The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed889000">Phia Unwrapped implementation entails setting up an EDI feed with the claims administrator, so claims are flagged, transferred, and repriced automatically. Phia Unwrapped is billed based on a percentage of actual savings, leading to fair rates and no excessive costs for unprecedented savings – and if there’s pushback or balance-billing, our Provider Relations team will handle it. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f921436bfc0">Out-of-network claims that run through Phia Unwrapped yield a whopping average savings of 74% off billed charges (three times the average wrap discount). On average, The Phia Group sees roughly 2% of claims result in balance-billing; these results are similar throughout different plan types and locations, proving that this program and these results can be replicated nationwide. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147badc0">Per our data, Phia Unwrapped has yielded significantly better savings than wrap networks. Can you and your clients afford to maintain the status quo given such results? <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147bb020">Contact Garrick Hunt, at <a href=" mailto:GHunt@phiagroup.com" data_liveedit_tagid="0x00007f92147bb280">GHunt@phiagroup.com<\/a> to learn more about The Phia Group’s Subrogation and Phia Unwrapped services. \n \n \n  <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f92147bb4e0"> <\/p><a name="russo4" data_liveedit_tagid="0x00007f91ff7a4e10"><\/a>\n \n <p class="bodytext" data_liveedit_tagid="0x00007f92147dbf40"><strong data_liveedit_tagid="0x00007f92147d56e0">Phia Case Study: Gag Clause Attestations<\/strong><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff75ae60">The Consolidated Appropriations Act made many changes for health plans, including prohibiting so-called gag clauses, which are contractual provisions prohibiting a plan from disclosing information involving cost of healthcare services or availability of lower-cost alternatives. This prohibition is intended to increase healthcare transparency and empower patients to make more informed decisions – but, ironically, the law applies to health plans. In other words, while providers suggest gag clauses, health plans are prohibited from agreeing to them, resulting in a strange contractual dynamic. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147b0430">A TPA utilizing Phia’s ICE service approached the consulting team hoping to receive an affirmation of its current process regarding the relatively new requirement for health plans to submit “gag clause” attestations. Specifically, although the requirement applies to the plan itself, the TPA tried to make things easier for its plans and offered to submit gag clause attestations for its clients for a nominal fee. When we asked how the TPA verifies the lack of gag clauses, we were told that they do not, and affirmations are submitted on a given plan’s request, even without asking the plan to prove or even verify it! <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147c0520">;We immediately cautioned against that practice, because although the TPA’s ASA had a broad indemnification provision, we know from experience that when a regulatory body finds fault with a particular plan’s operations, it also often takes a deep dive into the TPA’s operations on a larger scale as well, under the theory that the TPA’s actions often facilitate or promote the plan’s actions. We’ve seen this lately, particularly regarding mental health parity. If a TPA submits a gag clause attestation on behalf of a health plan and that attestation is ultimately imperfect, the TPA may be indemnified by the plan, but it’s a better idea for the TPA to at least confirm that the attestation is correct prior to submitting it. Furthermore, an audit of the TPA’s processes is burdensome.  <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f921422ab10">Proactively verifying accuracy of a gag clause attestation may be slightly more work, but anecdotally, protecting yourself is worth it! (Of course, Phia can help review contracts if necessary.) <\/p>\n<a name="pace3" data_liveedit_tagid="0x00007f92147bf980"><\/a>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff79efd0"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f9214229cd0"><strong data_liveedit_tagid="0x00007f92147c6490">Fiduciary Burden of the Quarter: Mental Health Parity – Past and Future<\/strong> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff744f80">It’s old news that health plans subject to Mental Health Parity and Addiction Equity Act must perform a nonquantitative treatment limitations analysis, intended to document a plan’s compliance with the law’s parity aspects. This has become an important plan function, and plan administrators must disclose the report per normal plan disclosures. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7ad100">There are many nuances involved in performing an NQTL analysis, which many readers may have experienced; for example, while plans are struggling to comply with mental health parity, they are updating documents and processes in the normal course of business and in response to unearthed parity concerns – but to perform a given analysis, the plan must travel back in time and report on what was the case, rather than what is now the case. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff75a020">The result? Many health plans want to have their NQTL analyses performed after they have updated their SPDs to change or remove noncompliant provisions. The logic makes sense: once a compliance issue was discovered and fixed, why would the plan want to perform an analysis of a version that is now old and defunct?! After all, plans understandably want to do whatever possible to get a “passing” grade on the analysis report.<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed887bf0">Unfortunately, though, that’s not what regulators look for, and not what health plans have been directed to do. An analysis is specifically designed to review the plan’s historical compliance, which is bolstered by the idea that analysis must also include data regarding the plan’s operational compliance. Updating SPDs is always good, but an NQTL analysis can’t scrutinize a new plan document that didn’t exist during the testing period, just as the analysis can’t inspect future operational data, since by definition it doesn’t exist at any given time either. When an SPD is updated, it’s updated for the future, not for the past, so the NQTL analysis needs to rely on the SPD that was in place in the past. The report can certainly document what changes were made after the testing period, which goes a long way if there’s an audit, but the report must nonetheless discuss the past.\n \n \n \n \n .<\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff7425e0"> <\/p>\n <hr class="horiz" data_liveedit_tagid="0x00007f91ff75ee00" \/>\n \n _<\/a>\n <\/p>\n \n \n <br data_liveedit_tagid="0x00007f91ff755720" \/><a name="pdef" data_liveedit_tagid="0x00007f9214351c60"><\/a>\n \n \n \n<\/p>\n <p class="heading1" data_liveedit_tagid="0x00007f91ff742820"><a name="p5" id="p5"><a name="pwebinars" id="pwebinars" data_liveedit_tagid="0x00007f92147d9720"><\/a>Webinars:<\/p>\n \n \n <p class="bodytext" data_liveedit_tagid="0x00007f91ff775830">• On February 15, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/love-is-in-the-healthcare" data_liveedit_tagid="0x00007f91ff742e30">“Love is in the (Health)Care!,”<\/a> in which we discussed important issues, best practices, and case studies. From disputes with providers, to subrogation, to regulatory updates, and beyond. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff744be0">• On January 19, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/an-omnibus-edition-to-kick-off-2023" data_liveedit_tagid="0x00007f91ff744e20">“An Omnibus Edition to Kick Off 2023,”<\/a> in which we discussed The Consolidated Appropriations Act of 2023, its inclusion of protections for pregnant and nursing mothers, regulatory updates regarding the No Surprises Act, and manufacturer assistance programs. <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff7451c0">Be sure to check out all of our <a href="https:\/\/www.phiagroup.com\/Media\/Webinars" target="_blank" data_liveedit_tagid="0x00007f91ff745850">past webinars<\/a>! <\/p>\n <br data_liveedit_tagid="0x00007f91ed8929c0" \/>\n \n\n \n \n <p data_liveedit_tagid="0x00007f91ff746080"\/>\n <br data_liveedit_tagid="0x00007f91ed892650" \/>\n <\/li>\n <hr class="horiz" data_liveedit_tagid="0x00007f91ed890750" \/>\n <p class="heading1" data_liveedit_tagid="0x00007f91ff7461b0"><a name="ppodcast" id="ppodcast" data_liveedit_tagid="0x00007f91ff7463f0"><\/a>Podcasts:<\/p>\n <center data_liveedit_tagid="0x00007f91ff746630"><p class="heading1" data_liveedit_tagid="0x00007f91ff744830">Empowering Plans<\/p><\/center>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7444c0">• On March 31, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p159-putting-the-patient-first-challenges-to-common-tpa-operations" data_liveedit_tagid="0x00007f91ff744390">“Putting the Patient First: Challenges to Common TPA Operations,”<\/a> in which our hosts, Katie Malkin and Jon Jablon, discussed three aspects of TPA operations designed to try to make the TPA\'s job more manageable. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed885b50">• On March 17, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p158-seek-and-ye-shall-find" data_liveedit_tagid="0x00007f91ff744260">“Seek and Ye Shall Find,”<\/a> in which our hosts, Chris Aguiar and Cindy Merrell, discussed how, particularly regarding auto accidents involving participants with substandard coverage, there is greater need to capitalize on opportunities for plans to recover funds. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff744130">• On March 3, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p157-new-tpa-liabilities-section-1557" data_liveedit_tagid="0x00007f91ff744000">“New TPA Liabilities – Section 1557,”<\/a> in which our hosts, Brady Bizarro and Andrew Silverio, discussed a recent federal court case whereby a TPA was found liable for violations of ACA’s Section 1557. <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff7469c0">• On February 16, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p156-accommodating-reasonably-navigating-the-ada-and-pwfa-in-2023" data_liveedit_tagid="0x00007f91ff746d30">“Accommodating Reasonably: Navigating the ADA and PWFA in 2023,”<\/a> in which our hosts, Kelly Dempsey and Kevin Brady, discussed the reasonable accommodation process under ADA and PWFA. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff746c00">• On February 10, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p155-the-state-of-the-union-2023-phias-take" data_liveedit_tagid="0x00007f91ff746f90">“The State of the Union 2023: Phia’s Take,”<\/a> in which our hosts, Ron Peck and Brady Bizarro, discussed the president’s speech, providing you with their reaction and analysis, and explained what you should be watching this year. <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff7470c0">• On February 3, 2023, The Phia Group presented<a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p154-no-ordinary-time-in-healthcare" data_liveedit_tagid="0x00007f91ff746e60"> “No Ordinary Time in Healthcare,” <\/a>in which our hosts, Corey Crigger and Nick Bonds, discussed the ever-changing world of healthcare. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff747340">• On January 20, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p153-living-up-to-expectations" data_liveedit_tagid="0x00007f91ff747800">“Living Up To Expectations,”<\/a> in which our hosts, Jen McCormick and Jon Jablon, discussed past predictions, their predictions for 2023, and what the best health plans need to do to stay ahead of the game this year! <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff747470">• On January 5, 2023, The Phia Group presented <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/empowering-plans-p152-the-contemporary-fiduciary-emerging-law-on-an-old-topic" data_liveedit_tagid="0x00007f91ff747930">“The Contemporary Fiduciary: Emerging Law on an Old Topic,”<\/a> in which our hosts, Katie MacLeod and Jon Jablon, discussed fiduciary status, both traditionally and in the new age of self-funding. <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff747a60"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff747cc0">Be sure to check out all of <a href="https:\/\/www.phiagroup.com\/Media\/Podcasts" data_liveedit_tagid="0x00007f91ff747df0">our latest podcasts!<\/a><\/p>\n <p class="heading1" data_liveedit_tagid="0x00007f91ff747f20"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff748510"><a href="https:\/\/podcasts.apple.com\/us\/podcast\/the-phia-groups-podcast\/id1246462552?mt=2" data_liveedit_tagid="0x00007f91ff748640"><img src="images\/apple.png" width="491" height="121" alt="" data_liveedit_tagid="0x00007f91ed890640"\/><\/a><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff748050"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7489d0"><br data_liveedit_tagid="0x00007f91ed88ee40" \/>\n <br data_liveedit_tagid="0x00007f91ed88ead0" \/>\n <a href="#top" data_liveedit_tagid="0x00007f91ff748770">Back to top ^<\/a> <br data_liveedit_tagid="0x00007f91ed88e500" \/>\n <\/p>\n <hr class="horiz" data_liveedit_tagid="0x00007f91ed88da70" \/>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7488a0"><span class="heading1" data_liveedit_tagid="0x00007f91ff748b00"><a name="pftp" id="pftp" data_liveedit_tagid="0x00007f91ff748c30"><\/a>Phia Fit to Print:<\/span><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff748d60">• BenefitsPro – <a href="https:\/\/www.benefitspro.com\/2023\/03\/22\/the-relevance-of-network-reimbursement-rates-to-mental-health-parity-compliance\/" data_liveedit_tagid="0x00007f91ff749220">The relevance of network reimbursement rates to mental health parity compliance<\/a> – March 22, 2023 <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff749480">• Self-Insurers’ Publishing Corp. – <a href="https:\/\/www.sipconline.net\/files\/Extended_Telehealth_Relief_For_HSA_Plans_by_Andrew_Silverio%2C_Esq.pdf" data_liveedit_tagid="0x00007f91ff749e80">Extended Telehealth Relief For HSA Plans<\/a> – February 5, 2023 <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff749fb0">• BenefitsPro – <a href="https:\/\/www.benefitspro.com\/2023\/01\/11\/health-care-2022-challenges-and-opportunities-in-the-years-ahead\/" data_liveedit_tagid="0x00007f91ff7496e0">Health care 2022: Challenges and opportunities in the years ahead<\/a> – January 11, 2023 <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff74a470"><br data_liveedit_tagid="0x00007f91ed88d590" \/>\n <br data_liveedit_tagid="0x00007f91ed88d350" \/>\n <a href="#top" data_liveedit_tagid="0x00007f91ff74c400">Back to top ^<\/a> <br data_liveedit_tagid="0x00007f91ed88afb0" \/>\n<\/p>\n <hr class="horiz" data_liveedit_tagid="0x00007f91ed88ad70" \/>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff74b730"><span class="heading1" data_liveedit_tagid="0x00007f91ff74b270"><a name="pblog" id="pblog" data_liveedit_tagid="0x00007f91ff74d6a0"><\/a>From the Blogoshpere:<\/span><span class="heading1" data_liveedit_tagid="0x00007f91ff74d570"><br data_liveedit_tagid="0x00007f91ed889f50" \/>\n <br data_liveedit_tagid="0x00007f91ed889d10" \/>\n <\/span><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff74e350">• <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/price-transparency-a-chief-concern-at-siias-recent-kanas-city-forum" data_liveedit_tagid="0x00007f92147cfe20">Price Transparency: A Chief Concern at SIIA’s Recent Kanas City Forum<\/a>. A look into SIIA’s Price Transparency Forum. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147d2900">• <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/the-state-of-paid-fmla-thirteen-states-and-counting" data_liveedit_tagid="0x00007f92147b5b80">The State of Paid FMLA: Thirteen States and Counting<\/a>. Thirteen states and the District of Columbia have enacted paid family leave. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147b5cb0">• <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/no-matter-the-remedy-no-language-no-luck" data_liveedit_tagid="0x00007f92147b5de0">No Matter the Remedy – No Language, No Luck!<\/a> If your language is lacking, so too will your remedies. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147d62a0">• <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/accommodating-pregnant-workers-enhanced-protections-under-new-legislation" data_liveedit_tagid="0x00007f92147d6170">Accommodating Pregnant Workers: Enhanced Protections Under New Legislation<\/a>. How much do you know about the Consolidated Appropriations Act of 2023? <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147d7560">• <a href="https:\/\/www.phiagroup.com\/Media\/Posts\/new-year-new-rules-but-dont-forget-about-the-old-ones" data_liveedit_tagid="0x00007f92147d71b0">New Year, New Rules – But Don’t Forget About the Old Ones.<\/a> Go into the new year knowledgeable about new rules. <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f92147d95f0">To stay up to date on other industry news, please <a href="https:\/\/www.phiagroup.com\/Media\/Blog.aspx" target="_blank" data_liveedit_tagid="0x00007f92147d9150">visit our blog<\/a>.<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147dd370"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92147deed0"><br data_liveedit_tagid="0x00007f91ed888e90" \/>\n <br data_liveedit_tagid="0x00007f91ed888b20" \/>\n <a href="#top" data_liveedit_tagid="0x00007f92147deb40">Back to top ^<\/a> <br data_liveedit_tagid="0x00007f91ed888550" \/>\n <\/p>\n <hr class="horiz" data_liveedit_tagid="0x00007f91ed888310" \/>\n <p class="bodytext" data_liveedit_tagid="0x00007f9214346440"><span class="heading1" data_liveedit_tagid="0x00007f9214346d80"><a name="pstacks" id="pstacks" data_liveedit_tagid="0x00007f9214346310"><\/a>The Stacks:<\/span><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f92143481a0"><strong data_liveedit_tagid="0x00007f9214347bb0">Extended Telehealth Relief for HSA Plans<br data_liveedit_tagid="0x00007f9214353e10" \/>\n <br data_liveedit_tagid="0x00007f9214353bd0" \/>\n <\/strong> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f9214349370">By: Andrew Silverio, Esq. – February 2023 – <a href="https:\/\/www.sipconline.net\/files\/Extended_Telehealth_Relief_For_HSA_Plans_by_Andrew_Silverio%2C_Esq.pdf" data_liveedit_tagid="0x00007f9214349f50">Self-Insurers Publishing Corp.<\/a> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f9214349110">The COVID-19 pandemic has led to many practical and regulatory challenges for self-funded plans and those serving them. Most of these regulatory changes create important protections for plan participants but create significant burdens and potential exposure for plans – including significant expansions to COBRA rights under the American Rescue Plan Act of 2021, vaccine and testing mandates under the FFCRA and CARES Act, and extension of plan deadlines relating to claim submission, appeals, enrollment, and COBRA.\n \n \n  <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f9214349cf0"><a href="https:\/\/www.phiagroup.com\/Media\/Posts\/the-stacks-2nd-quarter-2023-newsletter" data_liveedit_tagid="0x00007f921434ac60">Click here<\/a> to read the rest of this article <br data_liveedit_tagid="0x00007f9214352b90" \/>\n <br data_liveedit_tagid="0x00007f9214352820" \/>\n <\/p>\n\n\n<\/p>\n<\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f921434a7a0"><br data_liveedit_tagid="0x00007f9214352250" \/>\n <br data_liveedit_tagid="0x00007f9214350690" \/>\n <a href="#top" data_liveedit_tagid="0x00007f921434b7a0">Back to top ^<\/a> <br data_liveedit_tagid="0x00007f921434eeb0" \/>\n<\/p>\n<hr class="horiz" data_liveedit_tagid="0x00007f921434eb40" \/>\n <p class="bodytext" data_liveedit_tagid="0x00007f921434ba00"><span class="heading1" data_liveedit_tagid="0x00007f921434ca80"><a name="pcharity" id="pcharity" data_liveedit_tagid="0x00007f921434d840"><\/a>The Phia Group\'s 2022 Charity<\/span> <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f921434dd00">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.<\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f921434e7b0">The Phia Group\'s 2023 charity is the Boys & Girls Club of Metro South. <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f921434e1c0"><img src="images\/boysgirls.png" width="472" height="220" alt="" data_liveedit_tagid="0x00007f921434c840"\/><br data_liveedit_tagid="0x00007f9214346900" \/>\n <br data_liveedit_tagid="0x00007f9214345f90" \/>\n The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.<\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f921434daa0">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club. <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f921434e420">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. <\/p>\n \n \n\n<p data_liveedit_tagid="0x00007f921434f0f0"> <span class="bodytext"><br data_liveedit_tagid="0x00007f92147de660" \/>\n \n \n \n \n<p class="bodytext" data_liveedit_tagid="0x00007f9214350560"><strong data_liveedit_tagid="0x00007f9214350b30">The Leukemia and Lymphoma Society<\/strong> <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f9214351470">The Phia Group’s Louisville-based employees, Rebekah McGuire-Dye, Cindy Merrell, and Corey Crigger, and their wonderful relatives, represented our company with style at The Leukemia and Lymphoma Society (LLS)’s Student Visionaries of the Year Grand Finale Celebration, held at the Kentucky Derby Museum. The Phia Group is heavily invested in LLS and looks forward to continue supporting the noble organization by participating in the upcoming “Big Climb” event and fundraiser (May 13 at 1 Beacon St., Boston). Please see the following link to learn more about how LLS performs lifesaving blood cancer research for patients worldwide.<\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f9214351800"> <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f9214352490"> <\/p>\n <img src="images\/lym3.jpg" width="372" height="464" alt="" data_liveedit_tagid="0x00007f92147c2fa0"\/> <br data_liveedit_tagid="0x00007f92147dd700" \/>\n \n <p class="bodytext" data_liveedit_tagid="0x00007f92143533c0"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed884260"> <\/p>\n<\/p>\n \n \n<p data_liveedit_tagid="0x00007f91ed884850"><a href="#top" data_liveedit_tagid="0x00007f9214352f60">Back to top ^<\/a> <br data_liveedit_tagid="0x00007f92147d5cd0" \/>\n <\/p>\n \n <p class="heading1" data_liveedit_tagid="0x00007f91ed885560"><br data_liveedit_tagid="0x00007f92147d5940" \/>\n<\/p>\n <hr class="horiz" data_liveedit_tagid="0x00007f92147afcf0" \/>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed885ee0"><span class="heading1" data_liveedit_tagid="0x00007f91ed886930"><a name="pemployee" id="pemployee" data_liveedit_tagid="0x00007f91ed885c80"><\/a>Phia News: Get to Know Our Employee of the Quarter:<br data_liveedit_tagid="0x00007f92147b0190" \/>\n Kelsey Dillon<\/span><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed887180">Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed8866d0">The Phia Explore team has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Emily Rodriguez as The Phia Group’s 2023 Q1 Employee of the Quarter! <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed8878a0">Here is one person’s comments about Emily: “Above and beyond is the first thing that comes to mind when I think of Emily\'s work ethic. She will always put the success of the company over anything else - she has met with clients off-business hours, accepts every role and request thrown in the direction of PGC, and all the while acts as a mentor for her team. No matter what happens, she will always be understanding of every situation. She will always bring a friendly "can-do" attitude and swiftly assess how to solve any matter at hand. As she is the point of contact for many clients under PGC, I can think of nobody more suited to act as the face of Phia.” <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ed886f20"><img src="images\/emily3.jpg" width="490" height="420" alt="" data_liveedit_tagid="0x00007f92147cf720"\/><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed887f80"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed887640">Congratulations Emily, and thank you for your many current and future contributions. <\/p>\n \n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f91ed8881e0"> <\/p>\n \n \n \n \n <p class="bodytext" data_liveedit_tagid="0x00007f91ed888790"> <\/p>\n<\/p>\n<p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f91ed8894c0"><p class="bodytext" data_liveedit_tagid="0x00007f91ed8895f0"><span class="heading1" data_liveedit_tagid="0x00007f91ed889980"><a name="p11" id="p11" data_liveedit_tagid="0x00007f91ed889ab0"><\/a><\/span><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88a9e0"><strong data_liveedit_tagid="0x00007f91ed88b320">Valentine’s Day at Phia<\/strong> <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f91ed88b450">The Phia Family celebrated Valentine’s Day by hosting a contest to see who could guess how many candy hearts were in the jar below; one person submitted a very close guess. The jar had 737 candy hearts, and Irene Yalch guessed 732 candy hearts.<\/p>\n\n\n <img src="images\/hearts3.jpg" width="539" height="628" alt="" data_liveedit_tagid="0x00007f91ff74a6d0"\/>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ed88b7e0"><strong data_liveedit_tagid="0x00007f91ed88ba40">Saint Patrick’s Day at Phia<\/strong> <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f91ed88cc70">The Phia Family celebrated Saint Patrick’s Day by hosting a contest to see who had the best luck of the Irish! Employees guessed how many M&M’s were in the jar below, and one lucky person submitted a guess that was one off. The jar had 947 M&M’s, and Matthew Painten guessed 946 M&M’s.<\/p>\n\n <img src="images\/stpats3.jpg" width="521" height="570" alt="" data_liveedit_tagid="0x00007f91ff746af0"\/>\n<hr class="horiz" data_liveedit_tagid="0x00007f91ff746520" \/>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88c1c0"><span class="heading1" data_liveedit_tagid="0x00007f91ed88e740"><a name="pnews" id="pnews" data_liveedit_tagid="0x00007f91ff7adf80"><\/a>Job Opportunities:<\/span> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88cb40"> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88df10">• Claim and Case Support Analyst <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88f5a0">• Human Resources Generalist <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed88ff20">• Customer Service Representative <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed890f60">• EDI Data Engineer <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ed890510">See the latest job opportunities, here: <a href="https:\/\/www.phiagroup.com\/About-Us\/Careers " target="_blank" data_liveedit_tagid="0x00007f91ed891f30">https:\/\/www.phiagroup.com\/About-Us\/Careers <\/a><\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a8e30"><a name="pcert" id="pcert" data_liveedit_tagid="0x00007f91ff7a9090"><\/a> <\/p>\n <span class="boldtext" data_liveedit_tagid="0x00007f91ed892d30">Promotions<\/span>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed892e60">• Lisa Hill has been promoted from Senior Subrogation Attorney to Managing Attorney, Subrogation Services. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed893ce0">• Kaycee O’Toole has been promoted from Case Investigator to Claim Recovery Specialist IV. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ed893820">• Elizabeth Pels has been promoted from Subrogation Implementation Specialist, Recovery Services to Manager, Recovery Service Onboard & Support. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7582f0">• Olesya Avramenko has been promoted from Health Benefit Plan Consultant II to Health Benefit Plan Consultant III. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff755000">• Corrie Cripps has been promoted from Health Benefit Plan Consultant II to Health Benefit Plan Consultant III. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff75b300">• Ulyana Bevilacqua has been promoted from Manager, Drafting Services to Senior Manager, Drafting Services. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7581c0">• Sarah Ingle has been promoted from Claim Recovery Specialist IV to Sr. Claim Recovery Specialist. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff75ccc0">• Skyla Mrosk has been promoted from Claim Analyst to Senior Claim Analyst. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff75c470">• Emily King has been promoted from Customer Care Representative to Claim Analyst. <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff75d770"> <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f921498bff0"><strong data_liveedit_tagid="0x00007f91ff75e6e0">New Hires<\/strong> <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff75d640">• Ania Russo was hired as Specialist Projects Coordinator. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff761fd0">• Joanie Verinder was hired as Director, Service Strategist. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7611c0">• Denise Aubrey was hired as Director, Subrogation Implementation. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff763ed0">• Ernestine Cherubin was hired as Accounting Temp. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff762230">• Harman Singh was hired as Sr. Software Engineer. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a63b0">• Joanna Marden was hired as Customer Service Rep. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a64e0">• Richard Harrison was hired as Sr. Accountant. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a6cf0">• Saheed Yussuff was hired as Accounting Administrator. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a5de0">• Deonte Small was hired as Accounting Assistant. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a9b20">• Bharat Bogelli was hired as Business Analyst. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7a8250">• Kendall Jackson was hired as Health Benefit Plan Consulting Attorney. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7abbe0">• Nicholas Walsh was hired as Case Investigator. <\/p>\n<p data_liveedit_tagid="0x00007f91ff7ae6a0"><br data_liveedit_tagid="0x00007f91ff7462e0">\n<p class="boldtext" data_liveedit_tagid="0x00007f91ff7afdc0">Phia Attending the SIIA National Conference <\/p>\n <p class="bodytext" style="font-weight: normal" data_liveedit_tagid="0x00007f91ff7b1150">Several of Phia’s industry experts will attend SIIA’s National Conference in Phoenix, Arizona, from October 8th – 10th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: <a href="https:\/\/siiaconferences.org\/nationalconference\/2023\/index.cfm" data_liveedit_tagid="0x00007f91ff7b3fa0">https:\/\/siiaconferences.org\/nationalconference\/2023\/index.cfm<\/a>. \n \n  <\/p>\n<p class="bodytext" data_liveedit_tagid="0x00007f91ff7b21f0"> <\/p><a name="story">\n <p class="boldtext" data_liveedit_tagid="0x00007f91ff795130">  <\/p>\n \n <p class="bodytext" data_liveedit_tagid="0x00007f91ff795000"> <\/p><hr class="horiz" data_liveedit_tagid="0x00007f91ff745d10" \/><\/p>\n <p data_liveedit_tagid="0x00007f91ff7b46c0">\n \n<p class="bodytext" data_liveedit_tagid="0x00007f91ff795720"><br data_liveedit_tagid="0x00007f91ff745ab0"><br data_liveedit_tagid="0x00007f91ff745530">\n<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff796670"><strong data_liveedit_tagid="0x00007f91ff796a00">The Phia Group Reaffirms Commitment to Diversity & Inclusion<br data_liveedit_tagid="0x00007f91ff7450b0" \/>\n <br data_liveedit_tagid="0x00007f91ff744d10" \/>\n <\/strong>At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.\n<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7962e0">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff7975e0">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff797e10">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion. <\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff798970"><strong data_liveedit_tagid="0x00007f91ff799420"><br data_liveedit_tagid="0x00007f91ff744960" \/>\n <\/strong><br data_liveedit_tagid="0x00007f91ff744720" \/>\n<\/p>\n <p class="bodytext" data_liveedit_tagid="0x00007f91ff799e70"><br data_liveedit_tagid="0x00007f91ff742950" \/>\n <br data_liveedit_tagid="0x00007f91ff742710" \/>\n <a href="#top" data_liveedit_tagid="0x00007f91ff79c320">Back to top ^<\/a> <br data_liveedit_tagid="0x00007f9214229260" \/>\n<\/p>\n\n <p class="bodytext" style="text-align: center" data_liveedit_tagid="0x00007f91ff79b020"><img src="images\/footerlogo.png" width="372" height="346" data_liveedit_tagid="0x00007f9214980c60" \/><\/p>\n <\/tr>\n <tr data_liveedit_tagid="0x00007f91ff79be60">\n <td colspan="2" bgcolor="#4a85d3" data_liveedit_tagid="0x00007f91ff79ca20"><table width="100%" border="0" cellspacing="5" cellpadding="5" data_liveedit_tagid="0x00007f91ff79c6b0">\n <tr data_liveedit_tagid="0x00007f91ff79d010">\n <td class="whitetext" data_liveedit_tagid="0x00007f91ff79e1e0"><a href="mailto:info@phiagroup.com" class="whitetext" style="color: #FFFFFF" data_liveedit_tagid="0x00007f91ff7a24e0">info@phiagroup.com<\/a><br data_liveedit_tagid="0x00007f92147cd350" \/>\n 781-535-5600<\/td>\n <\/tr>\n <\/table><\/td>\n <\/tr>\n <\/table>\n<\/body>\n<\/html>\n');</script> </dw-container-div>1238The Stacks – 2nd Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1235/the-stacks-2nd-quarter-2023-newsletterNewslettersTue, 04 Apr 2023 15:21:38 GMT<p align="center" style="text-align:center; margin:0in 0in 8pt"><strong><span style="color:#0071ce;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Extended Telehealth Relief for HSA Plans</span></span></span></span></strong></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><strong><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Andrew Silverio, Esq. </span></span></span></strong></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:"Calibri",sans-serif">The COVID-19 pandemic has given rise to many practical and regulatory challenges for self-funded plans and those that serve them.  Most of these regulatory changes create important protections for plan participants but create significant burdens and potential exposure for plans – this includes significant expansions to COBRA rights under the American Rescue Plan Act of 2021, vaccine and testing mandates under the FFCRA and CARES Act, and the extension of various plan deadlines relating to claim submission, appeals, enrollment, and COBRA. </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:"Calibri",sans-serif">There is an important allowance in the CARES Act which benefits both plans and participants, however – under this, high deductible health plans (HDHPs) may provide benefits for telehealth services without application of any cost-sharing and without regard to whether any deductible has been met without impacting the plans’ ability to be paired with a health savings account (HSA).  Without this allowance, an HDHP providing any “first-dollar” coverage for non-preventive services would destroy the plan’s HSA compatibility, having serious tax consequences for all participants utilizing the HSA. This allowance was set to expire at the end of 2022; however, the passage of the Consolidated Omnibus Appropriations Act (2023) extends it through the end of 2024.  This means that HDHPs using HSAs may (but are not required to) continue to offer first-dollar coverage for telehealth and telemedicine services, whether preventive, through the end of plan years beginning on or before December 31, 2024. </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:"Calibri",sans-serif"> It's important to note, however, that this relief does <i>not </i>include an extension of a waiver that currently allows providers to prescribe controlled substances via telehealth for substance abuse treatment.  Because of this, most telehealth providers will default back to existing regulations which severely limit their ability to prescribe controlled substances for patients they haven’t treated in person. </span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The need for this relief is attributable to the severe restrictions imposed on HDHPs by the regulations governing HSAs.  In order to utilize an HSA, an individual must be covered under an HDHP which complies with strict limitations, most notably that the plan applies at least a minimum required deductible to almost all non-preventive services ($1,500 for individual coverage in 2023).  Additionally, an individual using an HSA must have no other health coverage besides that HDHP.  These requirements in tandem severely limit HDHPs’ ability to create steerage within the plan benefit structure, and thus their ability to utilize many popular cost-containment techniques.  For example, an HDHP cannot exempt certain high-cost non-preventive drugs from its deductible to steer individuals toward a specialty management program without bumping up against the “first-dollar” coverage requirement, while it also can’t create parallel coverage for those drugs outside the plan without bumping up against the “other coverage” problem.  These challenges are the major trade-off HDHP sponsors make in return for the tax benefits of making an HSA available. </span></span></span></span></p> 1235The Phia Group's 1st Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1213/the-phia-groups-1st-quarter-2023-newsletterNewslettersTue, 17 Jan 2023 22:18:33 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2023/phiaheader2023.jpg?ver=LNuJLp0wK5u9yLbzpXAetw%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2023/icons6622.png?ver=Kmh3XaUTDgDASsseb1CpSw%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Q1 2023/block0422l.png?ver=3uqrnGRjU0P5gcq-fx8ZYg%3d%3d" style="width: 325px; height: 216px;" /> </a></td> <td valign="top" width="323"><a href="#pace3"><img src="/Portals/phiagroup/Newsletters/Q1 2023/block0422r.png?ver=DBYGOasxBAlFj81sUQkuBg%3d%3d" style="width: 325px; height: 216px; float: right;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> </table> </td> </tr> <tr> <td valign="top" width="47%"> <p><br /> <img height="273" src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" width="276" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"></span></p> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">I wish it would snow here in Boston; even a little dusting would be nice. While I am sure that my friends in the Midwest and Western New York may disagree (based on the feet of snow you have seen there), here all I see is dull pavement and sad looking grass. It would be nice to do some sledding with my kids, or enjoy an awesome snowball fight. This is not the January in Massachusetts that I remember, or to which I am accustomed! Indeed… We can get so used to something, like snowfall in Boston, that we take it for granted. We assume it will continue to happen the same way, year after year. Planning for change, therefore, isn’t something we often think about, until change slaps us in the face. When it comes to self-funding health plans, compliance and regulatory issues represent sudden and unexpected change.</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Like New England snowfall in winter, you get comfortable assuming things will unfurl the same way, year after year. Then BOOM; the industry faces an unexpected blizzard of rulemaking, unlike anything seen in years. At The Phia Group, it almost seems like I am now your television meteorologist; monitoring a flurry of legislative and litigious changes, and telling the audience not to go outside! I’m here on the frontline, sitting on a sea-wall, about to get tossed into the water by gusty winds of transformation. Gosh. I guess things can change? Don’t get comfortable! In the world of insurance, there is always a “regulatory storm” out there… Sometimes it’s brewing in the atmosphere; sometimes it’s out to sea; and sometimes its bearing down on us! We can go months or even years, getting used to the peace and quiet (just like I have gotten used to annual picturesque winter snowscapes outside my home), only to suddenly have the status quo turn upside down. This is me, attempting to warn our listening audience of troubles ahead. That’s what our success at Phia has always been about – keeping you informed and knowing what we expect to happen before it does. Luckily for us, we are better at predicting what’s next, than the typical weather person.</p> <p class="bodytext"><a name="russo09"></a></p> <p class="bodytext">– Happy reading!</p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p><img src="/Portals/phiagroup/Newsletter 2018 Q2/inthisissue.png?ver=4_c-EncNsuJUxrT1QINLVg%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><a href="#Enhancement">Enhancements of the Quarter: Internal Handling of ICE Requests</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2023 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#pemployee">Employee of the Quarter & Year</a><br /> <a href="#pnews">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong><a id="Enhancement" name="Enhancement"></a></strong></p> <p class="bodytext"><strong>Enhancement of the Quarter: Internal Handling of ICE Requests </strong></p> <p class="bodytext" style="text-align: justify;">As is common, The Phia Group’s intake processes have historically entailed email distribution groups. In other words, when an email is sent to a given email address, multiple people receive the email, and it is catalogued and handled accordingly by certain recipients. This is a sensible system, although perhaps not as efficient as it could be. </p> <p class="bodytext" style="text-align: justify;">However, there was an idea recently proposed by a Phia employee to help declutter our systems and promote efficiency! This potentially useful (and currently being deployed) strategy across other lines of business as well was developed by a member of the ICE intake team to streamline the receipt of requests, optimize our internal processes, and promote quicker response times to ICE clients’ consulting requests! </p> <p class="bodytext" style="text-align: justify;">The nature of ICE is such that we get numerous submissions on a daily basis and making our internal processes more efficient is just one way that Phia is constantly improving the level of service we are able to provide to our valued clients. Greater efficiency optimizes resource usage, which allows us to minimize turnaround times and keep our ICE fee low! For more information on The Phia Group’s ICE service, please contact <a href="mailto:sales@phiagroup.com">sales@phiagroup.com</a>.</p> <p class="bodytext"><strong>Service Focuses of the Quarter: Independent Consultation and Evaluation (ICE) and No Surprises Act Support</strong> </p> <p class="bodytext"><u>Independent Consultation and Evaluation</u></p> <p class="bodytext" style="text-align: justify;">Here at The Phia Group, we’re not a TPA, but we sure do know ‘em. Like the back of our hand. That’s why we developed our Independent Consultation and Evaluation service, colloquially known as ICE.</p> <p class="bodytext" style="text-align: justify;">We know how difficult processing claims can be, especially when those claims involve complex situations. Asking Plan Administrators for guidance to avoid TPA liability is always a good idea, but is sometimes not feasible due to time constraints or simply the fact that most plan administrators are not well-versed in the art and science of claims processing. Your clients are school districts, or textile manufacturers, or labor unions; what can they reasonably be expected to know about the law related to when an illegal acts exclusion can be applied, and when it can’t? </p> <p class="bodytext" style="text-align: justify;">Nothing, that’s what. Enter The Phia Group’s ICE service. We are experts in the law related to health benefit offerings, and we know plan documents like Tom Brady knows a football. ICE was created to ensure that health plans and the TPAs that work with them have a resource to tap when things get hairy – and since it’s billed at a flat monthly fee rather than on an hourly basis, there are no surprises. </p> <p class="bodytext" style="text-align: justify;">(And speaking of “no surprises”…) </p> <p class="bodytext" style="text-align: justify;"><u>No Surprises Act Support</u> </p> <p class="bodytext" style="text-align: justify;">Phia’s No Surprises Act (NSA) support services entail non-network claim pricing, “open negotiation” support, and Independent Dispute Resolution (IDR) defense. Although every TPA potentially has a different set of needs related to the No Surprises Act, Phia can be engaged to perform functions such as checking NSA-related communications to verify the NSA’s applicability and performing a deadline review to ensure that the NSA’s timeframes are being adhered to. </p> <p class="bodytext" style="text-align: justify;">We are also well-equipped with the necessary benchmarking data, domain knowledge, and experience to negotiate claims with medical providers. In addition, if a claim becomes subject to Independent Dispute Resolution, our support services are available to vet and challenge an IDR entity if necessary, as well as review or draft the plan’s offer of payment. </p> <p class="bodytext" style="text-align: justify;">Our NSA support services provide the backbone of post-payment NSA compliance, with a particular focus on cost-containment. </p> <p class="bodytext" style="text-align: justify;">Please contact <a href="mailto:sales@phiagroup.com">sales@phiagroup.com</a> for more information on Independent Consultation and Evaluation (ICE) or No Surprises Act support!</p> <a name="russo4"></a> <p class="bodytext"><strong>Success Story of the Quarter: The NQTL Audit</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group was approached by a health plan currently undergoing an audit of its treatment of mental health and substance abuse disorder benefits. Rather than engaging Phia to perform an NQTL analysis, the plan asked us instead to help interpret certain criticisms of the plan’s treatment of mental health and substance abuse disorder claims, and help the plan become more compliant. </p> <p class="bodytext" style="text-align: justify;">What we discovered is that the criticisms of the plan were largely focused on medical necessity criteria relating to mental health and substance abuse disorder claims compared to medical necessity criteria applied to medical and surgical claims. This particular plan had engaged a vendor specifically to review medical necessity and perform other UM functions for its mental health claims, while the plan engaged its TPA to handle medical and surgical claims, considering the latter to be more “run-of-the-mill”. </p> <p class="bodytext" style="text-align: justify;">As can be expected, the UM vendor in charge of making determinations regarding mental health and substance abuse disorder claims applied a totally different set of criteria from what was listed in the plan document! Although the TPA followed the plan document to the letter (and in fact the relevant plan language was drafted specifically with this TPA’s UM processes in mind), the UM vendor disregarded plan language and applied its own chosen criteria, which were both more stringent and relied on different professional sources, notably including the UM vendor’s own internal set of medical policies. The discrepancy was identified, and Phia’s attorneys worked with the plan to coordinate with the UM vendor to make sure the vendor didn’t ignore the terms of the plan document. </p> <p class="bodytext" style="text-align: justify;">Unfortunately, it became clear that the UM vendor refused to deviate from its current processes; in order to be compliant, the plan was faced with the choice of either engaging the UM vendor for all claims – both mental health/substance abuse disorder and medical/surgical – or abandoning the vendor altogether and instead having the TPA perform UM functions for both medical/surgical and mental health/substance abuse disorder claims. The group ultimately erred on the side of its TPA, and although it required a major change in processes, the TPA has been working diligently to minimize the disruption.</p> <a name="pace3"></a> <p class="bodytext"><strong>Phia Case Study: TPAs Making Coverage Decisions</strong></p> <p class="bodytext" style="text-align: justify;">A question our consulting team is commonly asked is regarding to what extent a TPA should make claims determinations. As a TPA, of course, your groups rely on you to carry out everyday administrative functions; although making claims determinations may seem like just another one of those, in practice it can be far more complex. </p> <p class="bodytext" style="text-align: justify;">At its core, a benefit determination is a fiduciary action. That is, anyone who makes a benefit determination becomes a fiduciary to the extent discretion was exercised. Take the examples of two claims – one that requires only a certification of medical necessity to cover, and one that requires interpretation of a plan’s “illegal acts” exclusion. While the former is as simple as “If X, then Y”, the latter requires whoever is making the decision to exercise discretion to interpret the illegal acts exclusion. </p> <p class="bodytext" style="text-align: justify;">Rather than providing a very specific fact pattern to apply this principle to, this case study focuses more on the very common question from TPAs regarding how they should treat this claim’s determination burden. On one hand, groups are often loathe to make decisions like this on their own (either lacking the know-how, simply not feeling comfortable, or believing that the group’s TPA was contracted to make this decision for them [the “isn’t this what we pay you for?” approach]). On the other hand, though, many TPAs have the resources – and the vendor partners – to make these types of determinations with a degree of certainty. </p> <p class="bodytext" style="text-align: justify;">When making business decisions, we urge you all to remember that The Phia Group is here to help wherever you need us. Want to make claim determinations? Run a complex claim through ICE! Want to lower claims expenses and reliably limit balance-billing? Check out Phia Unwrapped! Want to take on appeals? PACE is here! Want to nail the No Surprises Act? We’ve got you covered there, too. Just let us know what you need, and we’ll find a way to make it happen.</p> <hr class="horiz" /> _ <p class="bodytext"><strong>Fiduciary Burden of the Quarter: The “Kitchen Sink” Approach to Adverse Benefit Determinations</strong></p> <p class="bodytext" style="text-align: justify;">A recent case out of the 9th Circuit Court of Appeals has brought up an issue that Phia’s attorneys and consultants have discussed with numerous clients through the years. The issue is whether or not to include all possible denial rationales in any given denial letter. </p> <p class="bodytext" style="text-align: justify;">Many TPAs and plans choose the most compelling and seemingly defensible denial reason and hang their respective hats on that, but Phia has always recommended that an Adverse Benefit Determination should identify any and all possible denial reasons that are supported by the SPD. The reasons for that are twofold: one is to be better able to defend itself in the event a claimant is able to successfully refute the denial reason used; the other is that we have not been confident that a court’s review would permit the plan to introduce new denial justifications not previously provided. This case underscores that second reason. </p> <p class="bodytext" style="text-align: justify;">In Collier v. Lincoln Life Assurance Co. of Bos., the court held that when a denial is litigated, the health plan may not introduce new arguments (i.e., new reasons) that were not previously brought up in the plan’s previous denials. According to the court, since ERISA’s claims procedure regulations provide that a denial letter must contain the specific reasons for the denial, “a plan administrator undermines ERISA and its implementing regulations when it presents a new rationale…that was not presented to the claimant as a specific reason for denying benefits during the administrative process.” Basically, judicial review of a denied appeal is not designed to erase what was already done and let the plan re-justify its denial; instead, it is designed to verify whether the Plan’s previous denial is supported by the facts and law underlying the claim. Another way to think about it is that if a patient sues the plan over a claim, it’s not really about the claim itself, but about the plan’s denial of the claim. </p> <p class="bodytext" style="text-align: justify;">As a general rule, if a health plan includes multiple provisions upon which a denial should be based, use them all! Don’t assume that the one chosen will necessarily hold up.</p> <a name="pdef"></a> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On December 13, 2022, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/a-flip-of-the-calendar-looking-ahead-to-healthcare-in-2023">“A Flip of the Calendar: Looking Ahead to Healthcare in 2023,”</a> in which the team discussed increasing healthcare costs, the No Surprises Act, and more. </p> <p class="bodytext" style="text-align: justify;">• On November 15, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/down-the-stretch-wrapping-up-a-historical-2022">Down the Stretch: Wrapping up a Historical 2022</a>,” in which the team discussed what they felt were the 10 most impactful healthcare developments of 2022. </p> <p class="bodytext" style="text-align: justify;">• On October 20, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/the-witching-hour-for-healthcare-plans">The Witching Hour for Healthcare Plans</a>,” in which we discussed regulatory changes impacting the healthcare industry (i.e., mental health parity, discretionary authority) and developments concerning plan drafting language.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p>   <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On December 20, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p151-the-who-what-and-when-of-offsetting-benefits">The Who, What, and When of Offsetting Benefits</a>,” in which our hosts, Chris Aguiar and Cindy Merrell, discussed offsetting benefits and when a Plan may consider it. </p> <p class="bodytext" style="text-align: justify;">• On December 8, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p150-manufacturer-assistance-programs">Manufacturer Assistance Programs</a>,” in which our hosts, Brady Bizarro and Andrew Silverio, discussed manufacturer/copay assistance programs and some of the different approaches being utilized to manage specialty drug spending. </p> <p class="bodytext" style="text-align: justify;">• On November 17, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p149-another-ping-ponging-of-icee-rules">Another Ping-Ponging of IC/EE Rules?</a>,” in which our hosts, Kelly Dempsey and Kevin Brady, discussed the ever-changing world of employee classification rules. </p> <p class="bodytext" style="text-align: justify;">• On November 3, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p148-the-ever-changing-times-of-healthcare">The Ever Changing Times of Healthcare</a>,” in which our hosts, Corey Crigger and Nick Bonds, discussed some of the more interesting developments they’ve seen in 2022. </p> <p class="bodytext" style="text-align: justify;">• On October 27, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p147-transparency-more-burning-caansa-faqs">Transparency & More: Burning CAA/NSA FAQs</a>,” in which our hosts, Jen McCormick and Jon Jablon, discussed some of the most common questions that The Phia Group’s consulting team has been asked to field over and over again. </p> <p class="bodytext" style="text-align: justify;">• On October 14, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p146-a-possible-threat-to-a-plans-discretionary-authority">A Possible Threat to a Plan’s Discretionary Authority</a>,” in which our hosts, Ron E. Peck and Kaitlyn MacLeod, discussed a new bill that has been announced that would ban all references to a plan administrator’s discretionary authority, as well as remove all deference courts give to their claims determinations. Book of Russo </p> <p class="bodytext" style="text-align: justify;">• On October 21, 2022, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/book-of-russo-chapter-5">Book of Russo: Chapter 5</a>,” in which our host, Adam Russo, and guest host, Mike Ferguson, discussed SIIA’s 2022 National Conference, the history of SIIA, and what to expect from SIIA in years to come.</p> <p class="bodytext" style="text-align: center;">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" style="width: 491px; height: 121px;" /></a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2022/12/15/the-debate-behind-quiet-quitting-the-younger-generations-approach/">The debate behind “quiet quitting”: The younger generation’s approach</a> – December 15, 2022 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/A_Historic_Opioid_Settlement_Could_Present_Opportunities_For_Insurers_To_Seek_Reimbursement_by_Brady_Bizarro%2C_Esq.pdf">A Historic Opioid Settlement Could Present Opportunities For Insurers To Seek Reimbursement</a> – December 2, 2022 </p> <p class="bodytext">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/In_Subrogation-Superior_Contract_Language_Matters_by_Scott_Byerley%2C_Esq.pdf">In Subrogation: Superior Contract Language Matters</a> – October 7, 2022<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1"></span><br />  </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/being-in-the-business-of-adderall-how-the-shortage-is-affecting-millions-of-americans">Being “in the business” of Adderall: How the shortage is affecting millions of Americans.</a> Across the country, Americans with attention-deficit hyperactivity disorder (ADHD) are struggling to find good alternatives to Adderall. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/healthcare-subrogation-and-reimbursement-and-why-it-matters">Healthcare Subrogation and Reimbursement and Why it Matters.</a> There is distinction between subrogation and reimbursement. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/nsas-model-notice-doing-your-own-thing">NSA’s Model Notice: Doing Your Own Thing</a>. The NSA imposes some major requirements on health plans. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/rxdc-reports-are-almost-due-make-sure-you-are-on-track-for-compliance">RxDC Reports Are Almost Due – Make Sure You Are on Track for Compliance</a>. How much do you know about the Prescription Drug and Health Care Spending reporting (RxDC) requirements? </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/mental-health-matters-why-the-mhpaea-needs-reinforcement">Mental Health Matters Act: Why the MHPAEA Needs Reinforcement.</a> An update on the Mental Health Parity and Addiction Equity Act.</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a>The Stacks:</span></p> <p class="bodytext"><strong>A Historic Opioid Settlement Could Present Opportunities For Insurers To Seek Reimbursement</strong></p> <p class="bodytext" style="text-align: justify;">By: Brady Bizarro, Esq. – December 2022 – <a href="https://www.sipconline.net/files/A_Historic_Opioid_Settlement_Could_Present_Opportunities_For_Insurers_To_Seek_Reimbursement_by_Brady_Bizarro%2C_Esq.pdf">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="text-align: justify;">On November 1, 2022, major media outlets reported that the nation’s three largest retail pharmacies – CVS, Walgreens, and Walmart – had agreed in principle to pay $13.8 billion in damages in a settlement to resolve thousands of claims related to the opioid epidemic. Due to the uniquely insidious nature of opioid addiction and the truly devastating scale of the crisis, hundreds of thousands of Americans have lost their lives, families have been shattered, and governments and health insurers alike have spent tens of billions of dollars on rehabilitation and increased claim costs. If this settlement proceeds, as appears very likely as of this writing, insurers, including self-funded plan sponsors, could have new opportunities to recover funds on behalf of their plan participants.  </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2023-newsletter">Click here</a> to read the rest of this article<br />  </p> <p class="bodytext"><strong>In Subrogation: Superior Contract Language Matters</strong></p> <p class="bodytext">By: Scott Byerley, Esq. – October 2022 – <a href="https://www.sipconline.net/files/In_Subrogation-Superior_Contract_Language_Matters_by_Scott_Byerley%2C_Esq.pdf">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="text-align: justify;">The United States Congress enacted the Employee Retirement Income Security Act ("ERISA") in 1974 to protect employees and place requirements on pension and health care plans. The legislation arose from the discourse and fallout that occurred after Studebaker-Packard (Studebaker), an automobile manufacturer that was very poorly fiscally managed, closed its plant in South Bend, Indiana, effectively eliminating employee pensions for thousands of employees. The problem wasn’t a new one or limited to Studebaker’s closure, which came about in 1963, but rather a systemic one: the lack of corporate accountability in financial reporting and management of pension and health care plans posed significant risks, prompting Congress to protect employees nationwide.  </p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2023-newsletter">Click here</a> to read the rest of this article<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2023 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2023 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. </p> <p style="text-align: justify;"><span class="bodytext"></span></p> <p class="bodytext" style="text-align: justify;"><strong>Thanksgiving Dinner Delivery</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Family was out and about the week of Thanksgiving, handing out 25 Thanksgiving dinners to the families of The Boys and Girls Club of Metro South! Additionally, our Phia Family in Idaho and Louisville were out and about spreading the same cheer to five families in the Boise area. Check out the great picture we were able to get from that special night! We hope everyone had a wonderful Thanksgiving!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/bandg2023.jpg?ver=33Wp1TS3fZxJqHHsXJNnEQ%3d%3d" style="width: 572px; height: 464px;" /> <p class="bodytext"><strong>Salvation Army Angel Tree</strong></p> <p class="bodytext" style="text-align: justify;">Each year employees of The Phia Group pick nametags from the Angel Tree that sits in our main lobby. On those tags are names, ages and the wish lists of children from The Salvation Army. This year we had over 150 nametags! The Phia family loves to give back to the community; our greatest joy is providing these children with all of their holiday wishes.</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/salvation2023.png?ver=uWuVqckgFgCGkITqTixgTg%3d%3d" style="width: 584px; height: 324px;" /> <p class="bodytext"><strong>Christmas Came Early</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group had the pleasure of bringing Christmas joy to the Boys & Girls Club of Metro South. Adam Russo and his helpers passed out hundreds of gifts to over 150 children. We hope these children enjoy their new toys as much as they enjoyed spending time with Santa!</p> <img alt="" height="299" src="/Portals/phiagroup/Newsletters/Q1 2023/Santers%20Helpers.jpg?ver=ztytHfj7OPtGS99Bc8g5SQ%3d%3d" width="252" /> <p><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a></span></p> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Year: Kelsey Dillon</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Kelsey Dillon as The Phia Group’s 2022 Employee of the Year! </p> <p class="bodytext" style="text-align: justify;">Here is what Kelsey’s Supervisor had to say about Kelsey: “Kelsey joined The Phia Group in December 2017. In her 5-year tenure with The Phia Group, she quickly became a top producer for the Claim & Case Support department & in 2021 was promoted to co-Team Lead. </p> <p class="bodytext" style="text-align: justify;">In early 2022, Kelsey took on an additional challenge – participating in the Lean Six Sigma Certification Program. This is a huge accomplishment for her to have successfully completed. </p> <p class="bodytext" style="text-align: justify;">Heading into 2023, she will be taking this skillset into a new role within the company, to support both incoming & existing clients in the Recovery Department. We are very excited to see what is in store for Kelsey & look forward to her continued success at The Phia Group.”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/kelsey1.jpg?ver=z04h9OOm8r0JpYkwQRecUg%3d%3d" style="width: 590px; height: 460px;" /></p> <p class="bodytext">Congratulations Kelsey, and thank you for your many current and future contributions.</p> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Get to Know Our Employee of the Quarter: Jeff Hanna</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Jeff Hanna as The Phia Group’s 2022 Q4 Employee of the Quarter! </p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Jeff: “Even though Jeff is a member of the Accounting team, he has become an integral part of the Provider Relations team. For years now Provider Relations has depended on Jeff's excellent work product, his turnaround time, and attention to detail. We depend on Jeff greatly to complete the accounting end of our work and it is often a very heavy workload and all with the specter of timeliness and deadlines hanging over him, creating even further urgency and stress to the work. The work that Jeff receives from Provider Relations is already heavy enough, and done under such time constraints, that it would qualify as "above and beyond" and he has worked in this manner for years with little or no recognition. Thank you for everything you do, Jeff!” </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/jeff1.jpg?ver=DBYGOasxBAlFj81sUQkuBg%3d%3d" style="width: 396px; height: 364px;" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext">Congratulations Jeff, and thank you for your many current and future contributions.</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a><span class="heading1"><span style="font-size:16px;"><strong>Phia News:</strong></span></span></span></p> <p class="bodytext"><span class="heading1">Job Opportunities:</span></p> <p class="bodytext">• EDI Data Engineer </p> <p class="bodytext">• PGC Attorney </p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• Senior Accountant </p> <p class="bodytext">• Accounting Assistant</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext" style="text-align: justify;">• Sandra Croteau has been promoted from Senior Manager of Client Success Team to Director of Client Success Team </p> <p class="bodytext" style="text-align: justify;">• Tara Otoka has been promoted from Health Benefit Plan Consultant I to Health Benefit Plan Consultant II </p> <p class="bodytext" style="text-align: justify;">• Brittney Willoughby has been promoted from Team Lead, Recovery Services to Manager, Recovery Services </p> <p class="bodytext" style="text-align: justify;">• Jacky Davis has been promoted from Health Benefit Plan Consultant I to Health Benefit Plan Consultant II </p> <p class="bodytext" style="text-align: justify;">• Bryan Dunton has been promoted from Health Benefit Plan Consultant I to Health Benefit Plan Consulting Attorney </p> <p class="bodytext" style="text-align: justify;">• Emily Rodriguez has been promoted from Project Coordinator I to Project Coordinator II </p> <p class="bodytext" style="text-align: justify;">• Adam Doherty has been promoted from Project Coordinator I to Project Coordinator II</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Michelle Haga was hired as a PACE Appeal Specialist </p> <p class="bodytext">• LaTrisha Keierleber was hired as a PACE Appeal Specialist </p> <p class="bodytext">• Kelvin Chun was hired as a Sr. FP&A Analyst </p> <p class="bodytext">• David Palmer was hired as a Claim Recovery Specialist </p> <p class="bodytext">• Kaycee O'Toole was hired as a Case Investigator </p> <p class="bodytext">• Michael Laino was hired as a Clinical Coding Analyst </p> <p class="bodytext">• Even Forrest was hired as a Case Investigator </p> <p class="bodytext">• Patrick Murphy was hired as a Case Investigator </p> <p class="bodytext">• Tanya Mendlowitz was hired as a Customer Service Representative </p> <p class="bodytext">• Shannon Mortimer was hired as a Claim and Case Support Analyst </p> <p class="bodytext">• Sabrina Dunn was hired as a Customer Service Representative </p> <p class="bodytext">• Gerry Dieudone was hired as a Provider Relations Coordinator </p> <p class="bodytext">• William Parlee was hired as a Case Investigator </p> <p class="bodytext">• Ray Joseph was hired as a Claim and Case Support Analyst </p> <p class="bodytext">• Julia Harvey was hired as a Customer Service Representative </p> <p class="bodytext">• Dylan Cleaves was hired as an Accounting Intern</p> <p class="boldtext">Halloween at Phia Phia</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Family celebrated Halloween in style as dozens of costumed employees and their families enjoyed trick-or-treating and a haunted house in the office. We are beyond thankful for everyone who helped make this an amazing and successful day! </p> <a name="story"> </a> <p class="boldtext"><a name="story"><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/halloween2023.jpg?ver=2SU6wBm5Q_QvfPIoyV2i5w%3d%3d" style="width: 520px; height: 250px;" /> </a></p> <a name="story"> </a> <p class="bodytext"><a name="story"> </a></p> <hr class="horiz" /><a name="story"> </a> <p class="bodytext"><span style="font-size:16px;"><strong><a name="story"></a><a id="pnews" name="pnews"></a></strong></span></p> <p class="boldtext">Ugly Sweater Day</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is tradition, The Phia family had employees dress up in their ugliest sweaters the week before Christmas, and we had a great turnout this year! With all of the great sweaters, we had to get a group photo, and, as you can see, there were many people who wanted to show off their ugly sweaters, as well as some adorable holiday outfits! Thanks to everyone who participated! </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/ugly2023.jpg?ver=yfN5wYVcvLO9MeBqlu-n0w%3d%3d" style="width: 650px; height: 319px;" /> <p class="boldtext"> </p> <p class="boldtext">Pumpkin Carving at Phia</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is tradition, The Phia family had employees carve pumpkins right before Halloween, and we had a great turnout this year! There was a large number of pumpkin carvers, and the pumpkins all turned out beautiful. Thanks to everyone who participated!<br />  </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/pumpkin1.jpg?ver=XB7m6F34KofvSZwmPyMXtw%3d%3d" style="width: 599px; height: 319px;" /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/pumpkin2.jpg?ver=yfN5wYVcvLO9MeBqlu-n0w%3d%3d" style="width: 599px; height: 250px;" /> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong>Phia BBQ and Ice Cream Truck</strong></p> <p class="bodytext" style="text-align: justify;">During what turned out to be a brilliant early autumn day, Phia employees enjoyed a delicious barbeque. Not only was there a wide assortment of both traditional and vegan meats to go along with savory side dishes, but an ice cream truck rolled by to cap off the event. We hope you enjoyed the delicious food and sweets!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2023/bbq2023.jpg?ver=6DSCHBNjs9Uk_Xa-WLKE9w%3d%3d" style="width: 522px; height: 503px;" /> <p class="bodytext" style="text-align: justify;"><strong></strong></p> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter 2018 Q2/footerlogo.png?ver=iYwkNviyLE_yU_0lKTSyJQ%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1213The Stacks – 1st Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1206/the-stacks-1st-quarter-2023-newsletterNewslettersWed, 14 Dec 2022 16:19:58 GMT<p style="text-align: center;"><span style="font-size:18px;"><span style="color:#0071ce;"><b><span style="font-family:"Calibri",sans-serif">A Historic Opioid Settlement Could Present Opportunities for Insurers to Seek Reimbursement</span></b></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif">By: Brady Bizarro, Esq.<br /> <br /> On November 1, 2022, major media outlets reported that the nation’s three largest retail pharmacies – CVS, Walgreens, and Walmart – had agreed in principle to pay $13.8 billion in damages in a settlement to resolve thousands of claims related to the opioid epidemic. Due to the uniquely insidious nature of opioid addiction and the truly devastating scale of the crisis, hundreds of thousands of Americans have lost their lives, families have been shattered, and governments and health insurers alike have spent tens of billions of dollars on rehabilitation and increased claim costs. If this settlement proceeds, as appears very likely as of this writing, insurers, including self-funded plan sponsors, could have new opportunities to recover funds on behalf of their plan participants.<br /> <br /> Readers may recall earlier settlements related to the opioid crisis, totaling tens of billions of dollars, that were reached between many state attorneys general and drug manufacturers, including Purdue Pharma. This settlement is notable not only for its size but also because it would be the first nationwide deal reached with retail pharmacies. The claims at issue were brought by states, localities, and tribal entities. Why would these pharmacy chains agree to settle such claims? This is mostly because evidence emerged in various trials, during the discovery process, that executives at these companies ignored repeated warnings from their own pharmacists that their dispensing actions were fueling the opioid crisis.<br /> <br /> According to the Centers for Disease Control and Prevention, prescription opioids can be up to 50 times more powerful and addictive than heroin. In 2021, as many as 100,000 Americans died from drug overdoses. Not all of these deaths were caused by prescription painkillers, but the vast majority of them were caused by opioids, both synthetic opioids and prescription opioids. The recent COVID-19 pandemic and the burgeoning nationwide mental health crisis have caused overdose deaths to spike in recent months; a trend which the data suggests will continue into next year.<br /> <br /> The economic toll of the opioid crisis cannot be overstated. In late September, the Joint Economic Committee of the U.S. Congress release a detailed report revealing that the opioid crisis has cost the country nearly $1.5 trillion in economic losses in 2020 alone. For health insurers, the cost has skyrocketed over the past few years, reaching well into the tens of billions of dollars. The scope and size of opioid-related claims may not be entirely obvious, even to seasoned industry veterans, and so they are worth reviewing here.<br /> <br /> A 2018 report from BioMed Central (BMC) concluded that “[i]ndividuals with high-risk prescription opioid use have significantly higher healthcare costs and utilization than their counterparts, especially those with chronic high-dose opioid use.” This study’s findings are in line with numerous other studies conducted by esteemed medical research institutions, including the Johns Hopkins Bloomberg School of Public Health. The BMC report demonstrated that the average claim cost for an employee who is prescribed a single opioid increased by a factor of four to eight. The specific claim costs the authors focused on were addiction treatment, rehabilitation, emergency room visits, death, and obviously, increased prescription drug costs.<br /> <br /> The most recent data available from Peterson-Kaiser Family Foundation, going back to 2016, reveals that the cost to large employers has jumped significantly, to $2.6 billion in 2016, up from $300 million in 2004, a more than nine-fold increase. Put another way, FAIR Health, which owns and continuously updates a database of more than 21 billion claims from privately insured individuals, concluded back in 2015 that “on average, private insurers and employers providing self-funded plans paid nearly $16,000 more per patient for those with diagnoses of opioid abuse or dependence than for those with any diagnosis.”<br /> <br /> As the human and economic tolls have come increasingly into focus, it should be no surprise that thousands of lawsuits have been filed against drug manufacturers, physicians, pharmacies. Litigation related to the opioid crisis is likely to continue for many years in suits brought by individuals, government entities, and insurers all of stripes. Indeed, there are numerous law firms working together to assemble litigation teams to help insurers recoup opioid-related costs. One obvious way to do this is for insurers to become part of nationwide opioid litigation, joining these cases (or initiating them) as plaintiffs. Another, perhaps less obvious way, is on the back end, in the form of subrogation.<br /> <br /> Many, if not most, of the thousands of lawsuits related to the opioid crisis will eventually end in settlements. For health insurers, this result, depending on the terms of the settlement, and any applicable law, may actually be more beneficial as it relates to recovering claim costs than relying on a judgment imposed by a court. For one thing, health insurers, especially smaller self-funded plans with limited resources, are not likely to be able to join most lawsuits on the front end. Even if a self-funded plan was able to track down and join a particular lawsuit in any given state, it is exceedingly unclear to what extent a health insurer’s claims will be prioritized in any given judgment, especially since the families of victims are almost certain to receive the lion’s share of any financial compensation, followed closely by federal, state, local, and tribal governments.<br /> <br /> A large share of the money received in most opioid-related settlements is paid out to government entities and designated to be invested in drug rehabilitation programs and efforts to respond to the ongoing opioid epidemic. Another, often equally substantial share, is reserved to establish victim restitution funds. True, victim restitution funds can be set up as a result of court judgments, but those set up pursuant to settlement agreements are often less restrictive. In most cases, when a victim restitution fund is established, whether by judgment or settlement, self-funded health plans have legitimate opportunities for recovery against amounts received by victims.<br /> <br /> Arguably, plan sponsors have a duty to pursue recovery opportunities against victim restitution funds, when practical. Even within the context of opioid-related litigation and settlements, plan sponsors have a fiduciary duty to act prudently with plan assets. This means that plan sponsors should be looking to employ legal, practical means of recovery for the billions of dollars they have collectively spent on opioid-related claim costs.<br /> <br /> In fact, there have already been examples of recoveries obtained by victims of the opioid crisis from trusts established after bankruptcy proceedings for opioid manufacturers, and there will undoubtedly be many more examples going forward as a result of settlement agreements. One such example involves Mallinckrodt Plc, an opioid manufacturer that filed a Chapter 11 bankruptcy proceeding in 2020, in the U.S. Bankruptcy Court for the District of Delaware. Mallinckrodt’s Chapter 11 Plan of Reorganization took effect on June 16, 2022.  As part of that Plan, the Court approved the establishment of the Mallinckrodt Opioid Personal Injury Trust. The Court also drafted procedures by which funds from the Trust could be dispersed, accounting for subrogation and reimbursement claims.<br /> <br /> In this, what would be the first-of-its-kind settlement with nationwide pharmacy chains related to the opioid epidemic, it is likely that a victim restitution fund will be established. If it is, it would present a new opportunity for plan sponsors to recover some of the claim costs they have incurred throughout the opioid epidemic. It will also likely serve as a blueprint for future settlements with pharmacy chains as long, arduous legal battles continue to play out.</span></span></p> <hr /> <p style="text-align: center;"><span style="color:#0071ce;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"></span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><b><span style="font-size:14.0pt"><span style="font-family:"Calibri Light",sans-serif">In Subrogation: Superior Contract Language Matters</span></span></b></span></span></span></span></span></p> <p><span style="color:#0071ce;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><b><span style="font-size:14.0pt"><span style="font-family:"Calibri Light",sans-serif"></span></span></b></span></span></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">By: Scott Byerley, Esq. </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">The United States Congress enacted the Employee Retirement Income Security Act ("ERISA") in 1974 to protect employees and place requirements on pension and health care plans.  The legislation arose from the discourse and fallout that occurred after Studebaker-Packard (Studebaker), an automobile manufacturer that was very poorly fiscally managed, closed its plant in South Bend, Indiana, effectively eliminating employee pensions for thousands of employees.  The problem wasn’t a new one or limited to Studebaker’s closure, which came about in 1963, but rather a systemic one: the lack of corporate accountability in financial reporting and management of pension and health care plans poses significant risks, prompting Congress to protect employees nationwide.<a href="#_edn1" name="_ednref1" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a>  </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">Since that time, ERISA qualified employer-sponsored pension and health care plans preempt state laws and, as such, are exclusively regulated by ERISA (and the resultant federal cases that interpret ERISA throughout the jurisdiction of the United States). To be clear, ERISA is by no means a simple piece of legislation, and courts have often been called to interpret provisions of the statute in relation to employer-sponsored pensions, health plans and their respective beneficiaries. In fact, over the past six decades, the U.S. Supreme Court has made several landmark rulings on health care subrogation cases, specifically impacting the interpretation and understanding of ERISA’s reach in this area, as well as its restrictions on both employers and employees.  </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">This article will focus on health care subrogation from an employer’s perspective under ERISA, highlighting key ERISA requirements and outlining the best way to protect the assets of an employer-sponsored fund <i>expressly</i> in the plan’s contract with the plan member. </span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">From the outset, when a confirmed ERISA plan member has been injured due to an accident potentially caused by a third-party (someone other than the plan member), it is important to gather as much information about the accident and the plan as possible.  As an employer-sponsored plan, it should be easy to determine of which plan the member is an active participant and accordingly eligible for benefits.  However, for employees of larger organizations, there may be different plan designs and coverage options, so it is always best to confirm exactly which plan the member is participating in and therefore which plan they are eligible for benefits under when an accident or injury has occurred.</span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">It is important to note, however, that not all health care plans are ERISA plans.  ERISA, as will be discussed in depth below, has granted protections to plans and plan beneficiaries that improve a plan’s ability to recover against a responsible third-party if the right steps are taken to protect the plan.</span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">First, in order to qualify as an ERISA plan and to maintain a cause of action under ERISA, § 502 (a) (3) (B)<a href="#_edn2" name="_ednref2" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a>, the plan needs to be defined as an “employee welfare benefit plan” or “employee pension benefit plan.”<a href="#_edn3" name="_ednref3" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a>  Moreover, the ERISA-governed plan must be established by the plan sponsor and maintained by a “written instrument.”<a href="#_edn4" name="_ednref4" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a>  Lastly, while almost all private employer plans are subject to ERISA, church, governmental and state plans are generally excluded.<a href="#_edn5" name="_ednref5" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a>  </span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">For the sake of subrogation claims, once the employer or its recovery agent has confirmed the plan is governed by ERISA, then the plan fiduciaries, plan participants, and beneficiaries must look to</span><span style="font-size:12.0pt"> § 502(a)<a href="#_edn6" name="_ednref6" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[6]</span></span></span></span></span></a> to determine the applicable causes of action.  Moreover, ERISA § 502 (a)(1)(B) allows a “participant” or “beneficiary” to bring an action (1) “to recover benefits due under the plan,” (2) “to enforce rights under the terms of the plan,” or (3) “to clarify his/her rights to future benefits under the terms of the plan.”<a href="#_edn7" name="_ednref7" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[7]</span></span></span></span></span></a>  The § 502 (a)(1)(B) claim may be brought in either state or federal court.<a href="#_edn8" name="_ednref8" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[8]</span></span></span></span></span></a>  ERISA § 502(a)(3) allows a “fiduciary, participant, or beneficiary” (1) “to enjoin any act or practice which violates the terms of the plan,” or (2) “to obtain other appropriate equitable relief to either redress violations or to enforce the provisions of ERISA or the terms of the plan.”<a href="#_edn9" name="_ednref9" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[9]</span></span></span></span></span></a>  With respect to actions brought under ERISA § 502(a)(3), the statute grants federal courts exclusive jurisdiction over these claims.<a href="#_edn10" name="_ednref10" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[10]</span></span></span></span></span></a></span></span></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">An employer or its recovery agent should be careful to confirm the ERISA status and to not make the costly mistake of trying to treat a fully insured health plan the same as a self-funded ERISA plan. To be clear, a fully insured health plan exists when the employer has purchased a group insurance policy from a health plan, insurer, or HMO to cover the health care claims that arise under the plan. The other defining feature of a fully insured health plan is that state law would apply to its reimbursement rights.<a href="#_edn11" name="_ednref11" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[11]</span></span></span></span></span></a> Since health care subrogation law varies from state to state and is often more restrictive to a plan’s recovery rights than ERISA federal law, every attempt to clarify the ERISA status and preemptive rights should be made. It’s often not easy to tell by the outward observance of plan operations, without delving into the plan documents and founding instruments of the plan.   </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">In short, a self-funded ERISA plan is a plan sponsored by the employer and funded by contributions directly from its employees.<a href="#_edn12" name="_ednref12" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[12]</span></span></span></span></span></a> In most scenarios, self-funded plans contract separately with a third-party administrator ("TPA") to administer claims under the plan (although the claims are funded and paid with the employer’s and employee’s contributions alone and not by any purchased insurance policy).  Utilizing a TPA is allowed under ERISA because although the TPA assists the plan in processing and paying claims, it is still the self-funded plan that bears the risk for the claims.<a href="#_edn13" name="_ednref13" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[13]</span></span></span></span></span></a>  Furthermore, self-funded plans also <i>preempt</i> state laws (not federal) that relate to employee benefit plans or regulate insurance.<a href="#_edn14" name="_ednref14" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[14]</span></span></span></span></span></a>  </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">To determine the employer plan’s rights, the contract between the plan (employer) and the beneficiary is the first place to look.<a href="#_edn15" name="_ednref15" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[15]</span></span></span></span></span></a>  The contract, the Master Service Agreement ("MSA") or Summary Plan Description ("SPD"), typically includes a provision which outlines the rights of each party to the contract under multiple benefit related scenarios, including payment of claims and/or responsibility for payment of claims or reimbursement of monies paid for claims when an injury or accident has occurred that may be deemed the responsibility of a third-party.  </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">Once you have the document, be prudent in making sure that it is the actual plan document that governs the benefits being paid and is not simply an SPD.  In <i>Cigna v. Amara, </i>the Court found that the CIGNA SPD was not a “plan document,” as it was only a summary and therefore did not properly outline all applicable plan provisions of an actual “plan document.”  Moreover, the Court held that only the terms of a plan (MSA and/or plan document) are enforceable, not the terms set forth in summaries.<a href="#_edn16" name="_ednref16" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[16]</span></span></span></span></span></a>  </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">When an accident or injury involves a member of an ERISA plan, the employer-sponsored health plan must have expressly stated its very strong recovery rights in the plan document, addressing key issues that have been litigated through the years, many of which have been decided by the U.S. Supreme Court. Moreover, the recovery provision addressing the plan’s rights when an at-fault third-party causes injury to the plan member is critical for determining the employer’s right to be reimbursed from any recovery made from said third-party for claims paid on the injured employee’s behalf. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><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%">In <i>U.S. Airways, Inc., v. McCutchen</i>, a landmark U.S. Supreme Court case, the Court addressed the enforceability of a plan’s contract head-on when ascertaining each party’s respective rights when a recovery is made by an injured plan member. The case in <i>McCutchen<a href="#_edn17" name="_ednref17" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><b><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[17]</span></span></span></b></span></span></a> </i>arose, when James McCutchen, an employee of U.S. Airways, participated in and received benefits from the company’s self-funded health plan.  Unfortunately, McCutchen, while covered under the plan,<i> </i>was injured in a motor vehicle accident, sustaining significant injuries that necessitated the plan paying $66,866 for medical treatment on his behalf.<i> </i></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><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%">As a result of his injuries, McCutchen filed a lawsuit against the third-party who caused the accident.  He subsequently recovered $110,000 from the third-party’s liability policy and his own underinsured motorist coverage.  The plan (employer) sought from his recovery the amount which they had expended on his behalf, relying on the following plan language from the contract:</span></span></span></span></span></p> <p style="margin-left:.5in; text-align:justify; margin:0in 0in 8pt; margin-right:0in"><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%">If [the plan] pays benefits for any claim you incur as the result of negligence, willful misconduct, or actions of a third-party…[y]ou will be required to reimburse for amounts paid for claims out of any monies recovered from third-party, including, but not limited to, your own insurance company as a result of the judgment, settlement or otherwise.<a href="#_edn18" name="_ednref18" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[18]</span></span></span></span></span></a></span></span></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">The Court held that the “clear and unambiguous” contract language in the actual plan document/agreement between the employer and the employee <u>controls a plan’s right to be reimbursed from the settlement against the at-fault third-party</u>.<a href="#_edn19" name="_ednref19" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[19]</span></span></span></span></span></a>  </span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><i><span style="font-family:"Calibri",sans-serif">Key Issues that should be addressed and included in the plan language in support of the Employer’s recovery rights:</span></i></span></span></p> <ul> <li style="text-align:justify; margin-right:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">The plan has a first priority right to recovery from the settlement/monies available to the injured plan member as a result of the accident or injury.</span></span></span></li> <li style="text-align:justify; margin-right:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">The plan should require recovery from the plan member’s recovery or directly from the at-fault third-party regardless of whether the plan member has been partially or fully compensated for third-party injuries from the available total recovery.</span></span></span></li> <li style="text-align:justify; margin-right:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">The member’s recovery shall not be construed as being only for pain and suffering and must include the medical claims paid by the employer.</span></span></span></li> <li style="text-align:justify; margin-right:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">The plan will not participate in the common fund (paying for the employee’s personal injury legal fees) or in the ascertaining of the settlement or recovery on behalf of the member.  The member shall bear sole responsibility for the costs of obtaining the recovery.</span></span></span></li> <li style="text-align:justify; margin-right:0in"><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%">What is expressly written in the plan document matters as where the plan is silent or ambiguous, the plan member will have an equitable defense where there is a “gap” in the language.<a href="#_edn20" name="_ednref20" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[20]</span></span></span></span></span></a></span></span></span></span></span></li> </ul> <p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><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%">While</span></span><i><span style="font-size:12.0pt"><span style="line-height:107%"> McCutchen </span></span></i><span style="font-size:12.0pt"><span style="line-height:107%">was a great result for those responsible for protecting the plan’s assets when a plan member has been injured because of a third-party accident, it does place a responsibility on the plan to have the proper recovery language expressly written into the plan document’s subrogation provision. Moreover, the plan must have clear and strong terms of reimbursement in its written contracts for when these accidents and injuries to the plan’s beneficiaries arise. Ignorance of the law or how to address it is no excuse.  The language is either there or it’s not.  If it’s not in the contract, then the employer may not be able to recover the benefits that it paid out for the accident.  Additionally, in that instance of missing language, the Court allowed plan beneficiaries to argue equitable defenses against the plan’s alleged recovery rights.<span class="MsoEndnoteReference" style="vertical-align:super"> <a href="#_edn21" name="_ednref21" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[21]</span></span></span></span></a> </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><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%">So, what does all this mean for employers and sponsors of self-funded ERISA health plans? First, the plan has a fiduciary obligation to protect the fund, and, secondly, unlike when there is an insurance policy, this money is contributed by employees and set aside for them to actually “fund” the plan to pay for coverable claims from the “fund” when an employee/plan member requires medical treatment. It is the plan’s fiduciary responsibility to proceed in the best interest of the plan and its participants and beneficiaries to protect plan assets. By not having the right language in the contract with the employee, the employer may be unable to recover from the third-party settlement and subject itself to a claim for breach of its fiduciary obligation to ALL plan members of the fund for inadequately protecting plan assets.</span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><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%">Indeed, this is a tricky landscape to navigate properly.  For that reason and given what’s at stake for the plan, employers are strongly recommended to consult with experts to ensure they are doing all they can to protect plan assets in such matters that are often litigated by plaintiff’s attorneys seeking to maximize recovery for their client, the injured plaintiff/employee.</span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif"></span></span></span></span></span></span></p> <div>  <hr align="left" size="1" width="33%" /> <div id="edn1"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref1" name="_edn1" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[1]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> Sarah Steers, ERISA History, Jurist, (Oct. 4, 2013, 12:01 PM), http://www.jurist.org/feature/2013/10/erisa-history.php.</span></span></span></p> </div> <div id="edn2"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref2" name="_edn2" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[2]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> § 502(a)(3), 29 U.S.C. § 1132(a)(3).</span></span></span></p> </div> <div id="edn3"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref3" name="_edn3" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[3]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> 29 U.S.C. § 1002 (3).</span></span></span></p> </div> <div id="edn4"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref4" name="_edn4" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[4]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> 29 U.S.C. § 1102 (a)(1).  </span></span></span></p> </div> <div id="edn5"> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref5" name="_edn5" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[5]</span></span></span></span></span></span></span></a><span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif"> ERISA § 4, 29 U.S.C. 1003.</span></span></span></span></span></span></p> </div> <div id="edn6"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref6" name="_edn6" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[6]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> 29 U.S.C. § 1132</span></span></span></p> </div> <div id="edn7"> <p style="margin-bottom:0in; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref7" name="_edn7" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[7]</span></span></span></span></span></span></span></a> <span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif">ERISA §502(a)(1)(B), 29 U.S.C. §1132(a)(1)(B).</span></span><span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif"></span></span></span></span></span></span></p> </div> <div id="edn8"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref8" name="_edn8" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[8]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> <div id="edn9"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref9" name="_edn9" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[9]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> <div id="edn10"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref10" name="_edn10" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[10]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> <div id="edn11"> <p class="Default" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="color:black"><a href="#_ednref11" name="_edn11" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif"><span style="color:black">[11]</span></span></span></span></span></span></span></span></a><span style="font-size:10.0pt"><span style="font-family:"Calibri Light",sans-serif"> <i>FMC Corp. v. Holliday</i>, 498 U.S. 52 (1990).  </span></span></span></span></span></p> </div> <div id="edn12"> <p style="margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref12" name="_edn12" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[12]</span></span></span></span></span></span></span></span></a><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif"> John MacDonald, Health Plan Differences: Fully-Insured vs. Self-Insured, Employee Benefit Research Institute, </span></span></span><a href="http://www.ebri.org/.../ffe114.11feb09.fin" style="color:#0563c1; text-decoration:underline"><span lang="EN" style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">www.ebri.org/.../ffe114.11feb09.fin</span></span></span></a><cite><span lang="EN" style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">.</span></span></span></cite><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif"></span></span></span></span></span></span></p> </div> <div id="edn13"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref13" name="_edn13" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[13]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i> </span></span></span></p> </div> <div id="edn14"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref14" name="_edn14" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[14]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>FMC Corp., supra </i>note 15.</span></span></span></p> </div> <div id="edn15"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref15" name="_edn15" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[15]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>U.S. Airways, Inc., v. McCutchen</i>, 133 S. Ct. 1537 (2013).</span></span></span></p> </div> <div id="edn16"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref16" name="_edn16" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[16]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> <div id="edn17"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref17" name="_edn17" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[17]</span></span></span></span></span></span></a><i><span style="font-family:"Calibri Light",sans-serif"> Id</span></i><span style="font-family:"Calibri Light",sans-serif">. at 1543.</span></span></span></p> </div> <div id="edn18"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref18" name="_edn18" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[18]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id</i>. at 1543.</span></span></span></p> </div> <div id="edn19"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref19" name="_edn19" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[19]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> <div id="edn20"> <p class="MsoEndnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref20" name="_edn20" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[20]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> <div id="edn21"> <p class="MsoEndnoteText" style="margin: 0in 0in 0in 40px;"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ednref21" name="_edn21" style="color:#0563c1; text-decoration:underline" title=""><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-family:"Calibri Light",sans-serif"><span class="MsoEndnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri Light",sans-serif">[21]</span></span></span></span></span></span></a><span style="font-family:"Calibri Light",sans-serif"> <i>Id.</i></span></span></span></p> </div> </div> <p><span style="color:#0071ce;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><b><span style="font-size:14.0pt"><span style="font-family:"Calibri Light",sans-serif"></span></span></b></span></span></span></span><span style="font-size:18px;"><b><span style="font-family:"Calibri",sans-serif"></span></b></span></span></p> 1206The Phia Group's 4th Quarter 2022 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1189/the-phia-groups-4th-quarter-2022-newsletterNewslettersWed, 19 Oct 2022 18:28:44 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2022/phiaheader2021.jpg?ver=kG0SmqlSJp67FY1HQzR8hA%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/icons6622.png?ver=7PgkCGGbJL898QUolrAmmw%3d%3d" style="width: 650px; height: 149px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/block0422l.png?ver=VxC4VdpyTnqeg9j6vaoq3A%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pace3"><img src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/block0422r.png?ver=VxC4VdpyTnqeg9j6vaoq3A%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> </table> </td> </tr> <tr> <td valign="top" width="47%"> <p><br /> <img height="282" src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" width="291" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">It’s fall here in New England; my second favorite time of the year. As we transition from the summer (my favorite time of year – for those wondering) to winter, many are saddened by what feels like an “end” of things… The end of a fun filled summer. The end of the year. Yet, I feel like autumn in Boston is more like a beginning. To me, it feels like an implementation of the holiday season. Halloween is the opening festivity or appetizer, followed by an incredible main course (Thanksgiving and Christmas), and concluding with New Year’s celebrations for dessert. I will admit I shed a tear when the pool was closed and the irrigation was locked down in anticipation of the inevitable cold and snow; but the anticipation itself is so exciting.</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">The self-funded health benefits space is no different. This is the time when we get to work! This is when we hunker down, and really dig into renewal season. Plan document updates, innovative design changes, stop-loss reviews, new business closings and client retentions … all locked into place as we prepare for the new year! What could be more exciting? Nothing beats that “new plan smell…” Not even pumpkin spice lattes. Speaking of which, skip the coffee shops and orchards. There is no better place to get ready for new beginnings than here at The Phia Group. When it comes to what you need to do to retain existing clientele, attract new prospects, and supply all of them with the best performing most robust plans, we are way ahead of the rest. Yes, we are the ones that already have the Halloween decorations up, and our leaves raked and bagged. Additionally, we are also monitoring pending and proposed legislation and regulation, so that we can tell you what to look out for, and what to stay away from, in the coming months. In other words, we have already confirmed which houses are giving out the full size candy bars, and which are handing out the floss. So many of you – spanning from coast to coast – have already reached out to us to discuss and implement new strategies. Our organization – and I personally – am so grateful for you, your energy, and your enthusiasm … all of which makes this season, and this industry, so exciting. Just know that we are here for you. I hope you all enjoy this issue of the newsletter and as always.</p> <p class="bodytext"><a name="russo09"></a></p> <p class="bodytext">– Happy reading!</p> <p class="bodytext"> </p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p class="tocbkgd"><img src="/Portals/phiagroup/Newsletter 2018 Q2/inthisissue.png?ver=4_c-EncNsuJUxrT1QINLVg%3d%3d" style="width: 101px; height: 18px;" /><br /> <a href="#russo4">Enhancements of the Quarter: Proactive ICE Stop-Loss Policy Reviews</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2022 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#pemployee">Employee of the Quarter</a><br /> <a href="#pemployee">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><a id="russo4" name="russo4"></a></p> <p class="bodytext"><strong>Enhancement of the Quarter: Proactive ICE Stop-Loss Policy Reviews </strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group prides itself on having enough experience in the industry to know what issues our clients are facing. With our Independent Consultation and Evaluation (ICE) service, we provide prepaid consultative services to help with all your self-funding needs; our ICE clients generally utilize this service a great deal, but there are certain issues brought to our attention that would be better taken care of before they arise. A perfect example is an unexpected stop-loss denial. </p> <p class="bodytext" style="text-align: justify;">In August, we undertook a large project to review stop-loss policies that our ICE clients send to us. If you are an ICE client, you have likely seen our emails with those reviews, and we hope they are helpful. Sending proactive policy reviews to all ICE clients is an enhancement to the service, designed to not only help TPAs, brokers, and health plans evaluate or vet a policy being pitched or renewed, but also to help provide information regarding which carriers’ policies may cause certain issues, and which don’t. </p> <p class="bodytext" style="text-align: justify;">We have never reviewed, read, or even heard of any stop-loss policy that didn’t contain some provisions that are actually or potentially problematic for a health plan, and we can tell you with confidence that even your preferred carriers’ policies have some language worth discussing to get ahead of an unexpected denial before it rears its ugly head. </p> <p class="bodytext" style="text-align: justify;">If you are a client of The Phia Group’s ICE service, feel free to send any policies you’d like reviewed to your dedicated ICE email address, and we will perform those reviews at no additional cost. This enhancement to the ICE service is meant to provide more than an ounce of prevention, and we’ve gotten great feedback so far. If you’re not an ICE client, feel free to send policies that need reviews to <a href="mailto:PGCReferral@phiagroup.com ">PGCReferral@phiagroup.com</a> (or just become an ICE client, and there won’t be any additional cost!).<a name="pace3"></a></p> <p class="bodytext"><strong>Service Focuses of the Quarter: Plan Appointed Claim Evaluator (PACE)</strong> </p> <p class="bodytext" style="text-align: justify;">The Phia Group’s Plan Appointed Claim Evaluator (PACE) service was created as a way to help health plans and TPAs manage complex and very personal second-level appeals, and to ensure that fiduciary duties are satisfied by a neutral third party. PACE, a fiduciary transfer service for applicable final-level internal appeals, is designed to help the health plan ensure that appeals are handled in accordance with the law, thereby insulating the health plan against liability and allowing the employer to focus on what it does best. </p> <p class="bodytext" style="text-align: justify;">Among other benefits, plan document and stop-loss policy reviews and suggestions promote compliance, eliminate coverage gaps, and ensure PACE readiness. Through the PACE service, The Phia Group analyzes final-level internal appeals and renders a determination as fiduciary and obtains clinical review and access to URAC-accredited IROs as necessary, with all third-party review costs included. With the advent of the No Surprises Act, the appeals process has been turned on its head, and PACE is more important than ever as a tool to sort out the complex issues inherent in the new paradigm. Some grievances are treated in different and perhaps unexpected ways, and PACE is here to help figure it all out. </p> <p class="bodytext" style="text-align: justify;">We also offer PACE Certification, through which your organization can enhance your PACE understanding and utilization, improve your general internal appeals processes, learn how to better ensure regulatory compliance, and improve your business as a whole. </p> <p class="bodytext" style="text-align: justify;"> To learn more, contact <a href="mailto:PACECertification@phiagroup.com">PACECertification@phiagroup.com</a>. </p> <p class="bodytext"><strong>Success Story of the Quarter: Revealing Compliance Shortcomings With NQTL Analyses</strong></p> <p class="bodytext" style="text-align: justify;">As you likely know, health plans subject to the Mental Health Parity and Addiction Equity Act are required to analyze the plan’s compliance with the MHPAEA and generate a report documenting compliance (or lack thereof) with respect to each nonquantitative treatment limitation (or NQTL) found within the plan. An NQTL is exactly what it sounds like: a limitation placed on treatment that is not readily quantifiable (an example being pre-certification requirements). Per the MHPAEA, a health plan is out of compliance if the plan applies any given NQTL more stringently to typical mental health or substance abuse disorder benefits than the plan applies the same NQTL to typical medical and surgical services. The law requires plans to analyze each NQTL not just in writing, but in operation as well – and sometimes the “in writing” and “in operation” pieces don’t quite match up, which is a problem for various reasons, not the least of which being MHPAEA compliance. </p> <p class="bodytext" style="text-align: justify;">In the process of performing an extensive NQTL analysis for a health plan, Phia’s team pored over the language of the plan document, a UM vendor’s written processes, and the UM vendor’s aggregate summary data for the prior plan year. In performing this analysis, one of Phia’s attorneys noticed that the three data points didn’t quite match up; it appeared that the UM vendor’s processes didn’t take into account the plan language, such that the plan language was not being applied as written – and then the aggregate data indicated that yet another set of standards was being used, other than the plan language and the vendor’s written processes. Not only were the vendor’s standard written processes noncompliant with the MHPAEA’s mandate of parity, but the existence of three different standards (one written by the plan, one written by the vendor, and one actually done by the vendor) presented not only an MHPAEA problem, but also an ERISA problem, since plan members were being given plan language that was not being followed. To make matters worse, the vendor was not even following its own written processes! </p> <p class="bodytext" style="text-align: justify;">Armed with this information, the plan was able to discuss the matter with its UM vendor, which is currently working to reconcile its written processes with its operational procedures – and the plan is working to update its plan document language to match the vendor’s updated written procedures (which the vendor has vowed to follow from now on!). Unfortunately, there is nothing the plan can do to rectify the compliance deficiency for the prior year, but taking good faith steps to cure a deficiency for future plan years goes a long way in the event of an audit. </p> <p class="bodytext" style="text-align: justify;">If you or a group need NQTL consulting or the analysis itself, please let us know via <a href="mailto:Phia-NQTL@phiagroup.com">Phia-NQTL@phiagroup.com</a>.</p> <p class="bodytext"><strong>Phia Case Study: Stop-Loss Isn’t Bound by the ACA!</strong></p> <p class="bodytext" style="text-align: justify;">A TPA provided us with a stop-loss denial scenario where one of the TPA’s groups was required to pay a previously-denied claim as the result of the decision of an Independent Review Organization, the process created by the ACA all those years ago. Even though the plan’s language specifically stated that the plan would pay a claim if an IRO reversed a denial and explicitly directed the plan to pay, the plan’s stop-loss policy had no such allowance. That’s because even though the plan was required by law to pay a denied claim when directed by an IRO, the plan’s stop-loss carrier was under no such obligation, and the carrier had elected to not include any such allowance in its policy. </p> <p class="bodytext" style="text-align: justify;">The policy was a 12/12, and the spec claim was incurred in month seven of twelve, denied in month eight of twelve, but not reversed by the IRO until month thirteen of twelve. As a result, even if the carrier would have otherwise reimbursed the expense, the plan benefits weren’t paid until after the policy period had ended, and therefore there was no stop-loss coverage for the claim, one that the plan had no choice to pay at more than three times the specific deductible. </p> <p class="bodytext" style="text-align: justify;">Needless to say, the TPA and plan were not pleased. </p> <p class="bodytext" style="text-align: justify;">Phia was engaged to scour the file and contracts and try to find some loophole, but unfortunately stop-loss policy limitations are usually drafted very clearly, and this one was no different. We tried to negotiate with the carrier, but as soon as we saw the name on the paper, we knew they weren’t going to make any concessions. As a result of this large denial, the group threatened to leave the carrier, but the carrier still did not balk. The group wasn’t bluffing, though; the group directed its broker to shop around for policies, which the TPA promised it would have Phia review prior to being placed this time to avoid a similar situation in the future!</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: “Avoiding Prohibited Transactions”</strong></p> <p class="bodytext" style="text-align: justify;">As a consumer protection law, the No Surprises Act provides very little, if any, meaningful protection for health plans. Some interpret that to mean that Congress doesn’t care about health plans – but we believe that the NSA is simply meant to serve a different purpose, and insurers simply got caught in the crossfire of charges versus payment. Either way, we’ve got ample evidence that Congress in fact does care about health plans, including the recent update made to ERISA’s “prohibited transaction” rules. </p> <p class="bodytext" style="text-align: justify;">In sum, health plan vendors must disclose all compensation earned directly or indirectly from a health plan, and service agreements must give a health plan the opportunity to gauge the reasonableness of fees being charged and compensation being earned. While many consider this a no-brainer, there is a lot of grey area; the self-funded industry is full of complex and ill-defined relationships, which now may need to be better defined, in particular where compensation is concerned. </p> <p class="bodytext" style="text-align: justify;">Congress has seen fit to help protect health plans from those companies that service them. The typical health plan is often conceptualized as being relatively uninformed, often blindly following a TPA’s or broker’s advice without questioning vendors, fees, or services; Congress has imposed this transparency rule to protect even the most naïve health plan from hidden or ill-defined fees. Since health plans are required to account for their outgoing compensation, vendors are now required to explain and justify their incoming compensation. </p> <p class="bodytext" style="text-align: justify;">If you’re concerned that your TPA, broker or other vendor service agreement needs some work in this (or any other) regard, we can help! For more information, please contact your dedicated ICE email, or <a href="mailto:PGCReferral@phiagroup.com">PGCReferral@phiagroup.com</a>.</p> <a name="pdef"></a> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On September 15, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/a-prescription-for-success-the-unknown-impact-of-recent-legislation-on-prescription-expenses">A Prescription for Success? The Unknown Impact of Recent Legislation on Prescription Expenses</a>,” in which the team discussed The Inflation Reduction Act, signed into law by President Biden, the recent Johnson & Johnson lawsuit involving patient assistance programs, and much more. </p> <p class="bodytext" style="text-align: justify;">• On August 18, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/unfinished-business-legal-fallout-leaves-plans-in-limbo">Unfinished Business: Legal Fallout Leaves Plans in Limbo</a>,” in which the team discussed the domino effect of the Supreme Court’s decision to overturn Roe v. Wade. </p> <p class="bodytext" style="text-align: justify;">• On July 19, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/supreme-decisions-a-proactive-approach-for-health-plans-to-dobbs-and-marietta">Supreme Decisions – A Proactive Approach for Health Plans to Dobbs and Marietta</a>,” in which we discussed landmark healthcare rulings that continue to reverberate across the country and our industry.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p>   <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On September 29, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p145-conflicting-views-on-covid-is-the-pandemic-over">Conflicting Views on COVID: Is the Pandemic “Over”</a>,” in which our hosts, Kelly Dempsey and Kevin Brady, discussed President Biden’s 60 Minutes interview that aired on Sunday, September 18, 2022. </p> <p class="bodytext" style="text-align: justify;">• On September 16, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p144-the-latest-developments-involving-patient-assistance-programs">The Latest Developments Involving Patient Assistance Programs</a>,” in which our hosts, Brady Bizarro and Andrew Silverio, discussed patient assistance programs. </p> <p class="bodytext" style="text-align: justify;">• On September 2, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p143-is-wrongful-death-the-death-of-a-subrogation-claim">Is Wrongful Death the Death of a Subrogation Claim?</a>,” in which our hosts, Chris Aguiar and Cindy Merrell, discussed the murky waters of wrongful death and healthcare subrogation claims. </p> <p class="bodytext" style="text-align: justify;">• On August 19, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p142-the-healthcare-times-they-are-a-changin">The (Healthcare) Times They Are A-Changin’</a>,” in which our hosts, Nick Bonds and Corey Crigger, discussed two shifts in the healthcare landscape, the FDA’s stance on OTC hearing aids, and recent developments that show that not all debt is created equal, especially medical debt. </p> <p class="bodytext" style="text-align: justify;">• On August 5, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p141-do-you-mind-the-gap">Do You Mind (…The Gap)?</a>,” in which our hosts, Jen McCormick and Jon Jablon, discussed the age-old topic of stop-loss gaps, with a modern twist. </p> <p class="bodytext" style="text-align: justify;"> • On July 22, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/should-plans-better-address-mental-health-benefits-the-phia-group">Should Plans Better Address Mental Health Benefits?</a>,” in which our hosts, Ron E. Peck and Kaitlyn MacLeod, discussed what plans are doing to address the mental health crisis and how mental health parity comes into play for plans, patients, and providers. </p> <p class="bodytext" style="text-align: justify;">• On July 8, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/stop-loss-and-subrogation-the-phia-group">Stop Loss and Subrogation</a>,” in which our hosts, Cindy Merrell and Chris Aguiar, discussed potential obligations of health plans to their stop-loss carriers in the event of a recovery through subrogation. </p> <p class="bodytext" style="text-align: justify;">• On July 1, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-dobbs-case-what-group-health-plans-and-employers-need-to-know-the-phia-group">The Dobbs Case – What Group Health Plans and Employers Need to Know</a>,” in which our hosts, Ron E. Peck, Jen McCormick, and Brady Bizarro, discussed the U.S. Supreme Court’s decision to overturn Roe v. Wade and the sweeping implications for group health plans.<br />  </p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" height="130" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" width="510" /></a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext">• BenefitsPro – <a href="https://www.benefitspro.com/2022/09/20/how-does-the-inflation-reduction-act-affect-self-funded-plans/">How does the Inflation Reduction Act affect self-funded plans?</a> – September 20, 2022 </p> <p class="bodytext">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/Regulatory_Recap-_COVID-19_and_The_Ongoing_Impact_on_Self-Funded_Plans_by_Kelly_E__Dempsey.pdf">Regulatory Recap: COVID-19 & The Ongoing Impact On Self-Funded Plans</a> – August 4, 2022<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1"></span><br />  </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/more-twists-to-the-idr-process-in-the-no-surprises-act">More Twists to the IDR Process in the No Surprises Act?</a>. The latest final rule on the No Surprises Act has finally been released. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/hhs-proposes-rules-for-1557-covered-entities">HHS Proposes Rules for 1557 Covered Entities</a>. On July 25, 2022, HHS announced a proposed rule that would strengthen the protections granted by Section 1557 of the ACA in various contexts. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/one-lesson-we-must-all-learn-from-dobbs-v-jackson-womens-health-organization">One Lesson We Must All Learn from Dobbs v. Jackson Women's Health Organization</a>. A lesson worth learning. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/lessons-from-mariettas-victory">Marietta Memorial Hospital Employee Health Benefit Plan v DaVita Inc. - Dialysis Carve-Out</a>. The framework for how plans can include language supporting well-drafted, neutrally applied dialysis carve-outs.</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a>The Stacks:</span></p> <p class="bodytext" style="text-align: justify;"><strong>Regulatory Recap: COVID-19 & The Ongoing Impact on Self-Funded Plans</strong><br />  </p> <p class="bodytext" style="text-align: justify;">By: Kelly E. Dempsey, Esq. – August 2022 – <a href="https://www.sipconline.net/files/Regulatory_Recap-_COVID-19_and_The_Ongoing_Impact_on_Self-Funded_Plans_by_Kelly_E__Dempsey.pdf">Self-Insurers Publishing Corp</a>. The self-funded industry and the insurance industry in general have always been subject to constant change and 2022 is not proving to be any different. From the Consolidated Appropriations Act of 2021 (CAA) (which includes the NQTL Comparative Analysis requirement, the No Surprises Act (NSA), and the Transparency Rules) to the Marietta dialysis carve-out case to the Dobbs abortion case, there are a lot of “fires” to keep our eyes on. </p> <p class="bodytext" style="text-align: justify;">And of course, we cannot forget about a fire that has been burning since early 2020: COVID-19. That is right, COVID-19 still has ongoing implications for group health plans, and those implications continue to compound. There has been no shortage of government oversight in terms of this virus; to do it all justice, it makes sense to start with a quick summary of rules that are still in existence and then move on to a review of the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) long COVID guidance, and finally to the United States Equal Opportunity Commission (EEOC) guidance that many have overlooked in light of the other regulatory fires burning at the end of 2021.  </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2022-newsletter">Click here</a> to read the rest of this article</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2022 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2022 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" height="240" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" width="489" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p><span class="bodytext"></span></p> <p class="bodytext" style="font-weight: normal">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs.<br /> <br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pemployee" name="pemployee"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><strong><span style="font-size:18px;">Phia News:</span></strong></span></p> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter: Sam Cox</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Sam Cox, The Phia Group’s 2022 Q3 Employee of the Quarter! </p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Sam: “Sam is the definition of “above and beyond”. No one in Provider Relations works more diligently and unselfishly on everything she is involved with and for years has given 110% daily effort in everything she does for Provider Relations. She has been acting as department coordinator and intake for all Provider Relations Units. Recently with the passage of the NSA, she took on the responsibility of intake and coordinator on all new NSA claims which takes considerable organizational skills. All of these activities are not accomplished independently and all require constant communication and coordination with Phia’s clients.”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/sam1.jpg?ver=VxC4VdpyTnqeg9j6vaoq3A%3d%3d" style="width: 390px; height: 460px;" /></p> <p class="bodytext"> </p> <p class="bodytext">Congratulations Sam, and thank you for your many current and future contributions.</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a></span></p> <p class="bodytext"><span class="heading1">Job Opportunities:</span></p> <p class="bodytext">• EDI Data Engineer </p> <p class="bodytext">• Accounts Receivable Specialist </p> <p class="bodytext">• Claim Analyst </p> <p class="bodytext">• Customer Service Rep </p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• Health Benefit Attorney </p> <p class="bodytext">• Provider Relations Coordinator</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext" style="text-align: justify;">• Diana Newburg has been promoted from PACE Specialist to PACE Specialist II </p> <p class="bodytext" style="text-align: justify;">• Jamie Johnson has been promoted from Team Lead of Recovery Services to Manager of Recovery Services </p> <p class="bodytext" style="text-align: justify;">• Andrew Silverio has been promoted from Attorney II to Senior Attorney</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Richard Hunt was hired as a Facilities Coordinator </p> <p class="bodytext">• Anthony Petrilli was hired as a Customer Service Representative </p> <p class="bodytext">• Matt Morrell was hired as a Project Coordinator </p> <p class="bodytext">• Maghen Keefe was hired as a PACE Appeal Specialist </p> <p class="bodytext">• Olivia Storey was hired as a Health Benefit Plan Consultant </p> <p class="bodytext">• Harman Singh was hired as a Software Engineer Intern</p> <p class="bodytext">• Alyssa Catalano was hired as a Customer Service Representative</p> <p class="boldtext">Energage Names The Phia Group a Winner of the 2022 Top Workplaces USA Award</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">It is with great honor and humility that The Phia Group announces that it has earned a 2022 Top Workplaces USA award, issued by Energage. Energage, an organization that develops solutions to build and brand a vast array of companies, leveraged its 15-year history of surveying more than 20 million employees across 54 markets to award this prize. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Earning this accolade was no small task. Several thousand organizations from across the country were invited to participate, and winners of the Top Workplaces USA were chosen based solely on employee feedback gathered through an employee engagement survey, issued by Energage. These results were then calculated by comparing the survey’s research-based statements, including 15 Culture Drivers that are proven to predict high performance against industry benchmarks. </p> <a name="story"> </a> <p class="boldtext"><a name="story"><img alt="" src="/Portals/phiagroup/Newsletters/Q2 2022/award09.png?ver=bR0_Taj_PRNhLrsBbLJTaA%3d%3d" style="width: 420px; height: 450px;" /> </a></p> <a name="story"></a><a name="story"></a> <p class="bodytext"><a name="story"><span class="heading1"></span></a><a id="pnews" name="pnews"></a></p> <p class="boldtext">Cornhole Tournament and Phia BBQ</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">It has become tradition at The Phia Group to celebrate the last day of summer with great games, food, and conversations. This year we invited all Phia employees to enter into our cornhole tournament. As you can see, we had a great turnout. The winners of the cornhole tournament were Julie Padden and Ujwal Shrestha. Congrats on the win, it was a close game!  </p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" height="307" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/cornhole1.jpg?ver=VxC4VdpyTnqeg9j6vaoq3A%3d%3d" width="439" /> <img alt="" height="304" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/cornhole2.jpg?ver=VxC4VdpyTnqeg9j6vaoq3A%3d%3d" width="437" /> <p class="boldtext">Ice Cream at Phia</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia family was visited by an all-you-can-eat ice cream truck a few times this past summer, and everyone in the office was excited to dive into the delicious treats. After a long day at work, there’s nothing better than biting into a delicious ice cream bar. The Phia family loved the variety of treats and were able to mingle outside on these beautiful days!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" height="286" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2022/icecream1.jpg?ver=VxC4VdpyTnqeg9j6vaoq3A%3d%3d" width="409" /> <p class="bodytext"><strong><br /> COVID - Appeals, Subrogation, and Stop Loss Issues No One Saw Coming - Help is Here</strong></p> <p class="bodytext"> </p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/covid.png?ver=1PYo1bACQA4zxTLKiRB-tA%3d%3d" style="width: 572px; height: 533px;" /></p> <p class="bodytext" style="text-align: justify;">COVID claims are coming - whether you pay or deny claims tied to COVID, you need The Phia Group.</p> <p class="bodytext" style="text-align: justify;">Claims tied to the treatment of COVID-19 are being submitted for payment and are passing through the claims process in record numbers. Many of these claims are substantial, with these considerable costs impacting our industry in both anticipated and unforeseen ways. As with any influx of new claims, we are also seeing growth in the number of denials and appeals arising from these COVID claims, as well as subrogation issues tied to the disease.</p> <p class="bodytext" style="text-align: justify;">COVID claims are routinely denied and/or paid incorrectly, due in large part to the inadequate time provided to consultants, administrators, and payers, to familiarize themselves with the ever changing rules, and thereby standardize appropriate handling of these claims in accordance with law and their plan documents. As a result, we are also seeing an increase in COVID related claim appeals, with heightened fiduciary liability issues also arising from these claim payment decisions.</p> <p class="bodytext" style="text-align: justify;">The Phia Group's PACE Service has existed for years and is the only service on the market where expert plan drafters, attorneys, and seasoned appeals professionals help you navigate these and other difficult appeals, thereby avoiding mistakes and costly liability. PACE ensures claim denials are legitimate, enforceable, and defended.</p> <p class="bodytext" style="text-align: justify;">As with claims processing and appeals, COVID has also created a new world for subrogation. When COVID claims are submitted, complex state law may be triggered regarding if and when COVID is "presumed" to be an occupational expense. The Phia Group was the first subrogation provider to build a custom process backed by its in-house legal team with a focus on identifying COVID related claims, determining whether the applicable geographic location and occupation are addressed by a regulation that presumes a link between the occupation and diagnosis, and quickly asserts a right to reimbursement against responsible parties if possible. The Phia Group has been applying this procedure to its existing process since June of 2020. Without an innovative subrogation solution like ours in place, plans not only lose money, but also fail in their obligation to stop-loss; a failure stop-loss carriers are increasingly unwilling to overlook.</p> <p class="bodytext" style="text-align: justify;">The stop-loss world has been handed a unique and difficult scenario. As it relates to claims arising from or tied to COVID-19, carriers are suspending reimbursement and asking questions such as: what is the Plan Participant's job description; is the Plan Participant a front line worker; what date did they test positive; are they an essential worker; did they file a workers' compensation claim; and so on. The Phia Group has the expertise to assist in these difficult stop-loss collaborations.</p> <p class="bodytext" style="text-align: justify;">Ensuring appeals are handled correctly, aligning plan documents with stop-loss policies, and fully understanding the bigger picture has never been more important. The Phia Group is uniquely positioned to help in this difficult time. With our unrivaled team and technology ready to help, there is no better partner to assist you now and in the days to come.</p> <p class="bodytext" style="text-align: justify;">Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com" target="_blank">ghunt@phiagroup.com</a> or <a href="mailto:info@phiagroup.com" target="_blank">info@phiagroup.com</a> to request more information and set a call to learn how The Phia Group can assist you with these COVID claim issues.</p> <p class="bodytext" style="text-align: justify;"><strong><br /> The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.<br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter 2018 Q2/footerlogo.png?ver=iYwkNviyLE_yU_0lKTSyJQ%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1189The Stacks – 4th Quarter 2022 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1188/the-stacks-4th-quarter-2022-newsletterNewslettersWed, 19 Oct 2022 16:43:42 GMT<p style="text-align:justify; margin:0in"><span style="font-size:18px;"><span style="color:#0071ce;"><span calibri="" style="font-family:"><b>The COVID-19 Fire is Still Burning</b></span></span></span><br /> <br /> <strong><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">By: Kelly E. Dempsey, Esq. </span></span></span></strong><br /> <br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">The self-funded industry and the insurance industry in general have always been subject to constant change and 2022 is not proving to be any different. From the Consolidated Appropriations Act of 2021 (CAA) (which includes the NQTL Comparative Analysis requirement, the No Surprises Act (NSA), and the Transparency Rules) to the<i> Marietta</i> dialysis carve-out case to the <i>Dobbs</i> abortion case, there are a lot of “fires” to keep our eyes on.</span><br /> <br /> <span style="color:#000000;">And of course, we cannot forget about a fire that has been burning since early in 2020: COVID-19. That is right, COVID-19 <i><u>still</u></i> has ongoing implications for group health plans, and those implications continue to compound. There has been no shortage of government oversight in terms of this virus; to do it all justice, it makes sense to start with a quick summary of rules that are still in existence and then move on to a review of the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) long COVID guidance, and finally to the United States Equal Opportunity Commission (EEOC) guidance that many have overlooked in light of the other regulatory fires burning at the end of 2021.</span><br /> <br /> <span style="color:#000000;"><i>Public Health Emergency (PHE) and the National Emergency Periods</i></span></span></span><span style="color:#000000;"></span></p> <p style="margin-left:.5in; text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">That’s right, you read that correctly: these emergencies are <i><u>still</u></i> in effect! These periods are often conflated, but the distinction is an important one, since some health plan requirements hinge on the PHE, while others hinge on the National Emergency.</span><br /> <br /> <span style="color:#000000;">The PHE (declared by the HHS Secretary) was extended in April 2022 and set to expire in mid-July 2022; however, the Biden administration noted there will be 60 days advance notice before the PHE will expire. No such notice has been given as of the date of this article was written, thus the PHE is likely ongoing, potentially for at least 60 more days. The coverage mandates related to COVID-19 testing and the vaccine are tied to the status of the PHE. </span><br /> <br /> <span style="color:#000000;">The “Extensions of Certain Timeframes” – often referred to as the “tolling of deadlines” – such as HIPAA</span></span></span><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">special enrollment rights, COBRA election periods, and, most daunting of all for many, claims and appeals submission timeframes – hinge on the National Emergency and especially the so-called Outbreak Period. The Outbreak Period ends 60 days after the announced end of the National Emergency, which to date is also still ongoing. President Biden last extended the National Emergency in February 2022 this year. </span><br /> <br /> <span style="color:#000000;"><i>Tolling of Deadlines Under COVID-19 Relief</i></span></span></span><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">Due to the COVID-19 pandemic, the DOL and IRS issued a Joint Rule extending certain deadlines for most group health plans, disability and other employee welfare benefit plans, and employee pension benefit plans.</span><a href="#_ftn1" name="_ftnref1" title=""><span style="color:#000000;"><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span calibri="" style="font-family:">[1]</span></span></span></span></span></a><span style="color:#000000;"> This rule defines an “Outbreak Period” from March 1, 2020 until 60 days after the end of the declared state of the National Emergency, and states that this Outbreak Period must be disregarded for the calculation of any applicable deadlines, including:</span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span calibri="" style="font-family:"> <span style="color:#010101"><br /> 1. With respect to plan participants, beneficiaries, qualified beneficiaries, and claimants:</span></span></span></p> <ul style="margin-left: 80px;"> <li style="text-align: justify; margin: 0in;"><span style="font-size:11pt"><span style="tab-stops:list .75in"><span calibri="" style="font-family:"> <span style="color:#010101">the 30- or 60-day period to request Health Insurance Portability and Accountability Act special enrollment;</span></span></span></span></li> <li style="text-align: justify; margin: 0in;"><span style="font-size:11pt"><span style="tab-stops:list .75in"><span calibri="" style="font-family:"> <span style="color:#010101">the 60-day election period for Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation coverage;</span></span></span></span></li> <li style="text-align: justify; margin: 0in;"><span style="font-size:11pt"><span style="tab-stops:list .75in"><span calibri="" style="font-family:"> <span style="color:#010101">the date by which COBRA premium payments must be made;</span></span></span></span></li> <li style="text-align: justify; margin: 0in;"><span style="font-size:11pt"><span style="tab-stops:list .75in"><span calibri="" style="font-family:"> <span style="color:#010101">the date by which individuals must notify the plan of a COBRA qualifying event or determination of disability;</span></span></span></span></li> <li style="text-align: justify; margin: 0in;"><span style="font-size:11pt"><span style="tab-stops:list .75in"><span calibri="" style="font-family:"> <span style="color:#010101">the date by which individuals may file a benefit claim or appeal under the plan’s claims and appeals procedures; and</span></span></span></span></li> <li style="text-align: justify; margin: 0in;"><span style="font-size:11pt"><span style="tab-stops:list .75in"><span calibri="" style="font-family:"> <span style="color:#010101">the date by which individuals may file a request for an external review or file information to perfect an incomplete request for external review.</span></span></span></span></li> </ul> <p style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span calibri="" style="font-family:"> <span style="color:#010101">2. With respect to group health plans and their sponsors and administrators, the date by which a COBRA election notice must be provided. </span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><br /> <span style="color:#000000;">On February 26, 2021, the Agencies released EBSA Disaster Relief Notice 2021-01, which clarified that there is a one-year limitation on the “Outbreak Period” tolling relief outlined above. To summarize the notice, there are three key points:</span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#010101"></span></span></span></p> <ul style="margin-left: 80px;"> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">The DOL interprets this one-year limit to apply to each individual event tolled, not the relief as a whole or the Outbreak Period.</span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">The period disregarded under the Final Rule above will end after one year, or at the end of the Outbreak Period as originally outlined, whichever comes first.</span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">This relief notice does not end the Outbreak Period.</span></span></span></li> </ul> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b></b></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">The crucial takeaway for Notice 2021-01 is that in no case will the disregarded period with respect to any of the events outlined above exceed one calendar year.</span><br /> <span style="color:#000000;"><br /> To illustrate an example of that guidance, a claim that ordinarily must be submitted on or before March 1, 2020 would now still be considered timely filed until March 1, 2021. Obviously, this causes self-funded plans and their claims administrators a great deal of grief; from the administrative headache to potential stop-loss denials (since stop-loss carriers are not bound to this same requirement!), the ongoing tolling period has proven problematic for many.</span><br /> <br /> <span style="color:#000000;">To summarize the above, the extension of timeframes to submit special enrollment information, appeals, and COBRA elections are all ongoing, as well as the requirement for group health plans to cover COVID-19 testing and the vaccine. Now that we have been living with COVID-19 for over two years, there is more developing guidance on those who suffer from longer term effects of COVID-19, so let’s switch gears.</span><br /> <br /> <span style="color:#000000;"><i>Guidance on “Long COVID” as a Disability Under the ADA, Section 504, and Section 1557</i></span></span></span><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">In July 2021, HHS and the DOJ issued guidance on “long COVID” as a disability.</span><a href="#_ftn2" name="_ftnref2" title=""><span style="color:#000000;"><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span calibri="" style="font-family:">[2]</span></span></span></span></span></a><span style="color:#000000;"> The Centers for Disease Control and Prevention (CDC) defines long COVID as a condition where an individual who has been infected with the COVID-19 virus experiences long-term effects from the infection. Long COVID symptoms can occur for months after the initial infection and can include new or recurring symptoms at a later point in time. </span><br /> <br /> <span style="color:#000000;">One might think that long COVID automatically qualifies as a disability, but the guidance indicates otherwise. An individual’s condition and any of the symptoms must substantially limit a major life activity in order to rise to the level of a disability. When assessing the individual’s situation, the impact to a major life activity must be reviewed without the benefit of medications, treatments, and other measures used to reduce or compensate for symptoms.</span><br /> <br /> <span style="color:#000000;">This guidance is not earth-shattering; it simply draws attention to those who suffer from long COVID and gives a high-level summary of the symptoms and impairments an individual with long COVID may experience. It also stresses the importance of determining whether these symptoms rise to the level of a disability on a case-by-case basis, which is also referenced by the EEOC.</span><br /> <br /> <span style="color:#000000;"><i>EEOC COVID-19 Technical Assistance </i></span></span></span><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">The EEOC has updated its guidance on COVID-19 and employment considerations approximately 20 times since March of 2020. In December 2021, the EEOC updated its COVID-19 technical assistance (again) to clarify when COVID-19 may be considered a disability under the Americans with Disabilities Act (ADA) and the Rehabilitation Act. Both Acts address employment discrimination and assist employers with balancing their rights and responsibilities with respect to individuals who have been diagnosed with a disability. </span><br /> <br /> <span style="color:#000000;">This technical assistance intentionally broadly addresses COVID-19 related to employment, while the DOJ/HHS guidance focuses on long COVID specifically. Each plays an important part in the regulatory oversight, and generally there is no meaningful overlap between the two.</span><br /> <br /> <span style="color:#000000;">The addition to the technical assistance added a new set questions and answers to assist employers with the application of the rules to individuals with COVID-19 or a post-COVID-19 condition that is classified as a disability. In general, individuals diagnosed with a disability are protected from employment discrimination, and these individuals may also be eligible for reasonable accommodations; with COVID-19 being so pervasive, this creates issues that are novel for many employers, or at least that occur on a larger scale than many employers are used to.</span><br /> <br /> <span style="color:#000000;">The December 2021 technical assistance included a few key pieces of information which can be summarized as follows:</span></span></span><br />  </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;"></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <ol> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">Even if COVID-19 does not constitute a disability, an individual may have impairments that arose from COVID-19 that will constitute a disability.</span></span><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">An individual who had COVID-19 that resulted in only mild symptoms, resolved in a few weeks, and had no other issues, will likely not be considered to have ADA disability and thus will not be eligible for reasonable accommodations.</span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"> The ADA is a floor for employers – meaning employers can always offer greater benefits than the ADA requires. </span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"> Individuals are only entitled to a reasonable accommodation if their disability requires it and that accommodation is not an undue hardship for the employer. </span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"> Employers are cautioned to rely on medical professionals and guidance related to determining when an employee can return to work (i.e., the person is medically able and does not pose a threat of exposing other workers to COVID-19). Employers should be careful to distinguish fact from assumptions and/or fear. </span></span></span></li> </ol> <p style="text-align: justify; margin: 0in 0in 0in 40px;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">The ADA, like most regulating authority, requires that the definition of “disability” is broadly construed in favor of the more expansive coverage. In other words, the rules are generally construed in favor of the individual with the disability; however, even with COVID-19, an individual must meet one of the three definitions of “Disability” under the ADA: </span></span></span><br />  </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <ol> <li style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"><u>“Actual” Disability:</u> The person has a physical or mental impairment that substantially limits a major life activity (such as walking, talking, seeing, hearing, or learning, or operation of a major bodily function);</span></span></span></li> <li style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"><u>“Record of” a Disability:</u> The person has a history or “record of” an actual disability (such as cancer that is in remission); or</span></span></span></li> <li style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="tab-stops:list .5in"><span calibri="" style="font-family:"><span style="color:#000000;"><u>“Regarded as” an Individual with a Disability:</u> The person is subject to an adverse action because of an individual’s impairment or an impairment the employer believes the individual has, whether or not the impairment limits or is perceived to limit a major life activity, unless the impairment is objectively both transitory (lasting or expected to last six months or less) and minor.</span><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 calibri="" style="font-family:">[3]</span></span></span></span></a></span></span></span></li> </ol> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><u></u></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">To determine whether an individual meets any of the three definitions of “disability,” ultimately the ADA requires the dreaded <i>case-by-case analysis</i> based on the facts and circumstances surrounding the individual person. Those tend to be some of the most difficult analyses to make, given the complexities involved in any given case. However, since COVID-19 has only been around for two years (despite seeming like a lifetime), the application and guidance will likely continue to evolve as medical professionals gather more data and information and continue to assess those with long-lasting COVID-19 effects, and the case-by-case analysis may get easier.</span></span></span><br /> <br /> <span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"><i>Health Benefit Plan Dynamics</i><i><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></i></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">Self-funded health plans have been on high alert for quite some time with all the aforementioned rules and regulations that have gone or will be going into effect in the near future. Employers should regularly review their summary plan descriptions and plan documents (SPD/PDs) to ensure that current regulatory requirements are accurately reflected. Additionally, employers may choose to address continuations of coverage related to short-term and long-term disabilities as the prevalence of COVID long-haulers will increase over time. </span><br /> <br /> <span style="color:#000000;">Unfortunately, COVID-19 long-haulers raise a lot of additional unknowns. How long will they need treatment? What side effects will be permanent? Will the permanent side effects need continuing care? It is a sure bet that the regulators will continue to modify and evolve their guidance and the number of COVID-19 cases found to be a disability will increase over time. </span><br /> <br /> <span style="color:#000000;">Aside from potential claims costs and the timeline extensions, employers need to be aware of their leave of absence and continuation of coverage provisions. Questions for employers include: How long should these ill individuals stay on the health plan? Does plan language support the continuation of coverage? Is stop-loss on the same page? These and other related questions need to be addressed based on the mindset of a particular employer.</span><br /> <br /> <span style="color:#000000;"><i>Conclusion</i></span></span></span><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="color:#000000;">In light of all of the above, the COVID-19 fire is still burning in the self-funding forest, whether we like it or not. Despite the various rules, pieces of guidance, and bits of technical assistance, there will always be more unknowns. In fact, year-old HHS and DOJ guidance provides that “The CDC and health experts are working to better understand long COVID.”</span><a href="#_ftn4" name="_ftnref4" title=""><span style="color:#000000;"><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span calibri="" style="font-family:">[4]</span></span></span></span></span></a><span calibri="" style="font-family:">  As the experts’ understanding evolves, so will the rules and regulations applicable to self-funded plans and the employers that sponsor them. Employers will need to keep a watchful eye on the COVID-19 fire, even if the flames seem small right now.<br /> <br /> Above all else, a best practice is that when in doubt, ask for help from your trusted self-funded health plan compliance gurus.</span></span></span></p> <p style="text-align:justify; margin:0in"> </p> <div> <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[1]</span></span></span></span></a> View the Joint Rule here: https://www.federalregister.gov/documents/2020/05/04/2020-09399/extension-of-certain-timeframes-for-employee-benefit-plans-participants-and-beneficiaries-affected</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[2]</span></span></span></span></a> See https://www.ada.gov/long_covid_joint_guidance.pdf?</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[3]</span></span></span></span></a> See N.1. at https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws?utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=#N</span></span></p> </div> <div id="ftn4"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[4]</span></span></span></span></a> See page 4, Section 3 at https://www.ada.gov/long_covid_joint_guidance.pdf?utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=</span></span></p> </div> </div> 1188The Stacks – 3rd Quarter 2022 Newsletter | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1169/the-stacks-3rd-quarter-2022-newsletter-the-phia-groupNewslettersFri, 22 Jul 2022 15:12:13 GMT<p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-size:18px;"><span style="color:#0071ce;">No Surprises Act Open Negotiations: Strategy and Compromise in the Shadow of the Rule.</span></span></span></b></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><strong><span style="color:#000000;"><span style="font-size:16px;">By: Scott Bennett, Esq.</span></span></strong><br /> <br /> <span style="font-size:12.0pt">2022 brings a new form to the inboxes of medical payment appeal departments nationwide: the Open Negotiation Notice.  Not to be ignored, this form carries with it a looming threat of formal action if negotiations fail after 30 business days. This article explores the important events and steps involved in the Open Negotiation process, examples of the factors and benchmarks available during the negotiation, and a few strategies that have surfaced in the early part of this year during these negotiations.</span><br /> <br /> <b><span style="font-size:12.0pt">An Out-of-Network Emergency Claim Walks Into a TPA… </span></b></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">The Open Negotiations process includes the following events: initial payment or denial, the Open Negotiation Notice, review and a good faith response, and  resolution or representation.  Each stage is an opportunity to leverage the available rules for efficient closure of the claim.<br /> <br /> Initial Payment or denial is most often communicated on the explanation of benefits (EOB) sent to the provider, and should include the contact email for the Open Negotiation Notice (perhaps in a reason code).  Including a contact email on the EOB not only provides a clear path to start the negotiation process, but that same EOB would serve as evidence if a party ignores the provided contact and sends the Open Negotiation Notice elsewhere and then attempts to leverage the failed notice later in the process.<br /> <br /> The Open Negotiation Notice most likely will arrive by email, and intake actions should include verification that the form is complete and includes all required information, and a secure request for any additional, necessary information to identify the claim (Open Negotiation Notice forms do not presently require patient or claim identifiers).<br /> <br /> Once the Open Negotiation Notice arrives and is verified as complete, a rapid review of the available benchmarks for the specific claim to validate the range for negotiation and a good faith response will keep the conversation on track.  A response might include an express intent to negotiate in good faith, a short explanation that the payment (or offer) is supported by independently reviewed benchmarks, and a clear outline of the dates and deadlines ahead.<br /> <br /> As offers are exchanged there may be possibility for resolution, which avoids the formal process of Independent Dispute Resolution (IDR).  However, If it looks like the negotiation will fail, any records of benchmarks and good faith attempts to negotiate should be documented, and the final letter prior to IDR should clearly identify the contact information (including an email address) for representation in IDR.</span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><br /> <span style="line-height:107%"></span></span></span><b><span style="font-size:12.0pt">The QPA no Longer Stands Out in a Crowd of Factors.</span></b></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">On January 1, 2022, the Interim Final Rule for the No Surprises Act (NSA) placed the qualifying payment amount (QPA) at the center of any dispute.  Independent Dispute Resolution Entities (IDREs) were instructed to presume the QPA as correct, and place the burden on a provider to prove why additional payment was necessary.  NSA negotiations (and disputes) looked like the exception rather than the norm.  However, the recent opinion in <i>Tex. Med. Ass'n v. United States Dep't of Health & Human Servs. (E.D. Tex. 2022)</i>, struck down the presumption that the QPA was correct, and guidance now pointed to a number of equal factors to be considered in a payment determination in addition to the QPA.  While this case will be appealed, this litigation has essentially relegated the QPA to one of many starting points (and potential end points) in a surprise billing negotiation.<br /> <br /> With the QPA in the relegated position (for now) the factors available for negotiation (and dispute resolution) are as follows: the QPA; the level of training, experience, and quality measurements; market share; patient accuity; teaching status, case mix, and scope of services; demonstration of good faith efforts; and additional related credible information.</span><br /> <br /> <u><span style="font-size:12.0pt">The QPA</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">This benchmark is either supplied by the network based on the median contracted rate, or derived from a database if the median contracted rate is not available. Identifying whether a QPA is from a network or derived from a database would be helpful information for an IDRE.  However, the rules do not identify the QPA as the primary factor, and the rules expressly do not require an exploration of the exact calculation or methodology as part of a negotiation or dispute.  A short and simple statement about the QPA source and calculation could avoid a situation where a QPA could be put on trial rather than the main issue: whether or not the payment is reasonable.</span><br /> <br /> <u><span style="font-size:12.0pt">The Level of Training, Experience, and Quality Measurements</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Facility quality benchmarks are publicly available through the Hospital Value Based Payment System Data, which is arguably published for use in this kind of analysis. Further, the Merit Based Incentive Payment System data is also available for analysis of professional service providers.  Some services (like durable medical equipment sold in emergency situations) would not rely on training or experience of the provider, which might be worth noting if those are a large portion of a surprise bill.</span><br /> <br /> <u><span style="font-size:12.0pt">Market Share</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">The most common available data for this factor is a provider directory, such as the Hospital General Information published by Medicare. Directories such as this would allow an analysis of the ownership percentages in the area and whether there is meaningful competition, or whether the market power in the area allows a single entity to dictate price.</span><br /> <br /> <u><span style="font-size:12.0pt">Patient Accuity</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">One method to identify the acuity of the patient is the score assigned to a specific diagnosis or procedure for its complexity and resource use, such as the Diagnosis Related Group Relative Weight information published by Medicare.</span><br /> <br /> <u><span style="font-size:12.0pt">Teaching Status, Case Mix, and Scope of Services</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Drawing from the individual case/acuity scores in patient acuity, a case mix index of the provider’s typical or historical services would help identify whether a specific case is an outlier for the provider. If the case is not an outlier, it would ,  not demand unique payment accommodations.</span><br /> <br /> <u><span style="font-size:12.0pt">Demonstration of Good Faith Efforts</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">The open negotiation period and related communications create an opportunity to document good faith. Also, if a party has access to past attempts to reach a network agreement, this data may be important as well. It would not be surprising if this factor tied in directly with market share to show that an entity with control over the market would not respond to any reasonable requests for compromise.</span><br /> <br /> <u><span style="font-size:12.0pt">Additional Related Credible Information</span></u>  </span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Specific cases may hinge on information that does not fit directly in the above categories. For instance, an article or interview that contradicts other pricing evidence, or an example of a medical device available online for a much lower or higher cost directly from the manufacturer could affect negotiations and dispute resolution when contract rates are in conflict.</span><br /> <br /> <b><span style="font-size:12.0pt">Early Negotiation Strategies and Responses.</span></b></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">While many parties are using the Open Negotiations process to efficiently resolve disputes, two suspect approaches to Open Negotiations that might threaten efficiency have surfaced in the short time since the process has been in place: Open Negotiations as pretext and Open Negotiations as discovery.<br /> <br /> Open Negotiations as Pretext.  </span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">If a party does not include all of the required information on an Open Negotiation Notice, sends only one email to a generic inbox without follow up, and then files for IDR as soon as the time has passed, this is strong evidence that the communication is a pretext to pull the other party into a dispute without a meaningful conversation. An effective response to this strategy is to identify that the Open Negotiations Notice is incomplete, so the process has not started, and any attempt to file for IDR will be promptly disputed as untimely.  Further, even if the Open Negotiation Notice is sufficient, bad faith negotiations could arguably be a viable reason to request an extension of time (available for reasons except payment) when a dispute is filed, and as credible evidence as to why the non-initiating party’s offer should be considered in a dispute.<br /> <br /> Open Negotiations as Discovery.</span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">When a negotiating party stalls negotiations with demands for very specific evidence about the variables, algorithms, and sources for a QPA payment, they may be trying to use the Open Negotiations process as a discovery process rather than to resolve the claim at issue in good faith.  This strategy, and the laundry list of “interrogatories” included in these letters give the impression that the origins of a QPA are on trial, or will be on trial.  An effective response to this strategy is to provide a short statement that the QPA was “provided by the network” or “derived from a database” and, state an intent to negotiate in good faith, evidenced by responding to communications, presenting offers, and identifying a credible basis for those offers;  identify that the IDR process specifically does not require the IDRE to consider the calculation of the QPA, and the QPA is not on trial; and  warn that repeated demands for extensive information that is not to be considered in IDR is evidence of bad faith and an attempt to derail any meaningful negotiations.</span><br /> <br /> <b><span style="font-size:12.0pt">Conclusion</span></b></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="font-family:"Calibri",sans-serif">From the initial payment to a settlement or final determination, a properly executed Open Negotiation strategy will likely resolve claims much faster than in the nebulous days of balance bill defense and confusing collection tactics.  The three most important strategies to adopt are:  a prompt response upon receipt of an Open Negotiation Notice, evidence packed communication in negotiations, and demonstrated, documented evidence of good faith.</span></span></p> <hr /> <p style="margin:0in"><span style="color:#0071ce;"><span style="font-size:18px;"><span style="font-family:"Calibri",sans-serif"><b>The Newest Fiduciary Duty: Protecting Participants From Themselves</b></span></span></span></p> <p style="margin:0in"><span style="font-size:16px;"><strong><span style="font-family:"Calibri",sans-serif">By: Jon Jablon, Esq.</span></strong></span></p> <p style="margin:0in"> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">In the recent case of <i>Hughes v. Northwestern University</i>, the US Supreme Court solidified some law that many feel is a misstep when applied broadly to fiduciary duties. Although regarding 401(k) plans, this case has potentially broad implications for any plans governed by the Employee Retirement Income Security Act, or ERISA.</span><br /> <br /> <b><span style="font-size:12.0pt">The Old Way of Thinking</span></b></span></span></p> <p 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></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">The industry at large tends to conceptualize fiduciary duties a bit nebulously, especially in the context of what benefits are offered by a given health plan. In general, although there are a few federal laws that tend to require that certain benefits be offered and under what circumstances, plan sponsors have enjoyed a great deal of freedom to offer any combination of benefits they see fit. Pension plans are subject to some different regulation given the different subject matter, but they are mostly in the same boat, especially when it comes to rules regarding plan administration under ERISA: pension plan sponsors are given a wide latitude to decide which investment options should be made available to their plan participants.<br /> <br /> The plan administrator is charged with administering the benefits laid out in the applicable plan document, and ERISA plan administrators are subject to some strict burdens, which sometimes intersect with the plan sponsor’s basic framework for the plan.  The plan administrator is not necessarily permitted to administer the plan exactly as written, though, which creates a very odd distinction between the employer’s role as the plan sponsor and the employer’s (or a third party’s) simultaneous role as the plan administrator.<br /> <br /> With <i>Hughes</i>, the Supreme Court has handed down some additional clarification on how exactly plan administrators can satisfy, or perhaps more relevantly, <i>fail</i> to satisfy, their considerable duties.</span><br /> <br /> <b><span style="font-size:12.0pt">The New Way of Thinking</span></b></span></span></p> <p 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></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">To summarize this case, some 401(k) plan participants sued the Plan Administrator, alleging that the aggrieved plan participants had made poor investments, and that the Plan Administrator should not have allowed that to happen.<br /> <br /> The Seventh Circuit Court of Appeals disagreed with that logic, opining that the participants were given all available information and made their own choices, and it is not the Plan Administrator’s responsibility to curate 401(k) plan participants’ investments. According to the appeals court, the participants <i>could</i> have made better investments; they just <i>didn’t</i>.<br /> <br /> The US Supreme Court, however, unanimously disagreed, indicating that – among other things – “even…where participants choose their investments, plan fiduciaries are required to conduct their own independent evaluation to determine which investments may be prudently included in the plan’s menu of options. If the fiduciaries fail to remove an imprudent investment from the plan within a reasonable time, they breach their duty.”<br /> <br /> In other words, although plan administrators can certainly give plan participants freedom of choice in their investment options, the plan administrator must ensure that those investment options are all <i>good</i> options. The Supreme Court imposed a fiduciary responsibility to protect plan participants from <i>themselves</i>, holding that the existence of “bad” options is not excused even by the prevalence of “good” options.<br /> <br /> The Court’s opinion may seem confined to the pension plan space, but this case interprets the fiduciary duties imposed by ERISA, which of course apply to self-funded healthcare plans as well.</span><br /> <br /> <b><span style="font-size:12.0pt">Scope of Benefits</span></b></span></span></p> <p 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></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Take, for instance, a section 125 cafeteria plan that offers a cash-in-lieu-of-benefits option, a traditional and robust health plan, a high deductible health plan with qualified HSA, and a preventive-only health plan. Intuitively, the practical result is that the Plan Administrator can compliantly offer three competing options, since participants choose to pay (or receive) a certain amount of money in exchange for benefits (or no benefits). That is a matter of participant choice, and traditionally there has been no question of whether it is appropriate for the plan to offer these options.<br /> <br /> But, then again, we might have said the same thing about 401(k) investments.<br /> <br /> One could argue that being uninsured is inherently a poor decision, since most individuals will need some sort of medical care at some point. Regardless, consider a situation where a young, healthy, low-risk employee decides that having health insurance is unnecessary, and the employee elects the cash-in-lieu plan option.<br /> <br /> To quote the Supreme Court, a fiduciary may have “breached the duty of prudence by failing to properly monitor investments and remove imprudent ones”. Interestingly, the difference between <i>investments</i> and <i>benefits </i>seems inconsequential here, since the defining relevant factors are apparently (1) that plan participants make the choice, and (2) that choice has a financial impact on the chooser.<br /> <br /> Admittedly, there are other factors at play in the <i>Hughes</i> case other than the participants’ poor investment decisions. For example, certain investments were offered at a higher, retail-class rate than their institutional-class counterparts, thus costing participants more money than perhaps necessary. The complaint also alleged that the plan fiduciary offered too many investment options, which “thereby caused participant confusion and poor investment decisions”.<br /> <br /> The Supreme Court did not elaborate, however, regarding which factors were relevant to this particular allegation, or how many investment options would <i>not</i> have caused undue confusion, since making such specific determinations is not the Supreme Court’s job; with any luck, now that the Supreme Court sent the case back – or “remanded” it – to the lower Court of Appeals with further instructions on how to correct its prior errors, we may eventually get more clear guidance.<br /> <br /> It seems a bit irrational to think that a cafeteria plan fiduciary can be faulted for including a plan option that could result in financial detriment to the plan participant, despite being elected by an informed decision – but the Supreme Court has so determined with respect to 401(k) investments.</span><br /> <br /> <b><span style="font-size:12.0pt">Reference-Based Pricing</span></b></span></span></p> <p 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></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">In the industry today, no discussion of health plan practices seems to be complete without some mention of reference-based pricing (or RBP). That’s because there are so many different factors involved in reference-based pricing, and it touches on so many aspects of the industry, making it an excellent example for so many things.<br /> <br /> Reference-based pricing – or pricing claims based on Medicare or some other reference other than billed charges – is a practice that is increasingly common, necessitated by the growing feeling among those in the the self-funded industry that most medical bills are exorbitant, arbitrarily marked-up, and somehow immune from ordinary market forces.<br /> <br /> Typically, health plans using reference-based pricing models are able to save a great deal of money in claims payments, which results in a lower overall participant contribution – but the primary trade-off is that the lower-than-billed payments provide significantly less protection for affected plan participants. Whenever a non-contracted medical provider is paid less than its full billed charges, the provider may bill the balance to the patient (assuming that the claim in question is not one for which the patient is protected by the No Surprises Act, such as emergency claims, out-of-network air ambulance claims, or certain out-of-network claims rendered at in-network facilities). This bill for the balance – aptly known as a “balance bill” – is a reality of almost all reference-based pricing programs.<br /> <br /> Many health plans and their reference-based pricing vendors wisely adopt some way to mitigate balance bills and increase participant security, but there can be situations where balance bills still negatively impact the patient. Health plans can create “safe harbors” for participants with contracts or otherwise finding providers that will not balance bill, but one of the staples of a reference-based pricing model is that participants can choose to visit any providers they want.<br /> <br /> Recall that 401(k) plan participants are also able to choose which investments they want. Recall also that the Supreme Court iterated that the fiduciary must ensure that participants are not even <i>able</i> to make poor decisions.</span></span></span></p> <p 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></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Since balance billing can have deleterious effects on plan participants when not effectively managed by a health plan, an important question is how the duty of prudency, as explained by the <i>Hughes</i> case, might apply to a situation where a health plan has elected to utilize some type of reference-based pricing model.<br /> <br /> The <i>Hughes</i> decision tells ERISA-governed plans that their fiduciaries must protect plan participants from their own decisions. If a plan participant has the option to visit a contracted provider but chooses instead to visit a non-contracted provider, the participant may end up subject to a balance bill. In that case, it seems clear that the plan fiduciary has allowed the participant to make what amounts to a poor investment decision: the patient effectively elected to incur a balance bill from its chosen provider, whereas a comparable provider down the street would have been subject to a contracted rate, leaving the patient with <i>no</i> balance.<br /> <br /> Digging a bit deeper, perhaps the <i>Hughes</i> precedent would even require a plan fiduciary to remove higher-charging providers from the pool of provider options, effectively offering no benefits for those providers. Literally speaking, if a provider is excluded from benefits altogether, the participant’s cost for the claim is maximized (since the full bill is the participant’s responsibility) – but perhaps including all providers within the class of covered providers increases the number of analogized “investment options”, contributing to the consumer confusion referenced by the plan beneficiaries in <i>Hughes</i>.</span><br /> <br /> <b><span style="font-size:12.0pt">The Parallels</span></b></span></span></p> <p 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></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">The aggrieved plan participants in <i>Hughes</i> identified three primary allegations:</span></span></span></p> <p 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></span></span></p> <ol> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">For some investments, there were multiple ways to elect them, some costing more than others for virtually the same result.</span></span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Some poor investment options were offered among the better options.</span></span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">Too many investment options caused consumer confusion.</span></span></span></li> </ol> <p 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></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:12.0pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt">With the examples provided above – a cafeteria plan and a reference-based pricing model – those three allegations can be extrapolated into the health benefits universe. It would be folly to suggest that the <i>Hughes</i> decision is confined to the pension plan space; the fiduciary duty explained by the Supreme Court in <i>Hughes</i> is an interpretation of existing ERISA law, which is the common denominator of pension plans and health benefit plans alike.<br /> <br /> With an increased focus on consumer protection (take, for instance, the recent advent of the No Surprises Act and additional Mental Health Parity and Addiction Equity Act obligations and enforcement), health plans and their fiduciaries should be acutely aware of emerging consumer protection laws that in many ways change the historical application of ERISA.</span><br /> <br /> ERISA is almost 50, but it continues to evolve with the times as much as ever. <i>Who ever said you can’t teach an old dog new tricks?</i></span></span></p> <hr /> <p style="margin:0in 0in 8pt"><span style="color:#0071ce;"><span style="font-size:18px;"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b>Ongoing Litigation of Interest to Employer Group Health Plans</b></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">By: Corrie Cripps</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></span></span></p> <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">With COVID-19 temporary coverage mandates, transparency in coverage rules, and implementation of the No Surprises Act (NSA) provisions, the first quarter of 2022 has been a busy one for group health plan sponsors and third party administrators (TPAs). As policy changes and compliance issues continue to evolve this year, there is also a wide variety of court cases to watch, as they will have implications for employer-sponsored health plans. </span></span></span></p> <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></span></span></p> <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"><b>COVID-19 Testing Payment</b></span></span></span></p> <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"><b></b></span></span></span></p> <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">The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) require group health plans to cover the cost of COVID-19 diagnostic testing and related services, but the CARES Act doesn’t specify a reimbursement amount for out-of-network providers. Instead, the law states these items are paid at the negotiated rate, if one exists.  If no negotiated rate exists, the plan will pay the cash price publicly posted on the provider’s website, or such other amount as may be negotiated by the provider and plan.  </span></span></span></p> <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></span></span></p> <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">As a result, there are lawsuits involving both payers and providers. For example, a Texas medical lab (Diagnostic Affiliates of Northeast Houston) is suing United Healthcare Services, Inc. in federal court alleging that the insurer failed to properly reimburse for COVID-19 testing services (<i>Diagnostic Affiliates of Northeast Houston v. United Healthcare Servs.</i>, No. 21-cv-0131 (N.D. TX Jan. 18, 2022)).  From a payer perspective, Premera Blue Cross is suing a COVID testing company (GS Labs), in Western Washington District Court, alleging that the lab attempted to exploit the pandemic through price gouging for its services (<i>Premera Blue Cross v. GS Labs,</i> No. 2:21-cv-01399 (W.D. WA filed Oct. 14, 2021)). </span></span></span></p> <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></span></span></p> <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">Plan sponsors should monitor these cases and review how payment is processed for out-of-network COVID test claims with their TPAs.</span></span></span></p> <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></span></span></p> <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"><b>ACA’s Preventive Care Mandate</b></span></span></span></p> <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></span></span></p> <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">The Affordable Care Act’s (ACA’s) preventive care mandate (under Section 2713 of the Public Health Service Act) requires non-grandfathered group health plans to cover, without cost-sharing, in-network, certain preventive care services. These services are identified by the US Preventive Services Task Force, the Health Resources and Services Administration, and the Advisory Committee on Immunization Practices. </span></span></span></p> <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></span></span></p> <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">The entire preventive care mandate is being litigated in a case called <i>Kelley v. Becerra</i> (<i>Kelley v. Becerra</i>, No. 20-cv-00283 (N.D. TX filed July 20, 2020)).  The plaintiffs in Kelley argue that Section 2713 is unconstitutional and unenforceable because it violates the “nondelegation doctrine,” the Appointments Clause, and the Vesting Clause. The plaintiffs are asking the court to declare that all preventive service mandates under Section 2713 are no longer required to be covered. They further argue that some of the recommendations—to cover contraceptives and pre-exposure prophylaxis (PrEP) to prevent HIV—also violate the Religious Freedom Restoration Act (RFRA).</span></span></span></p> <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></span></span></p> <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">A decision is expected this year and could significantly impact the coverage of preventive services in group health plans.</span></span></span></p> <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></span></span></p> <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"><b>ACA Section 1557</b></span></span></span></p> <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">The US Department of Health & Human Services (HHS) is expected to issue a revised ACA Section 1557 rule this year, which will be the third version of this rule.<a href="#_ftn1" name="_ftnref1" style="color:#0563c1; text-decoration:underline" 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>  ACA Section 1557 is the law’s nondiscrimination provision that prohibits health programs or facilities that receive federal funds from discriminating based on race, color, national origin, age, disability, or sex. There are ongoing legal challenges to the two previous iterations of the rule (from the Obama administration and from the Trump administration). The district court orders for these cases will stay in place unless overturned.</span></span></span></p> <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></span></span></p> <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">A decision from the US Supreme Court is expected soon in <i>Cummings v. Premier Rehab Keller</i> (Cummings v. Premier Rehab Keller, No. 20-219 (US filed Aug. 21, 2021)). In this case, a physical therapy provider refused to provide Jane Cummings (who is deaf and legally blind) with an ASL interpreter to help treat her chronic back pain. Cummings sued, alleging that the refusal is a form of disability discrimination, and is asking for damages for the emotional distress caused by her experience. The court is deciding whether damages for emotional distress can be awarded under Section 504 of the Rehabilitation Act of 1973 and Section 1557. This will be an important case to watch, as it involves discrimination claims brought under Section 1557 by individuals.</span></span></span></p> <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></span></span></p> <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"><b>Federal IDR Process of the NSA</b></span></span></span></p> <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></span></span></p> <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">The No Surprises Act (NSA) of the Consolidated Appropriations Act, 2021 (CAA) contains extensive provisions intended to protect consumers from surprise medical bills for services provided by nonparticipating providers or facilities.</span></span></span></p> <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></span></span></p> <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">Many medical providers and facilities take issue with the presumption in the federal independent dispute resolution (IDR) interim final rule (IFR) that the qualifying payment amount (QPA) is the correct reimbursement amount for out-of-network services. Provider groups argue that the law lists many factors that an arbitrator may consider, such as the out-of-network provider’s experience and training, and does not give presumptive weight to the QPA.</span></span></span></p> <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></span></span></p> <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">On February 23, 2022, a federal judge in Texas struck down a narrow piece of the NSA IFR dealing with the IDR process (<i>Texas Med. Ass’n v. HHS</i>, No. 21-0425 (E.D. Tex. Feb. 23, 2022)). The lawsuit was led by the Texas Medical Association (TMA), which argued that parts of the IDR rule are inconsistent with the NSA and should be invalidated. The judge agreed and vacated these provisions on a nationwide basis. An appeal is expected.</span></span></span></p> <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></span></span></p> <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">The TMA lawsuit is one of six NSA-related lawsuits filed by health care providers. Plan sponsors should monitor these provider lawsuits, since they could impact the amount health plans must pay out-of-network providers for protected services under the NSA.</span></span></span></p> <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></span></span></p> <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">The federal agencies have indicated they will issue a final IDR rule by May 2022.</span></span></span></p> <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></span></span></p> <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"><b>Mental Health Parity</b></span></span></span></p> <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></span></span></p> <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">The CAA further enhanced federal mental health parity protections, with an emphasis on compliance regarding non-quantitative treatment limitations (NQTLs) on mental health and substance use disorder (MH/SUD) benefits. As federal enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) for employer-sponsored health plans continues to increase, plans should be aware of several class action lawsuits related to plan coverage of MH/SUD benefits.</span></span></span></p> <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></span></span></p> <ul> <li style="margin: 0in 0in 8pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">In a class action lawsuit against UMR, Inc., the plaintiffs, who were denied coverage for residential treatment of mental health or substance abuse issues, ask for a declaratory judgment that clinical criteria used by UMR to deny coverage are overly restrictive and breach generally accepted medical care standards (<i>Berceanu v. UMR Inc.,</i> No. 3:19-cv-00568 (W.D. WI Dec. 15, 2021)). Further, they seek a determination that the administrator acted in an arbitrary and capricious manner by adopting these guidelines.</span></span></span></li> </ul> <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></span></span></p> <ul> <li style="margin: 0in 0in 8pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">In a class action lawsuit against United Behavioral Health (UBH), six plaintiffs allege UBH unlawfully denied coverage for medically necessary mental health and substance use disorder treatment (<i>Beach v. United Behavioral Health</i>, No. 3:21-cv-08612 (N.D. CA filed Nov. 4, 2021)). The lawsuit is challenging a UBH coverage policy that allegedly causes UBH to deny coverage for certain services merely because they are provided in a residential treatment setting, even though UBH accepts that the services themselves are medically necessary.  <i></i></span></span></span></li> </ul> <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></span></span></p> <ul> <li style="margin: 0in 0in 8pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">The complaint filed in <i>Deighton v. Aetna Life Insurance</i> by a proposed class of health plan participants allege that Aetna applies disparate limits to residential mental health/substance abuse facilities and rehabilitation amenities, in violation of MHPAEA. (<i>Deighton v. Aetna Life Ins. Co</i>., No. 2:21-cv-07558 (C.D. CA filed Sept. 21, 2021)).</span></span></span></li> </ul> <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></span></span></p> <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">The Department of Labor’s (DOL’s) published enforcement reports suggest that the DOL is continuing to investigate compliance with MHPAEA. To ensure compliance, self-insured health plans should consider conducting periodic claims audits and reviews, and can use the DOL’s self-compliance tools to assist with this.<a href="#_ftn2" name="_ftnref2" style="color:#0563c1; text-decoration:underline" 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></span></span></span></p> <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></span></span></p> <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"><b>Dialysis Benefits</b></span></span></span></p> <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></span></span></p> <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"><i>Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita, Inc.</i> is a case scheduled for argument before the Supreme Court of the United States on March 1, 2022 (<i>Marietta Mem’l Hosp. Emp. Health Benefit Plan v. DaVita, Inc.</i> (No. 20-1641 (US filed May 21, 2021)).</span></span></span></p> <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></span></span></p> <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">The case concerns the Medicare Secondary Payer Act (MSPA), which prohibits group health plans from considering a plan participant’s eligibility when the individual has end-stage renal disease (ESRD) and from providing different benefits to these individuals than from other covered participants. The case also involves how much plans must reimburse their members for dialysis treatment costs.</span></span></span></p> <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></span></span></p> <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">The outcome of this case could have a significant impact on dialysis benefits in employer-sponsored group health plans.</span></span></span></p> <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></span></span></p> <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"><b>Conclusion</b></span></span></span></p> <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></span></span></p> <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">For plans and TPAs, being well-informed on regulatory developments is always of the upmost importance. Due to rapid changes in the regulatory landscape, plan sponsors should review their plan documents as well as their plan administration procedures to ensure they are compliant.</span></span></span></p> <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></span></span></p> <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></span></span></p> <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></span></span></p> <p style="text-align: justify;"><i><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Corrie Cripps is a plan drafter/compliance consultant with The Phia Group.  She specializes in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act. </span></span></span></i></p> <div>  <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="margin: 0in; text-align: justify;"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref1" name="_ftn1" style="color:#0563c1; text-decoration:underline" 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> <i>Department of Health and Human Services, Statement of Regulatory Priorities for Fiscal Year 2022,</i> October 2021, <a href="https://www.reginfo.gov/public/jsp/eAgenda/StaticContent/202110/Statement_0900_HHS.pdf" style="color:#0563c1; text-decoration:underline">https://www.reginfo.gov/public/jsp/eAgenda/StaticContent/202110/Statement_0900_HHS.pdf</a>, (last visited February 28, 2022).</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin: 0in; text-align: justify;"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref2" name="_ftn2" style="color:#0563c1; text-decoration:underline" 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> <i>Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA),</i> October 23, 2020, <a href="https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/self-compliance-tool.pdf" style="color:#0563c1; text-decoration:underline">https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/self-compliance-tool.pdf</a>, (last visited February 28, 2022).</span></span></p> </div> </div> 1169The Phia Group's 2nd Quarter 2022 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1150/the-phia-groups-2nd-quarter-2022-newsletter-1NewslettersWed, 27 Apr 2022 14:15:33 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2022/phiaheader2021.jpg?ver=kG0SmqlSJp67FY1HQzR8hA%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q2 2022/icons6622.png?ver=7cG10MHBGYsNcVJQQpVUkQ%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Q2 2022/block0422l.png?ver=DJCeOU2uORgcXxaUcvU2tQ%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#story"><img src="/Portals/phiagroup/Newsletters/Q2 2022/block0422r.png?ver=rgsf6Jjd1tPI9KOvhD9phw%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td valign="top" width="47%"> <p><br /> <img height="300" src="/Portals/phiagroup/Newsletter Q1 2018/adam.jpg?ver=KAJlFem5DERRpjAI9hFfew%3d%3d" width="300" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">Are we back to the Pre-COVID “old-normal” (as opposed to the trendy “new normal”)? That’s the question I keep asking myself as more and more events, conferences, meetings, and travel are ramping up, while cancellations and virtual visits are ramping down. Even mask mandates seem to be vanishing – from airlines (by Federal Court order) to my kids’ little league teams. From a personal perspective, I certainly want to make sure we take steps in a well thought out, reasonable fashion – to avoid undue risk and harm to others – but also long for the days of normalcy. From a professional perspective, we are certainly seeing claims activities reaching pre-COVID levels (i.e. elective procedures, routine care, travel related treatments, etc.), and we are seeing “other” pre-COVID trends continuing to develop just like they were before the pandemic.</p> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Specifically, the amount paid per claim is still on the way up, drug costs are on the rise, and the average American has no idea what a self-funded plan is. Man, oh man… It’s feeling like 2019 already!  </p> <p class="bodytext"><a name="russo09"></a></p> <p class="bodytext">– Happy reading!</p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p class="tocbkgd"><img src="/Portals/phiagroup/Newsletter 2018 Q2/inthisissue.png?ver=4_c-EncNsuJUxrT1QINLVg%3d%3d" style="width: 101px; height: 18px;" /><br /> <a href="#russo4">Enhancements of the Quarter: ICE & PACE Value Reports</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2022 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#pemployee">Employee of the Quarter</a><br /> <a href="#pnews">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><a id="russo4" name="russo4"></a></p> <p class="bodytext"><strong>Enhancement of the Quarter: ICE & PACE Value Reports </strong></p> <p class="bodytext" style="text-align: justify;">As always, we at The Phia Group are constantly looking for ways to enhance our service offerings. We have recently enhanced our reporting in certain ways – and our confidence in our services lends itself to full transparency, which we are eager to share with our clients through these reports and others. </p> <p class="bodytext" style="text-align: justify;"><i>Phia Unwrapped Value Report</i> </p> <p class="bodytext" style="text-align: justify;">Users of the Phia Unwrapped service already enjoy unprecedented savings, and we’ve made the reporting even better with the Value Report. This is useful as a sales and informational tool for new or existing groups. It can help showcase differences between a group’s prior wrap network usage and Phia Unwrapped – including providing de-identified information regarding claims volume and savings generated. Reports like this one are designed to help TPAs, brokers, and groups make informed decisions regarding their business processes. </p> <p class="bodytext" style="text-align: justify;"><i>PACE Value Report</i> </p> <p class="bodytext" style="text-align: justify;">Intended for users of The Phia Group’s Plan Appointed Claim Evaluator (PACE) service, this report goes into detail regarding the number of appeals handled, appeal denial reasons, IRO utilization, a numerical summary of appeal outcomes, and more. This report is designed to demonstrate the value of the PACE service, as well as to give the user an idea of what might be the primary issues with its appeals decisions. For instance, if the report revealed that a large number of first-level appeals were overturned by the PACE service, it could spur important process changes.</p> <p class="bodytext" style="text-align: justify;"><strong>Service Focus of the Quarter: Phia Unwrapped and No Surprises Act Support</strong></p> <p class="bodytext" style="text-align: justify;">Phia Unwrapped </p> <p class="bodytext" style="text-align: justify;">Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited billing rights. With Phia Unwrapped, The Phia Group replaces wrap network access and modifies non-network payment methodologies, securing payable amounts that are unbeatably low based upon fair market parameters.  </p> <p class="bodytext" style="text-align: justify;">Phia Unwrapped places no minimum threshold on claims to be repriced or potential balance billing to be negotiated. Additionally, The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full – and if there’s pushback or balance-billing, our Provider Relations team is ready to handle it. </p> <p class="bodytext" style="text-align: justify;">Phia Unwrapped implementation entails setting up an EDI feed with the claims administrator, so claims are flagged, transferred, and repriced automatically. Phia Unwrapped is billed based on a percentage of actual savings, leading to fair rates and no high costs for unprecedented savings. </p> <p class="bodytext" style="text-align: justify;">Out-of-network claims run through The Phia Group’s Unwrapped program yielded an average savings of 74% off billed charges (three times the average wrap discount). On average, The Phia Group sees roughly 2% of claims result in some form of balance-billing; these results are similar throughout many different plan types and geographies, proving that this program and these results can be replicated nationwide. </p> <p class="bodytext" style="text-align: justify;">No Surprises Act Support </p> <p class="bodytext" style="text-align: justify;">Phia’s new No Surprises Act (NSA) support services entail non-network claim pricing, “open negotiation” support, and Independent Dispute Resolution (IDR) defense. Although every TPA potentially has a different set of needs related to the No Surprises Act, Phia can be engaged to perform functions such as checking NSA-related communications to verify the NSA’s applicability and doing a deadline review to ensure that the NSA’s timeframes are being adhered to. </p> <p class="bodytext" style="text-align: justify;">We are also well-equipped with the necessary benchmarking data, domain knowledge, and experience to negotiate claims with medical providers. In addition, if a claim becomes subject to Independent Dispute Resolution, our support services are available to vet and challenge an IDR entity if necessary, as well as review or draft the plan’s offer of payment. Our NSA support services provide the backbone of post-payment NSA compliance, with a particular focus on cost-containment. </p> <p class="bodytext" style="text-align: justify;">Please contact <a href="mailto:sales@phiagroup.com">sales@phiagroup.com</a> for more information on Phia Unwrapped or No Surprises Act support! </p> <p class="bodytext" style="text-align: justify;"><strong>Success Story of the Quarter: Improving Employee Presentation Skills</strong></p> <p class="bodytext" style="text-align: justify;">As many of our readers have experienced first-hand, The Phia Group’s employees are frequent speakers at conferences and symposiums hosted by TPAs, brokers, captives, stop-loss carriers, and other industry associations, as well as presenters on webinars for both Phia and our clients, podcasts, TPA and broker meetings with groups, and more. </p> <p class="bodytext" style="text-align: justify;">In an effort to help ensure the best experiences for Phia’s valued clientele, Adam Russo (Phia’s CEO) and Ron Peck (Phia’s Chief Legal Officer) – as Phia’s self-proclaimed (yet undisputed) two best public speakers – recently embarked on a large-scale project to help improve presentation skills across Phia’s employees. By having Phia’s key speakers present to them, Adam and Ron scrutinized and critiqued each presentation and gave constructive feedback. </p> <p class="bodytext" style="text-align: justify;">The self-funding industry and its many exciting presentation opportunities are starting to get back to normal, and Phia is excited to get its speakers and presenters back to traveling all over the country for some face-to-face presenting. It’s an exciting time for self-funding and for all those involved in the industry, and it’s a perfect time for Adam and Ron to take steps to improve each presenters’ skills, which will benefit Phia’s clients! </p> <p class="bodytext" style="text-align: justify;">If you need a presenter at a conference, a sales meeting with a group, a webinar for your clients, or anything in between, please keep Phia in mind. Our attorneys and consultants are now even more prepared than ever to present an entertaining, informative, and creative take on any topic you need. </p> <p class="bodytext" style="text-align: justify;">Please contact us at <a href="mailto:sales@phiagroup.com">sales@phiagroup.com</a> for all your presentation-related needs.</p> <p class="bodytext" style="text-align: justify;"><strong>Phia Case Study: Vendor Contracts & Fiduciary Duties</strong></p> <p class="bodytext" style="text-align: justify;">A TPA client of Phia’s Independent Consultation and Evaluation (ICE) service asked our team to review a proposed agreement between a vendor and one of the TPA’s employer groups. This review was performed at no additional cost to the TPA since it fell under the ICE service (so having the review performed was a bit of a no-brainer). </p> <p class="bodytext" style="text-align: justify;">As we reviewed the agreement, we noticed that it contained language whereby the vendor simultaneously claimed authority to make certain claim and appeal determinations and disclaimed all fiduciary duties. The Phia attorney performing the review inserted some commentary to note the discrepancy and also mentioned it specifically to the TPA as an item for discussion. The employer brought the concern to the vendor to try to get clarity, and the vendor asserted that even though it would make claims determinations, it was not going to be doing so as a fiduciary. From there, Phia explained that that is not possible to perform a fiduciary act but avoid assuming the requisite fiduciary duties for that act. </p> <p class="bodytext" style="text-align: justify;">Armed with this additional clarity, the employer was able to discuss the language with the vendor. As it turns out, the vendor misunderstood the nature of fiduciary duties, and Phia’s feedback helped the employer and vendor better understand their respective legal and contractual obligations and reform the contract to be more accurate. This eliminated potential ambiguity regarding fiduciary liability. It also eased the TPA’s worries that its client, the employer, would get stuck with fiduciary duties for a claim determination that someone else made! .</p> <p class="bodytext"> </p> <hr class="horiz" />  <p class="bodytext" style="text-align: justify;"><strong>Fiduciary Burden of the Quarter: Responding to Appeals</strong></p> <p class="bodytext" style="text-align: justify;">ERISA and analogous state law require that provider appeals be responded to. It’s usually a core TPA function, and some TPAs have standard appeal forms that must be filled out in order for the TPA to accept a given piece of provider correspondence as a valid appeal. When there is no “standard” form to fill out to file an appeal, however, appeals may come in all shapes and sizes, and it’s not always so simple to tell what actually constitutes an appeal. </p> <p class="bodytext" style="text-align: justify;">For example, we have seen many letters written by providers that express their dissatisfaction with the way a given health plan handled a claim. Those letters contain all sorts of statements, ranging from (and we’re quoting from real letters here) “this company has [expletive deleted] benefits” to “I demand you compensate me fully,” and everything in between. Some constitute appeals, while others do not. The first example, which we don’t want to offend anyone by reproducing in its original form, is perhaps not an appeal since it didn’t ask for any additional benefits or make any statements, instead suggesting that the plan erred. The fact is, whether a given health plan has [expletive deleted] benefits is a matter of interpretation, but it’s not an actionable request. To contrast, a demand for additional compensation – with or without expletives – is much more likely to constitute an appeal, and we generally believe that it and similar straightforward requests should be treated as one. </p> <p class="bodytext" style="text-align: justify;">When in doubt, our advice is to treat any letter as an appeal. If the appeals have been exhausted, then it may just make a response simpler – but if appeals have not been exhausted, many TPAs see no harm in responding to a general insult of plan benefits and reiterating why those benefits have been paid. If the provider comes back and says, “hang on, that wasn’t meant to be an appeal!” then the response is out there anyway, and it’s all on the record as a good-faith response to a pointless letter. We view it as a win-win. </p> <p class="bodytext" style="text-align: justify;">One thing is certain: if a provider files what a court later deems an appeal and the plan or its designee has not responded to that appeal, that can cause some administrative headaches. </p> <p class="bodytext" style="text-align: justify;">If you need help figuring out whether something is an appeal or the best way to respond to a letter, please don’t hesitate to contact us at <a href="mailto:PGCReferral@phiagroup.com">PGCReferral@phiagroup.com</a> or your designated Independent Consultation and Evaluation (ICE) mailbox. (For clients of our Independent Consultation and Evaluation service, our guidance is included at no additional cost!)</p> <a name="pdef"></a> <a id="pwebinars" name="pwebinars"></a><a id="p5" name="p5"></a> <hr class="horiz" /> <p class="heading1">Webinars:</p> <p class="bodytext" style="text-align: justify;">• On March 22, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/recognizing-risks-reaping-rewards-industry-responses-to-costly-threats-and-how-plans-must-prepare">Recognizing Risks, Reaping Rewards… Industry Responses to Costly Threats, and How Plans Must Prepare</a>,” where we discussed costly medical procedures, devices, and specialty drugs </p> <p class="bodytext" style="text-align: justify;">• On February 15, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-compliance-landscape-for-2022">The Compliance Landscape for 2022</a>,” where we reveal how you can best prepare a compliance strategy to keep up with new legal developments in ERISA law and with COVID-19. </p> <p class="bodytext" style="text-align: justify;">• On January 25, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/tune-in-to-win-are-you-ready-for-2022">Tune in to Win – Are You Ready for 2022</a>,” where we addressed the issues and trends most in need of your attention, from ongoing litigation to political and regulatory developments to procedural best practices.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p>  <a id="ppodcast" name="ppodcast"></a> <hr class="horiz" /> <p class="heading1">Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On March 22, 2022 The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p131-a-balancing-act-of-reduction-requests-and-plans-fiduciary-duties">A Balancing Act of Reduction Requests and Plan’s Fiduciary Duties</a>,” where our hosts, Chris Aguiar and Cindy Merrell, discuss the balancing act of health plan members’ reduction requests and plans’ fiduciary duties. </p> <p class="bodytext" style="text-align: justify;">• On March 4, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p130-healthcare-policy-in-the-state-of-the-union-address">Healthcare Policy in the State of the Union Address</a>,” where our hosts, Brady Bizarro and Andrew Silverio, break down the important healthcare policy items the President discussed, and just as importantly, which ones he did not. </p> <p class="bodytext" style="text-align: justify;">• On February 18, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p129-single-scoops-only-no-double-dipping-covid-otc-testing">Single Scoops Only (No Double Dipping): COVID OTC Testing</a>,” where our hosts, Kelly Dempsey and Kevin Brady, discuss over-the-counter COVID testing and the complications surrounding up-front payment by participants with account-based plans (HSA, FSA, HRA). </p> <p class="bodytext" style="text-align: justify;">• On February 3, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p128-the-comparative-analysis-a-year-in-the-life">The Comparative Analysis: A Year in the Life</a>,” where our hosts, Jon Jablon and Nick Bonds, discuss some of what they’ve learned from a year’s worth of analyzing NQTLs, some practical considerations for health plans, and their takeaways from the recently-published report on MHPAEA compliance from the DOL, HHS, and Treasury. </p> <p class="bodytext" style="text-align: justify;">• On January 20, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p127-what-is-required-for-plans-for-otc-covid-19-testing-coverage">What is Required for Plans for OTC COVID-19 Testing Coverage?</a>,” where our hosts, Jen McCormick and Katie MacLeod, discuss the controversial new OTC COVID-19 Testing coverage requirement that went into effect on January 15, 2022 for plans – how it interacts with other COVID-19 coverage requirements, what plans need to cover and available safe harbors, and how plans can be prepared for compliance. </p> <p class="bodytext" style="text-align: justify;">• On January 6, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p126-challenges-and-opportunities-with-value-based-care-for-2022">Challenges and Opportunities with Value-Based Care for 2022</a>,” where our hosts, Ron E. Peck, and Micah Iberosi-Parnell, talk value-based care, what it is, where it’s at right now, and where it’s headed.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletter 2019 Q1/Apple%20Podcasts.jpg?ver=goypGkLDYbWCGYXontbItA%3d%3d" style="width: 491px; height: 121px;" /></a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pftp" name="pftp"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2022/03/21/top-health-care-issues-to-monitor-for-2022-and-beyond/">Top health care issues to monitor for 2022 and beyond</a> – March 21 2022 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Make_Mental_Health_Parity_A_Priority_For_Your_Plan_by_Kaitlyn_MacLeod%2C_Esq.pdf">Make Mental Health Parity A Priority For Your Plan</a> – March 4, 2022 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2022/02/23/buyer-beware-using-account-based-plans-to-pay-for-otc-covid-tests/">Buyer beware: Using account-based plans to pay for OTC COVID tests</a> – February 23, 2022 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/The_Cold_War_Over_Health_Prices-_by_Micah_D__Iberosi-Parnell.pdf">The Cold War Over Health Prices: The value-based care gap and steps for employers to maximize plan value while reducing expenses</a> – February 4, 2022 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2022/01/21/new-year-new-covid-strain-new-tests/">New year, new COVID strain, new tests</a> – January 21, 2022</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pblog" name="pblog"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">From the Blogoshpere:</span><span class="heading1"></span><br />  </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/mental-health-parity-the-hits-just-keep-on-coming">Mental Health Parity: The Hits Just Keep on Coming</a>. For most of the industry, the acronym “NQTL” has become a bit of a four-letter word. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/being-a-prudent-plan-fiduciary-has-gotten-harder">Being a Prudent Plan Fiduciary Has Gotten Harder.</a> Being a Plan fiduciary carries a lot of responsibility and potential risk for liability – even more so now thanks to a recent retirement fund ERISA case. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/dont-forget-about-third-party-liability-when-dealing-with-covid-19-claims">Don’t Forget About Third-Party Liability When Dealing with COVID-19 Claims</a>. When dealing with COVID-19 claims, payers shouldn’t disregard the possibility of third-party liability. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-dol-wants-to-reduce-stigma-and-raise-awareness-why-your-plan-needs-to-be-concerned-about-mental-health-parity">The DOL wants to Reduce Stigma and Raise Awareness: Why Your Plan Needs to Be Concerned about Mental Health Parity</a>. If your NQTL Comparative Analysis is requested by the DOL, you need to be prepared. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/reasons-for-the-value-based-care-gap-between-public-payers-and-employer-groups">Reasons for the Value-Based Care Gap Between Public Payers and Employer Groups</a>. The long-term struggle over the price of health care services between providers and payers is a tale as old as time.</p> <p class="bodytext" style="text-align: justify;">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.</p> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a></span><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">The Stacks:</span></p> <p class="bodytext"><strong>Make Mental Health Parity A Priority For Your Plan</strong></p> <p class="bodytext" style="text-align: justify;">By: Kaitlyn MacLeod, Esq. – March 2022 – <a href="https://www.sipconline.net/files/Make_Mental_Health_Parity_A_Priority_For_Your_Plan_by_Kaitlyn_MacLeod%2C_Esq.pdf">Self-Insurers Publishing Corp</a>. </p> <p class="bodytext" style="text-align: justify;">In their recent 2022 Mental Health Parity and Addiction Equity Act (“MHPAEA”) Report to Congress, the U.S. Department of Labor (“DOL”) reiterated that mental health parity is a top enforcement priority for the current administration. In the DOL’s eyes, plans are not fully complying with the MHPAEA Non-Quantitative Treatment Limitations (NQTL) Comparative Analysis requirement put in place last year, resulting in DOL audits and insufficiency findings. </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-phia-groups-2nd-quarter-2022-newsletter">Click here</a> to read the rest of this article</p> <p class="bodytext" style="text-align: justify;"><strong>The Cold War Over Health Prices: The value-based care gap and steps for employers to maximize plan value while reducing expenses</strong></p> <p class="bodytext" style="text-align: justify;">By: Micah D. Iberosi-Parnell, Esq. – February 2022 – <a href="https://www.sipconline.net/files/The_Cold_War_Over_Health_Prices-_by_Micah_D__Iberosi-Parnell.pdf">Self-Insurers Publishing Corp</a>. </p> <p class="bodytext" style="text-align: justify;">The long-term struggle over the price of health care services between providers and payers is a tale as old as time. On one side, providers want to preserve the status quo, fee-for-service payment (FFS) system, which triggers unnecessary treatment and wasteful health care spending. Meanwhile, payers have been consistently pushing new payment models that attempt to tie spending with results. Collectively, these models are often referred to as “value-based care” (VBC) or “alternative payment models.” </p> <p class="bodytext" style="text-align: justify;">In 2020, 40.9 percent of all health care payments in the U.S. were paid through some form of VBC model – an all-time high – according to the Health Care Payment Learning & Action Network (LAN). Traditional Medicare and Medicare Advantage plans were the main drivers of this achievement, as 85 and 62 percent of their payments, respectively, were value-based. Meanwhile, with only 49 percent of payments tied to VBC, employers and commercial payers lagged significantly behind Medicare. The survey did not measure the difference between self-insured employer plans and large commercial plans like UnitedHealth, but employer VBC payments are likely lower than the LAN survey suggests. </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-phia-groups-2nd-quarter-2022-newsletter">Click here</a> to read the rest of this article<br /> <br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pcharity" name="pcharity"></a></span></p> <hr class="horiz" /> <p class="bodytext" style="text-align: justify;"><span class="heading1">The Phia Group's 2022 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2022 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.</p> <p class="bodytext" style="font-weight: normal"><span class="bodytext"></span><a href="#top">Back to top ^</a><span class="heading1"><a id="pemployee" name="pemployee"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter: Joanna Wilmot</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job expectations but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Joanna WIlmot, The Phia Group’s 2022 Q1 Employee of the Quarter! </p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Joanna: “Joanna Wilmot has gone way above and beyond to help a client defend themselves and their client in an expensive lawsuit. I’ll spare you the details of the suit, but our client desperately needed Phia’s help compiling data. Joanna was given and completed in just two days, the daunting task of sifting through an estimated 1900 plan documents, document reviews, and PACE appeals histories to look for certain specific plan provisions. In addition to the volume, the identification and analysis of the language were far from simple. I’ll repeat that: 1900 plan documents in two days. Thanks, Joanna, for dropping everything and embracing this assignment to help our client in their time of need. You are awesome.”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Q2 2022/joanna1.jpg?ver=k-fXvwVCSNtezj4GLEpxBg%3d%3d" style="width: 390px; height: 460px;" /></p> <p class="bodytext" style="text-align: justify;">Congratulations Joanna, and thank you for your many current and future contributions.</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a><span class="heading1"><a id="pnews" name="pnews"></a></span></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">Job Opportunities:</span></p> <p class="bodytext">• VP, Business Analytics and Data Services </p> <p class="bodytext">• Claim Analyst</p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• PGC Project Coordinator </p> <p class="bodytext">• Plan Drafter </p> <p class="bodytext">• Accounts Payable Specialist</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext" style="text-align: justify;">• Garrick Hunt has been promoted from Sales Manager to Director of Business Development </p> <p class="bodytext" style="text-align: justify;">• Matthew Painten has been promoted from Marketing Manager to Marketing Director </p> <p class="bodytext" style="text-align: justify;">• Kevin Brady has been promoted from Health Benefit Plan Consulting Attorney II to Director, Plan Document Compliance </p> <p class="bodytext" style="text-align: justify;">• Andrew Silverio has been promoted from Compliance and Oversight Counsel to Compliance and Oversight Counsel, Team Lead </p> <p class="bodytext" style="text-align: justify;">• Amanda DeRosa has been promoted from Team Lead, Recovery Services to Manager, Recovery Services </p> <p class="bodytext" style="text-align: justify;">• Naviana Duterlien has been promoted from Compliance Analyst to Internal Audit Manager </p> <p class="bodytext" style="text-align: justify;">• Jen Costa has been promoted from Director, Recovery Services to Senior Director, Recovery Services </p> <p class="bodytext" style="text-align: justify;">• Brady Bizarro has been promoted from Director, Legal Compliance & Regulatory Affairs to Senior Director, Legal Compliance & Regulatory Affairs </p> <p class="bodytext" style="text-align: justify;">• Maya Tamhankar has been promoted from Director, Project Management Office to Senior Director, Project Management Office </p> <p class="bodytext" style="text-align: justify;">• Nick Murphy has been promoted from Senior Project Manager to Director, Project Manager </p> <p class="bodytext" style="text-align: justify;">• Christine Sands has been promoted from Senior Business Analyst to Manager, Data Integrity and Analytics</p> <p class="bodytext" style="text-align: justify;"><strong>New Hires</strong></p> <p class="bodytext" style="text-align: justify;">• Jillian Painten was hired as a Sr. Claims Recovery Specialist </p> <p class="bodytext" style="text-align: justify;">• Matthew Kyle was hired as a Sr. Claims Recovery Specialist</p> <a name="story"> </a> <p class="bodytext"><a name="story"> </a><a id="pnews" name="pnews"></a><a name="story"></a></p> <hr class="horiz" /> <a name="story"> </a> <p class="bodytext"><a name="story"><span class="heading1"></span></a>Phia News:</p> <p class="boldtext">Energage Names The Phia Group a Winner of the 2022 Top Workplaces USA Award</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">It is with great honor and humility that The Phia Group announces that it has earned a 2022 Top Workplaces USA award, issued by Energage. Energage, an organization that develops solutions to build and brand a vast array of companies, leveraged its 15-year history of surveying more than 20 million employees across 54 markets to award this prize. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Earning this accolade was no small task. Several thousand organizations from across the country were invited to participate, and winners of the Top Workplaces USA were chosen based solely on employee feedback gathered through an employee engagement survey, issued by Energage. These results were then calculated by comparing the survey’s research-based statements, including 15 Culture Drivers that are proven to predict high performance against industry benchmarks.  </p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Q2 2022/award09.png?ver=bR0_Taj_PRNhLrsBbLJTaA%3d%3d" style="width: 420px; height: 450px;" /></p> <p class="bodytext"><strong>Celebrating Mardi Gras at Phia</strong></p> <p class="bodytext" style="text-align: justify;">The Diversity and Inclusion Committee wanted to make sure the Phia Family celebrated Mardi Gras in the most traditional way possible, with multiple Mardi Gras king cakes. The Phia family had a great time celebrating, and the cakes were enjoyed by all! To learn more about the history of Mardi Gras, visit <a href="https://www.mardigrasneworleans.com/history/">https://www.mardigrasneworleans.com/history/</a>.</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q2 2022/div3.jpg?ver=kDc9NWGR41Fey8kNmzjDnQ%3d%3d" style="width: 426px; height: 515px;" /> <p class="bodytext"><strong>COVID - Appeals, Subrogation, and Stop Loss Issues No One Saw Coming - Help is Here</strong></p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/covid.png?ver=1PYo1bACQA4zxTLKiRB-tA%3d%3d" style="width: 572px; height: 533px;" /></p> <p class="bodytext" style="text-align: justify;">COVID claims are coming - whether you pay or deny claims tied to COVID, you need The Phia Group.</p> <p class="bodytext" style="text-align: justify;">Claims tied to the treatment of COVID-19 are being submitted for payment and are passing through the claims process in record numbers. Many of these claims are substantial, with these considerable costs impacting our industry in both anticipated and unforeseen ways. As with any influx of new claims, we are also seeing growth in the number of denials and appeals arising from these COVID claims, as well as subrogation issues tied to the disease.</p> <p class="bodytext" style="text-align: justify;">COVID claims are routinely denied and/or paid incorrectly, due in large part to the inadequate time provided to consultants, administrators, and payers, to familiarize themselves with the ever changing rules, and thereby standardize appropriate handling of these claims in accordance with law and their plan documents. As a result, we are also seeing an increase in COVID related claim appeals, with heightened fiduciary liability issues also arising from these claim payment decisions.</p> <p class="bodytext" style="text-align: justify;">The Phia Group's PACE Service has existed for years and is the only service on the market where expert plan drafters, attorneys, and seasoned appeals professionals help you navigate these and other difficult appeals, thereby avoiding mistakes and costly liability. PACE ensures claim denials are legitimate, enforceable, and defended.</p> <p class="bodytext" style="text-align: justify;">As with claims processing and appeals, COVID has also created a new world for subrogation. When COVID claims are submitted, complex state law may be triggered regarding if and when COVID is "presumed" to be an occupational expense. The Phia Group was the first subrogation provider to build a custom process backed by its in-house legal team with a focus on identifying COVID related claims, determining whether the applicable geographic location and occupation are addressed by a regulation that presumes a link between the occupation and diagnosis, and quickly asserts a right to reimbursement against responsible parties if possible. The Phia Group has been applying this procedure to its existing process since June of 2020. Without an innovative subrogation solution like ours in place, plans not only lose money, but also fail in their obligation to stop-loss; a failure stop-loss carriers are increasingly unwilling to overlook.</p> <p class="bodytext" style="text-align: justify;">The stop-loss world has been handed a unique and difficult scenario. As it relates to claims arising from or tied to COVID-19, carriers are suspending reimbursement and asking questions such as: what is the Plan Participant's job description; is the Plan Participant a front line worker; what date did they test positive; are they an essential worker; did they file a workers' compensation claim; and so on. The Phia Group has the expertise to assist in these difficult stop-loss collaborations.</p> <p class="bodytext" style="text-align: justify;">Ensuring appeals are handled correctly, aligning plan documents with stop-loss policies, and fully understanding the bigger picture has never been more important. The Phia Group is uniquely positioned to help in this difficult time. With our unrivaled team and technology ready to help, there is no better partner to assist you now and in the days to come.</p> <p class="bodytext" style="text-align: justify;">Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com" target="_blank">ghunt@phiagroup.com</a> or <a href="mailto:info@phiagroup.com" target="_blank">info@phiagroup.com</a> to request more information and set a call to learn how The Phia Group can assist you with these COVID claim issues.</p> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter 2018 Q2/footerlogo.png?ver=iYwkNviyLE_yU_0lKTSyJQ%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1150The Stacks – 2nd Quarter 2022 Newsletter | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1148/the-phia-groups-2nd-quarter-2022-newsletterNewslettersTue, 26 Apr 2022 19:34:48 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#0071ce;"><span style="font-size:18px;"><span style="line-height:107%"><span calibri="" style="font-family:"><b>Make Mental Health Parity a Priority for Your Plan </b></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 calibri="">By: Kaitlyn MacLeod, Esq. </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 calibri="">In their recent 2022 Mental Health Parity and Addiction Equity Act (“MHPAEA”) Report to Congress, the U.S. Department of Labor (“DOL”) reiterated that mental health parity is a top enforcement priority for the current administration. In the DOL’s eyes, plans are not fully complying with the MHPAEA Non-Quantitative Treatment Limitations (NQTL) Comparative Analysis requirement put in place last year, resulting in DOL audits and insufficiency findings. </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 calibri=""><b>What is the MHPAEA and Does It Affect Your Plan?</b></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 calibri="">The goal of the MHPAEA is to reduce stigma, discrimination and barriers inside and outside of the health care system for people with mental health or substance use disorder (“MH/SUD”) conditions. Treatment for MH/SUD conditions often operate in a disparate and separate system than treatment for medical and surgical (“M/S”) care. The MHPAEA is intended to promote equal access to treatment for MH/SUDs by prohibiting coverage limitations that apply more restrictively to MH/SUD benefits than to M/S benefits. </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 calibri="">The Consolidated Appropriates Act of 2021 amended the MHPAEA to require covered plans to produce a current NQTL Comparative Analysis that can be requested at any time by a plan participant or the DOL/CMS. This required report must include an analysis of the plan’s NQTLs in both writing and in practice, along with conclusions on parity and corrective action plans. Typical NQTLs include utilization reviews, prior authorization, provider credentialing standards, and plan provisions (like medical necessity or experimental/investigative determinations and exclusions).</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 calibri="">MHPAEA applies to self-funded or fully-insured plans with over 50 employees, meaning that these plans also need to have a NQTL Comparative Analysis on file. While the MHPAEA does not apply directly to small group health plans, its requirements are applied indirectly through the ACA’s essential health benefit requirements for mental health coverage. Even if the MHPAEA does not apply, some states have implemented mental health parity requirements that are even stricter than federal requirements, so mental health parity is still a concern. </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 calibri=""><b>Barriers to Mental Health and Substance Use Disorder Access for Plan Participants</b></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 calibri="">Seeking treatment for MH/SUD conditions can often be a significant barrier to individuals who may need said treatment – there is a stigma attached to “needing help” to manage these issues. Labor Secretary Marty Walsh expressed his own experience with the struggle to seek help with alcoholism by writing “I knew something was wrong, but it was so hard to take that first step. I’m so grateful that as a union member I had access to the care I needed, because once I did ask for help, my life started to change for the better.”</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 calibri="">Once an individual does decide to seek care, obtaining that care can often be an obstacle in its own right. Walsh described that “[f]rom identifying professionals who will take your insurance to figuring out what requirements you need to meet for treatment to be covered by your plan, the process can be incredibly difficult to navigate. Not only is this frustrating for those who need critical services – in many cases, it’s illegal.” </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 calibri="">In 2019, nearly 52 million adults in the United States experienced some form of mental illness and in 2020, an estimated 40.3 million people had a substance use disorder. The COVID-19 pandemic has only exacerbated MH/SUD conditions in the US – between August 2020 and February 2021, the percentage of adults exhibiting symptoms of anxiety/depressive disorder has increased from 36.4% to 41.5%. Further, deaths resulting from substance overdose rose by approximately 30,000 from when comparing 2019 numbers to 2022. U.S. Secretary of Health and Human Services Xavier Becerra noted that access to mental and behavioral health support is critical as the COVID-19 pandemic continues to impact so many lives across the country, but “health plans and insurance companies are falling short of providing access to the treatment many working families need.” </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 calibri=""><b>Jumpstart into Compliance</b></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 calibri="">Now that NQTL Comparative Analyses are required for most plans, how do you complete one? It is a detailed process that takes vendor and plan administrator participation to obtain sufficient information to conduct an analysis of each individual NQTL to ensure that MH/SUD benefits do not have any limitations that are stricter than corresponding M/S benefits. A common example is duration limitations – many plans impose visit limits for higher cost services, but plans must understand that those limits should not apply to MH/SUD benefits if there are not any limits for M/S benefits. </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 calibri="">It is essential to have a plan’s NQTL Comparative Analysis on hand before a DOL audit occurs. The DOL typically require plans to produce a detailed NQTL analysis within a very short timeframe (10-14 days). It is not practical to compile a detailed report with the level of information needed within that short timeframe. </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 calibri="">The 2022 MHPAEA Report’s main takeaway is that many plans and issuers were unprepared for a request of their analysis – and approximately 40% of plans responded to the DOL with a request for an extension to compile the required analysis. EBSA found that plans stated they were unable to comply because they erroneously assumed that vendors would prepare a comparative analysis for the plan, or that those vendors would have prepared their own comparative analysis that the plan could rely on – in many cases, vendors had not. Compliance is ultimately the responsibility of the plans themselves.</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 calibri=""><b>Common Compliance Challenges in Current Plan Language</b></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 calibri="">When drafting NQTL Comparative Analyses, we have come across plan language and operational data that is consistently problematic. In the past year, EBSA has requested a NQTL analysis on the following common NQTL violations:</span></span></span></span></p> <ul> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""> Precertification/concurrent care requirements;</span></span></span></span></li> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""> Limitations on applied behavior analysis or treatment for autism spectrum disorder;</span></span></span></span></li> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""> Network provider admission standards; </span></span></span></span></li> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""> Outof-network reimbursement rates; and</span></span></span></span></li> <li style="text-align: justify; margin: 0in 0in 8pt 0.5in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""> Treatment plan requirements. </span></span></span></span></li> </ul> <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="">The following is an overview of common compliance issues that often trip up plans. </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 calibri=""><u>ABA Therapy</u></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 calibri="">Many plans exclude ABA Therapy, one of the key treatments used for Autism Spectrum Disorder, due to the high cost of the treatment. Research has shown that early intervention and access to ABA therapy can improve the trajectory of a child’s development. The DOL has indicated that ABA Therapy in particular is a MHPAEA compliance concern – and that plans need to have evidence that an ABA Therapy exclusion is no more stringent than any comparable M/S benefit. </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 calibri=""><u>Pre-Certification Requirements for MH/SUD Benefits</u></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 calibri="">It is not uncommon to come across pre-certification requirements for all (or the vast majority of) MH/SUD benefits, while not requiring pre-certification for the same scope of M/S benefits. This is a classic example of a parity issue. Plans cannot have an overly strict list of MH/SUD benefits subject to pre-certification, without also having an equally strict list of M/S benefits subject to those requirements. EBSA has identified pre-certification as a common issue and has had plans alter pre-certification requirements and even provide an opportunity for participants to submit claims through retroactive changes in plan terms. </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 calibri=""><u>Autism Spectrum Disorder</u></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 calibri="">Autism Spectrum Disorder coverage and associated limitations can often crop up based on state-level requirements for coverage. For instance, some plans follow Wisconsin state law’s requirement to cover Autism treatment for ages two to nine, for a cumulative total of four years, and for intensive-level treatment of less than 20 hours per week. While providing coverage in line with state law will meet compliance on a state-level, it does not guarantee compliance with any federal laws. In particular, the MHPAEA requires that any of these limitations on autism spectrum disorder be no stricter than similar M/S conditions – this means that age limitations, duration of coverage, and weekly hour limitations cannot be stricter than any limitations that are in place for M/S conditions. In many cases, M/S conditions do not have age, duration, or weekly hour limitations, so these restrictions may create compliance issues with the MHPAEA. </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 calibri=""><b>Next Steps for the DOL and Compliance</b></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 calibri="">The DOL is seeking action from Congress to amend ERISA to expressly provide the DOL with the authority to directly pursue parity violations by entities that provide administrative services to ERISA group health plans, as well as assess civil monetary penalties for parity violations. </span></span></span></span></p> <p><span style="color:#000000;"><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="">The DOL and EBSA have made their stance clear – mental health is their priority and it should be a plan’s priority to comply with the MHPAEA as well. Now more than ever, it is imperative to ensure that plans are complying with the MHPAEA and its NQTL Comparative Analysis requirement. This is important not only to avoid the consequences of a DOL audit, but also to ensure that access to mental health treatment is available to plan participants in a meaningful way. </span></span></span></span></p> <hr /> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:18px;"><span style="color:#0071ce;"><b>The Cold War Over Health Prices:  The Value-Based Care Gap and Steps for Employers to Maximize Plan Value While Reducing Expenses</b></span></span><br /> <br /> <span style="color:#000000;">By Micah D. Iberosi-Parnell, Esq.<br /> <br /> The long-term struggle over the price of health care services between providers and payers is a tale as old as time. On one side, providers want to preserve the status quo, fee-for-service payment (FFS) system, which triggers unnecessary treatment and wasteful health care spending. Meanwhile, payers have been consistently pushing new payment models that attempt to tie spending with results. Collectively, these models are often referred to as “value-based care” (VBC) or “alternative payment models.”<br /> <br /> In 2020, 40.9 percent of all health care payments in the U.S. were paid through some form of VBC model – an all-time high – according to the Health Care Payment Learning & Action Network (LAN). Traditional Medicare and Medicare Advantage plans were the main drivers of this achievement, as 85 and 62 percent of their payments, respectively, were value-based. Meanwhile, with only 49 percent of payments tied to VBC, employers and commercial payers lagged significantly behind Medicare. The survey did not measure the difference between self-insured employer plans and large commercial plans like UnitedHealth, but employer VBC payments are likely lower than the LAN survey suggests.<br /> <br /> This gap translates into real-world disparities between Medicare and group plans including:</span></span></span><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"> </p> <p><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <ul> <li style="margin-right:.5in; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Group plans pay hospitals double the Medicare rate for inpatient services and triple the rate for outpatient services;</span></span></span></li> <li style="margin-right:.5in; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Inpatient hospital prices for groups grew 42 percent from 2007 to 2014, while physician prices for inpatient care grew 18 percent;</span></span></span></li> <li style="margin-right:.5in; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Employer dollars spent per employee for healthcare increased twice as fast as Medicare after the ACA was passed in 2008. </span></span></span></li> </ul> <p style="margin-right:.5in; text-align:justify; margin:0in"> </p> <p><span style="color:#000000;"></span></p> <p style="margin-right:.5in; text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><i>The Reasons for the VBC Gap</i><br /> <br /> The chief causes of the VBC gap have nothing to do with a lack of trying from within the self-funding industry and boil down to basic principles of market position and bargaining power. At the highest level, self-funded groups must lease provider networks through one of a few national carriers, which impose mandatory FFS rates and prevent plans from steering patients to better value in-network providers or directly contracting with outside providers. A 2013 antitrust lawsuit against a California-based provider network, Sutter Health, provided an up-close example of how these practices work. The plaintiffs accused Sutter Health of using coercive contracting practices to require group plans to penalize (either directly or through forfeited discounts) participants for using non-network providers or risk being completely frozen out of the in-network rates. One of the contract provisions at issue was:</span></span></span></p> <p style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align: justify; margin: 0in 0in 0in 40px;"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Sutter Health shall require each group health payer accessing Sutter Health providers through the [health plan] network to actively encourage members obtaining medical care to use Sutter Health providers … If Sutter Health or any provider learns that a payer ... does not actively encourage its members to use network participating providers, … Sutter shall have the right … to terminate that payer’s right to the negotiated rates … [The] terminated payer shall pay for covered services rendered by providers at 100% of billed charges until … Sutter reasonably believes that the payer does in fact actively encourage its members to use network participating providers …</span></span></span></p> <p style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Anti-competitive network language like this is commonplace and generally legal; Sutter Health won its case. Unless a plan is willing to cut all network ties (which has its own drawbacks), most group plans must tolerate all-or-nothing network agreements. The bargaining power of group plans in these arrangements today is akin to one person trying to negotiate Apple’s terms and conditions.<br /> <br /> Provider demands underpin these one-sided networks agreements. Increasingly-consolidated provider chains are the main source of high prices and resistance to VBC. Today, nearly 90 percent of all U.S. metro areas are “highly concentrated” in terms of provider competition. For context, the U.S. soda market between Coke and Pepsi is also considered “highly concentrated.” Large providers leverage their monopolization of regional markets to demand higher reimbursements and one-side contract arrangements from the networks, which then offset the costs upon group plans.<br /> <br /> Medicare has always counteracted these forces because of its market position as America’s largest health insurer (by enrollees) and political power. That is a major reason why Medicare has historically paid lower prices than groups plans. In recent years, though, the disparity between the two has accelerated because Medicare has gradually deployed VBC reforms that have helped curb rapidly rising health care prices. Providers cannot do much to stop Medicare’s VBC efforts aside from lobbying Congress. Meanwhile, group plans must tolerate unilateral network agreements or find alternative solutions that may increase the risk of balance billing on plan members.<br /> <br /> By this point, it might seem impossible for group plans to overcome coercive network agreements and provider monopolies – especially for mid-to-small-size employers. There is light on the horizon, however. Group plans and employers can still contain health costs and boost coverage with a balance of available VBC solutions and thoughtful plan design.<br /> <br /> <i>Solutions Available for Employers</i><br /> <br /> The solutions that help employers contain group plan expenses and increase the value of coverage come in two flavors based on whom they target. The first category of “supply-side” interventions seeks to change providers’ incentives to increase prices. The second category of “demand-side” solutions targets participants’ incentives to choose more efficient care through benefits design and education. Supply-side solutions include many traditional VBC models such as capitation, bundled payments, etc., and can be highly effective in combatting wasteful provider practices, especially unbundling and upcoding.<br /> <br /> In the self-funding space, employers who implement supply-side solutions typically agree to prepay providers, often on a per employee per month (PEPM) basis, for the care. Direct primary care (DPC) – where an employer directly contracts with a primary care physician practice that provides comprehensive treatment to eligible employees for a set fee – is probably the most widespread VBC solution among employers today. Primary care is hardly the only type of medicine where employers can experience significant savings; bundled payments may enable employers to reduce health expenses for certain complex treatments. For example, recent research by the RAND Corporation showed that self-insured employers save up to 11 percent of health by switching to bundled care services for complex operations – including total knee and hip replacement, spinal fusion, and bariatric weight loss procedures. Aside from the financial benefits, many supply-side solutions can also boost employee satisfaction with the plan since it usually increases low-cost access to necessary care.<br /> <br /> As discussed above, network contracts often block employers from employing these solutions. Employers should carefully examine their network agreement and weigh their own comfort level prior to implementing most VBC solutions. Aside from networks, participants not utilizing prepaid DPC services or other VBC services can be a financial risk for employers. This can be counteracted by making employees aware of the program and reducing the number of participants enrolled in the program to those who will actually use it. Additional compliance considerations dependent on the specific VBC program and group plan may also exist and should be analyzed on a case-by-case basis.<br /> <br /> A practical consideration for employers interested in DPC, bundled payments, or other supply-side solution is whether the provider contract includes two-sided risk factors. In other words, employers may want to consider VBC arrangements that financially penalize the provider for poor-quality care and reward them for improved-quality care. These carrot-stick arrangements are already popular with public payers and can help better align plan costs with health outcomes and care quality than PEPM and other set fee arrangements. They also are generally more adaptable to patient demands and surges in care that have become a mainstay in the COVID-19 era.<br /> <br /> Next, while supply-side solutions are effective, providers still often cave to patient demands even in the face of a financial penalty. This is why it is crucial for employers to consider the value of health care when designing benefits. A simple way that employers can do this is by tying cost-sharing to the value of specific treatments, which then nudges participants to utilize more clinically and cost-effective health care.<br /> <br /> The Phia Group incorporates some of these demand-side nudges into its own plan, such as waiving cost-sharing when a generic alternative exists for a brand-name drug or using urgent care over emergency departments for non-emergent conditions. Other models have been developed by public health researchers and can already be seen in Medicare Advantage plans and on the ACA Exchanges. Specifically, the “VBID-X Model” offers a good starting point for plans to reference when tailoring cost-sharing to the value of certain services. The basic framework of the plan design is built upon the below principles:</span></span></span></p> <p style="text-align:justify; margin:0in"> </p> <p><span style="color:#000000;"></span></p> <p style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <ul> <li style="margin-right:27.0pt; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Favor services with the strongest evidence-based and external validation;</span></span></span></li> <li style="margin-right:27.0pt; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Favor services that are more responsive to cost-sharing;</span></span></span></li> <li style="margin-right:27.0pt; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Favor services with a high likelihood to be high or low-value (e.g., services with the least nuance in value are the easiest to implement);</span></span></span></li> <li style="margin-right:27.0pt; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Considering how the plan design features intersect with related reforms and initiatives (e.g., favor services already rewarded under value-based payment models);</span></span></span></li> <li style="margin-right:27.0pt; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Focus on areas with the most need for improvement;</span></span></span></li> <li style="margin-right:27.0pt; text-align:justify; margin:0in 0in 0in 0.5in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Consider equity, adverse selection, impact on special populations, and the risk pool.</span></span></span></li> </ul> <p style="text-align:justify; margin:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The designers of the VBID-X were able to use these principles to increase the actuarial value of a group plan’s coverage without increasing the actual plan costs. Importantly, designing plan benefits based on value is significantly less likely to conflict with network agreements and is the easiest way for employers to decrease plan expenses without decreasing coverage.<br /> <br /> Overall, as rapidly rising prices impact employees through rising premiums and deductibles, participants are likely to demand better value coverage. Beginning to implement VBC payment arrangements and high-value plan design can help employers take control of their future health care costs now. </span></span></span></p> <p style="text-align:justify; margin:0in"> </p> <p style="text-align:justify; margin:0in"> </p> <p style="text-align:justify; margin:0in"> </p> 1148The Phia Group's 1st Quarter 2022 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1120/the-phia-groups-1st-quarter-2022-newsletterNewslettersThu, 20 Jan 2022 15:49:10 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2022/phiaheader2021.jpg?ver=kG0SmqlSJp67FY1HQzR8hA%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2022/icons66.png?ver=svYiG0s-6SaKQwFgPkjP5Q%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Q1 2022/block12021.png?ver=svYiG0s-6SaKQwFgPkjP5Q%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#russo5"><img src="/Portals/phiagroup/Newsletters/Q1 2022/block11021.png?ver=UFJDtDpRwdYuJ6XU81bwmA%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td valign="top" width="47%"> <p><br /> <img src="/Portals/phiagroup/Newsletter Q1 2018/adam.jpg?ver=KAJlFem5DERRpjAI9hFfew%3d%3d" style="width: 264px; height: 255px;" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">What a year. I mean… what a couple of years, huh? As always, I try to be mindful of the present while also looking optimistically toward the future, and I wonder if – twenty years from now – will we look back at this time in our lives and laugh (and/or cry)? Will we tell our grandkids, and will they tell their kids, about “those COVID days” that their ancestors powered through, on a path back to “how things used to be?” Or, will this be the “new normal” … and those same grandkids will listen in disbelief as we tell them about how once upon a time, we could go out in public without masks or proof of vaccines? Or about our fight to avoid getting sick, to avoid getting others sick... How we fought so hard to return to a life we once enjoyed, not recognizing that things would never be the same, and we would need to find a way to go on with this as the new status quo?</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">None of us know the answer to this and similar questions, but what we do know is that – just as many of us feel that many of the measures we are taking now cannot last forever – so too is the rapid-fire deluge of regulations and court rulings moving fast - too fast - to keep up. This must stop at some point, right? I can’t help but feel overwhelmed. </p> <p class="bodytext" style="text-align: justify;"> Yet, when I stop to think… I also feel pride. I feel proud that people are at least trying to help one another, even if they disagree on how to do it. I am proud also of our team at The Phia Group, and how we have absorbed this overwhelming tidal wave of change, digested it, and provided guidance to others … allowing us to maintain an industry reputation as one of the trust-worthiest sources of vital information; both when it comes to compliance and successful formation and management of self-funded health plans. We have built a team of amazing experts who analyze and then implement the right services, procedures and plan language to fit every unique employee benefit plan and need. We strive to be the best at what we do because we know that every plan member and employer deserves access to the best health plan they can get; something that can only be achieved through access to timely information and implementation of needed updates. <a name="russo4"></a> We are here for you during these crazy times and I promise that we understand what is at stake.</p> <p class="bodytext">– Happy reading!</p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p><img src="/Portals/phiagroup/Newsletter Q2 2017/inthisissue.png?ver=MccyVIGCQMCOF4LSnwUjkQ%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><a href="#russo5">Enhancements of the Quarter: ICE & PACE Value Reports</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2022 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#pemployee">Employee of the Year & Quarter</a><br /> <a href="#pnews">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><br /> <a id="russo5" name="russo5"></a></p> <p class="bodytext"><strong>Enhancement of the Quarter: ICE & PACE Value Reports </strong></p> <p class="bodytext" style="text-align: justify;">As always, we at The Phia Group are constantly looking for ways to enhance our service offerings. This month, we have improved reporting via our ICE Value Report and our PACE Value Report. </p> <p class="bodytext" style="text-align: justify;"><i>ICE Value Report</i> </p> <p class="bodytext" style="text-align: justify;">This is designed to provide a wealth of information to users of The Phia Group’s Independent Consultation and Evaluation (ICE) service. As a result of user feedback, this report chronicles data such as the number of inquiries, number of lives, topics of requests, individuals who have submitted requests, quarterly comparisons, and more. This information is intended to help an ICE user to recognize and communicate the value of the service, and having these operational metrics in one simple report can help the user recognize trends or areas of particular concern (including ICE benefits of which the user has not taken advantage!). </p> <p class="bodytext" style="text-align: justify;"><i>PACE Value Report</i> </p> <p class="bodytext" style="text-align: justify;">Intended for users of The Phia Group’s Plan Appointed Claim Evaluator (PACE) service, this report goes into detail regarding the number of appeals handled, appeal denial reasons, IRO utilization, a numerical summary of appeal outcomes, and more. This report is designed to demonstrate the value of the PACE service, as well as to give the user an idea of what might be the primary issues with its appeals decisions. For instance, if the report revealed that a large number of first-level appeals were overturned by the PACE service, it could spur important process changes.<br />  </p> <p class="bodytext"><strong>Service Focus of the Quarter: PACE</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group’s Plan Appointed Claim Evaluator (PACE) service is a fiduciary transfer service created to help health plans and TPAs manage complex and very personal final-level appeals and ensure that fiduciary duties are satisfied by a neutral third party. Through the PACE service, The Phia Group assumes a fiduciary duty to the plan and analyzes final-level internal appeals to render a directive. If the directive is overturned on external appeal, The Phia Group will cover the resulting expenses on behalf of the PACE client. The Phia Group also obtains clinical reviews and access to URAC-accredited IROs, as necessary. These services, along with any other third-party review costs, are included in the cost of the PACE service and do not cost PACE clients extra fees. </p> <p class="bodytext" style="text-align: justify;">PACE clients also receive complimentary plan document and stop-loss policy reviews to promote compliance, eliminate coverage gaps, and ensure PACE readiness. Overall, PACE is designed to help the health plan ensure that appeals are handled correctly in accordance with the law, insulating the health plan from liability and allowing the employer to focus on what it does best. </p> <p class="bodytext" style="text-align: justify;">We also offer PACE Certification, through which your organization can enhance your PACE understanding and utilization, improve your general internal appeals processes, learn how to better ensure regulatory compliance, and improve your business as a whole. </p> <p class="bodytext" style="text-align: justify;">To learn more, contact attorney Tim Callender at <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a> or 208-830-8400.</p> <p class="bodytext"> </p> <p class="bodytext"><strong>Success Story of the Quarter: The Delinquent Group</strong></p> <p class="bodytext" style="text-align: justify;">A long-time TPA client of ours reached out to The Phia Group’s Consulting (PGC) department regarding a group that had termed some time ago. Upon termination, the TPA, of course, remitted the value of the group’s assets in its possession back to the group. Due to a simple clerical error, the TPA remitted the same amount to the group a second time, resulting in a duplicate payment. </p> <p class="bodytext" style="text-align: justify;">The group was unreceptive to any of the TPA’s attempts to recoup the duplicate payment. Since this was not a payment of plan assets or to a provider, it was not a matter that The Phia Group’s robust Overpayments department could assist with, but our consulting team was up to the task! </p> <p class="bodytext" style="text-align: justify;">Our team got to work brainstorming and ultimately drafted a ghost letter for the TPA to use to communicate with the group. PGC’s ghost letter included arguments based on the Administrative Services Agreement, the law, and general principles of equity and reasonableness. Just a few weeks later, our client happily reported that the refund had been issued, noting that “your letter got us paid!” </p> <p class="bodytext" style="text-align: justify;">The Phia Group is quite varied in our service offerings, and we find that there is always some way we can help. Even if you are not sure what can be done, we can help flesh it out! Please do not hesitate to contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> or 781-535-5644 with any questions or issues that arise in the course of your self-funded business offerings.</p> <p class="bodytext" style="text-align: justify;"> </p> <p class="bodytext"><strong>Phia Case Study: Leaving Out The Leaves</strong></p> <p class="bodytext" style="text-align: justify;">Drafting and designing an SPD is hard work. Even if a plan or TPA engages some third party to do it, it is still far from rinse-and-repeat since all groups potentially want different benefits! Leaves of absence (LOA) are no small part of that, too. </p> <p class="bodytext" style="text-align: justify;">Many health plans choose to incorporate their LOA policies only by having the SPD reference something like “…according to the Employer’s internal Leave of Absence policies.” Other plans, however, choose to be more explicit about referencing those policies into the SPD and include language in the SPD to the effect of identifying certain employer-created leave policies and their relevant timeframes. </p> <p class="bodytext" style="text-align: justify;">This particular case study has to do with stop-loss. We were recently faced with a situation where one of our clients had a large stop-loss claim denied by the carrier. The SPD provided that coverage would be continued during an employer-approved LOA, which of course, incorporated the employer’s LOA by reference rather than explicitly. The employer approved an LOA for the employee, and everyone was happy. </p> <p class="bodytext" style="text-align: justify;">During that LOA, however, the employee incurred a catastrophic claim. When submitted to the stop-loss carrier, the carrier said, essentially, “whoa, hang on – this person was not “Actively at Work” and should not have been covered!” The employer responded by pointing to the SPD language that incorporates the employer’s LOA policies and decisions. Still, the carrier continued to deny the claim by citing language in the applicable stop-loss policy that specifically said that employer LOA policies and other “internal” employment-type benefits are explicitly not a part of the Plan Document. </p> <p class="bodytext" style="text-align: justify;">That creates quite a dilemma since the stop-loss policy essentially denies that language in the SPD actually exists! That is a problem for plans, and one course of action is to write specific leave of absence timeframes into the SPD. That can be harder to maintain, since a change to the Handbook or LOA policies may necessitate a change to the SPD, but it can help avoid this type of stop-loss “gap”. </p> <p class="bodytext" style="text-align: justify;">Proactively identifying gaps is always the best way to become aware of and get ahead of issues like this, and The Phia Group can help! Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> or 781-535-5644 for more information on our Gap-Free Analysis service.</p> <p class="bodytext" style="text-align: justify;"> </p> <hr class="horiz" />_ <p> </p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Compensation Disclosure and Prohibited Transactions</strong></p> <p class="bodytext" style="text-align: justify;">For most folks working in the self-funded industry, the term “prohibited transaction” is a term that might get glossed over. The issue is easy to ignore because of its incredibly complex nature, and irrelevance to most daily activities, along with many company’s reliance on corporate counsel to tell them whether they are doing something they should not be doing. </p> <p class="bodytext" style="text-align: justify;">Beyond the No Surprises Act, other parts of the Consolidated Appropriations Act (CAA) enacted major changes for the self-funded industry. Mainly, it enhanced the responsibility of brokers, TPAs, and other select service providers to disclose compensation received by a health plan. Disclosing fees is the norm, of course, since no plan can be expected to agree to pay an unknown amount – but the new broker disclosure laws expand that requirement a bit and amend ERISA. Of course, where ERISA is concerned, there are fiduciary implications! </p> <p class="bodytext" style="text-align: justify;">The new disclosure requirements, at <a href="https://www.law.cornell.edu/uscode/text/29/1108#b_2">29 U.S.C. § 1108</a>, create certain exemptions from ERISA’s “prohibited transaction” rules. In general, the law now provides that a service agreement must be “reasonable” or else it is presumed to be a prohibited transaction. The CAA has indicated that a service agreement is only “reasonable” if it meets certain requirements, primarily including a description of the services provided and disclosure of all direct, indirect, or other fees received or expected to be received from the plan. </p> <p class="bodytext" style="text-align: justify;">Gone are the days when a service agreement could vaguely describe an undefined fee structure with a relatively uninformed plan agreement; Congress has ushered in an era of full disclosure and transparency. For some TPAs and brokers, this may mean revamping contracts and adding unprecedented layers of specificity and disclosure, while others may be able to say, “Well, no problem, since we already do that!” Whichever camp you find yourself in, we recommend checking your contracts to make sure they are up to snuff since many anticipate frenzied enforcement of this new portion of ERISA.</p> <a name="pdef"></a>  <hr class="horiz" /> <p> </p> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On December 14, 2021, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/the-11th-hour-last-minute-moves-to-make-for-2022-as-a-new-era-in-cost-containment-begins">“The 11th Hour - Last Minute Moves to Make for 2022 as a New Era in Cost Containment Begins,”</a> where we learn, plan, save and protect your plans – now and in the future. </p> <p class="bodytext" style="text-align: justify;">• On November 16, 2021, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/act-now-plan-ahead-the-2021-endgame-and-2022-outlook">“Act Now, Plan Ahead – The 2021 Endgame and 2022 Outlook</a>,” where we discuss what must be done now to finish 2021 strong, as well as forecast what to expect in 2022. </p> <p class="bodytext" style="text-align: justify;">• On October 19, 2021, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/a-spooky-surprise-nsa-regulations-on-idr-released">“A Spooky Surprise: NSA Regulations on IDR Released,”</a> where we tap supernatural forces to reveal the secrets of this rule, explain the implications for claims and appeals, and help you stay one step ahead of the competition.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p>   <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a></p> <p class="heading1">Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On December 22, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p125-the-night-before-an-emergency-room-visit">The Night Before an Emergency Room Visit</a>,” where our hosts, Rebekah McGuire-Dye and Lisa Hill, bring you back to the basics of recovering subrogation dollars and identifying subrogation opportunities through an entertaining holiday story. </p> <p class="bodytext" style="text-align: justify;">• On December 10, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p124-healthcare-subrogation-and-plan-document-requests">Healthcare Subrogation and Plan Document Requests</a>,” where our hosts, Chris Aguiar and Cindy Merrell, discuss what a health plan should do in the event of a pesky U.S.C. 1024(b)(4) records request. </p> <p class="bodytext" style="text-align: justify;">• On November 23, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p123-supreme-court-takes-major-dialysis-case">Supreme Court Takes Major Dialysis Case</a>,” where our hosts, Brady Bizarro and Andrew Silverio, discuss important developments in dialysis case law. </p> <p class="bodytext" style="text-align: justify;">• On November 12, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p122-covid-19-vaccine-mandate-update">COVID-19 Vaccine Mandate Update</a>,” where our hosts, Kelly Dempsey and Kevin Brady, discuss the controversial OSHA vaccine mandate rules – where they started, where they stand now, and the many legal challenges that have arisen. </p> <p class="bodytext" style="text-align: justify;">• On October 29, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p121-transplants-the-future-is-now">Transplants: The Future is Now!</a>,” where our hosts, Nick Bonds and Jon Jablon, discuss a highly nuanced topic that has been the bane of many health plans: organ transplants. </p> <p class="bodytext" style="text-align: justify;">• On October 15, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p120-to-appeal-or-not-to-appeal">To Appeal, or not to Appeal</a>,” where our hosts, Ron Peck and Jen McCormick, dissect the No Surprises Act and reveal how and why there will be confusion regarding what constitutes a basis for appeal, and what should be disputed per the NSA.</p> <p class="bodytext">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletter 2019 Q1/Apple%20Podcasts.jpg?ver=goypGkLDYbWCGYXontbItA%3d%3d" style="width: 491px; height: 121px;" /></a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a></span></p> <p class="bodytext"><span class="heading1">Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/12/09/a-word-of-warning-for-grandfathered-health-plans/">A Word of Warning for Grandfathered Health Plans</a> – December 9, 2021 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Ingredients_for_a_successful_2022-_A_Recipe_for_self-funded_plan_Sponsors_by_Jennifer_M__McCormick.pdf">Ingredients for a Successful 2022: A Recipe for Self-Funded Plan Sponsors</a> – December 4, 2021 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/A_Rose_By_Any_Other_Name_by_Ron_E_Peck.pdf">A Rose by Any Other Name ...</a> – November 7, 2021 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/10/25/colorados-updated-essential-health-benefits-what-employers-need-to-know/">Colorado’s updated essential health benefits: What employers need to know</a> – October 25, 2021</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a></span></p> <p class="bodytext"><span class="heading1">From the Blogoshpere:</span><span class="heading1"></span><br />  </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/a-teaser-a-rose-by-any-other-name">A Teaser! A Rose by Any Other Name …</a> Appeals used to be the only way to secure a review of a disputed plan decision. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-needle-of-damocles-oshas-anticipated-vaccine-rules">The Needle of Damocles: OSHA’s Anticipated Vaccine Rules</a>. President Biden took a step he’d previously been reluctant to take – imposing new vaccine rules on federal workers and contractors, health care workers, and large employers. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-nba-health-care-scandal">The NBA Health Care Scandal</a>. One person submitted paperwork for $48,000 worth of root canals and crowns on eight teeth at a Beverly Hills dental office--while he was living in Taiwan. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/what-kind-of-month-has-it-been">What Kind of [Month] Has it Been?</a>. Take a moment to pause and reflect on the whirlwind of policies, proposals, and issues swirling in the end-of-2021 zeitgeist as we brace for 2022. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/stop-loss-gaps-level-funding-is-far-from-immune">Stop-Loss “Gaps”: Level Funding Is Far From Immune.</a> Learn all about level-funding in this great blog post.</p> <p class="bodytext" style="text-align: justify;">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.</p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a></span></p> <p class="bodytext"><span class="heading1">The Stacks:</span></p> <p class="bodytext" style="text-align: justify;"><strong>Ingredients for a Successful 2022: A Recipe for Self-Funded Plan Sponsors</strong><br /> <br /> By: Jennifer M. McCormick, Esq. – December 2021 – <a href="https://www.sipconline.net/files/Ingredients_for_a_successful_2022-_A_Recipe_for_self-funded_plan_Sponsors_by_Jennifer_M__McCormick.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">With 2022 rapidly approaching, employers and plan sponsors of self-funded plans must act quickly to make important health benefit plan implementation decisions. Specifically, this upcoming plan year will create a puzzle for plans as they navigate compliance with the evolving regulatory landscape, complex COVID regulations, and the corresponding financial implications. </p> <p class="bodytext" style="text-align: justify;">Not dissimilar to plan years past, employers should have already at least initiated the plan design discussions. These conversations are crucial as annual benefit modifications are needed to address the changing employee and participant population needs. Plan vitality is no less important, so these revisions should be balanced against the potential economic factors. Additionally, prior to instituting these updates the employer must carefully and thoughtfully address the many regulatory requirements to ensure the plan’s foundation is compliant.</p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2022" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>A Rose by Any Other Name ...</strong></p> <p class="bodytext" style="text-align: justify;">By: Ron E. Peck, Esq. – November 2021 – <a href="https://www.sipconline.net/files/A_Rose_By_Any_Other_Name_by_Ron_E_Peck.pdf">Self-Insurers Publishing Corp.</a> The year is 2009. You are busy serving as a claims administrator for a self-funded health plan, on a lovely Monday morning in March. On this day, a couple appeals roll into your office. In one instance, a claim was denied due to a lack of medical necessity. Nothing was paid; the claim was denied in full. In the other instance, the appeal relates to an out-of-network provider’s bill. The original claim that was submitted for payment exceeded $30,000. At the time, the applicable benefit plan paid an amount it calculated to be “usual and customary” (or “U&C”); the process it applies when determining a maximum allowable payment when there is no pre-existing contractual rate. </p> <p class="bodytext" style="text-align: justify;">In the first case, the provider is filing an appeal, arguing that the treatment did meet the plan’s definition of medical necessity. In the second case, the provider is filing an appeal arguing that the plan’s calculation of U&C is flawed.</p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2022" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a></span></p> <p class="bodytext"><span class="heading1">The Phia Group's 2022 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2022 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8-18, signed up as club members. In the 25 years since, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.</p> <p><span class="bodytext"><br /> <strong>Halloween in the Haunted House</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">This year, The Phia Group had the opportunity to participate in something extra spooky. A group of Phia employees volunteered to dress up as characters in a haunted house to raise money for the Boys & Girls Club of Metro South. We raised a total of $3,500.00 this year and cannot want to do it again next year!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2022/haunted.jpg?ver=aUl1mlsP4Y5dJ9i0VUiEbQ%3d%3d" style="width: 500px; height: 502px;" /> <p><span class="bodytext"><strong></strong></span></p> <p><span class="bodytext"><strong>Thanksgiving Dinner Delivery</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Family was out and about the week of Thanksgiving, delivering dinners to the Boys and Girls Club of Metro South, so the families could pick up their meals when they picked up their children. Additionally, our Phia Family in Idaho and Boise were out and about spreading the same cheer to ten families in their local communities. In total, Phia delivered 25 meals this year! Check out the great picture we could get from that special day! We hope everyone had a wonderful Thanksgiving!<br /> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2022/bandg2.jpg?ver=kG0SmqlSJp67FY1HQzR8hA%3d%3d" style="width: 400px; height: 319px;" /></p> <p><span class="bodytext"><strong>Angel Tree</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Each year employees of The Phia Group pick nametags from the Angel Tree that sits in our cafeteria. On those tags are names, ages, and the wish lists of children from The Salvation Army. This year we had over 150 nametags! The Phia family loves to give back to the community; our greatest joy is providing these children with all of their holiday wishes.<br /> <br /> <img alt="" height="403" src="/Portals/phiagroup/Newsletters/Q1 2022/angeltree2.jpg?ver=UFJDtDpRwdYuJ6XU81bwmA%3d%3d" width="433" /></p> <p><span class="bodytext"><strong>Christmas Came Early</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group had the pleasure of bringing Christmas joy to the Boys & Girls Club of Metro South. Adam Russo and his helpers passed out hundreds of gifts to over 120 children. We hope these children enjoy their new toys as much as they enjoyed spending time with Santa and his helpers! </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2022/santa2.jpg?ver=aUl1mlsP4Y5dJ9i0VUiEbQ%3d%3d" style="width: 400px; height: 303px;" /> <p class="bodytext" style="font-weight: normal"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a></span></p> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter: Jon Jablon</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job expectations but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Jon Jablon, The Phia Group’s 2021 Q4 Employee of the Quarter! </p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Jon: “This quarter - and this year in general - Jon has provided vital contributions to the Provider Relations department, despite having left the department almost two years ago. Just this past week, Jon has taken the lead in answering questions from two different Provider Relations clients regarding general plan language as well as NSA-specific matters. He has also made himself available numerous times to consult on provider appeal responses, ERISA questions, and many other topics. Jon has, for all intents and purposes, become a mentor to the Provider Relations attorneys. In addition, Jon has become a go-to for questions that arise in any department, including in-house legal matters. While it may be expected that PGC employees assist other departments in matters related to the law, plan language, etc., Jon has gone above and beyond what should reasonably be expected of him.”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2022/jon2.jpg?ver=UFJDtDpRwdYuJ6XU81bwmA%3d%3d" style="width: 400px; height: 560px;" /></p> <p class="bodytext">Congratulations Jon, and thank you for your many current and future contributions.</p> <h2><strong>Get to Know Our Employee of the Year: Jen Costa</strong></h2> <p class="bodytext" style="font-weight: normal; text-align: justify;">To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must transcend their established job expectations and demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Jen Costa, The Phia Group’s 2021 Employee of the Year! </p> <p style="text-align: justify;">Here is what a few people had to say about Jen: "The effort it takes to work your way up in a company is often overlooked.  To learn this business from the ground up is challenging.  Dedication, hard work and perseverance are needed to ensure you advance within this company.  Jen is the most knowledgeable person in all areas of recovery from intake thru data.  She has spent the past year implementing HRS program with Phia.  She has worked tirelessly to ensure the best possible transition for our clients as well as HRS clients.  She has worked nights and weekends to make sure her team can handle the new business.  She holds us all accountable for each step in this HRS process and makes sure to think of the company as a whole.  The effort she has put in over the years as well as this last year makes her one of the best employees we have." </p> <p style="text-align: justify;">"Jen not only ensures that the support side of the business runs smoothly, but this year in particular she took on the feat of taking the lead of starting a new line of business in Mass Tort.  From reviewing language to creating compliant letters, scheduling letters to be sent out, to ensuring that the HRS team as well as the client was kept informed of the progress, this project would not have been as streamlined if Jen was not at the head of it. Anytime anything related to Mass Tort comes up, the first person that people go to is Jen for a definitive answer (including myself and I'm not even in her dept!).  Meetings to determine next steps, troubleshoot ideas, and compose a process to ensure success have all been driven by her questions, observations, and knowledge that she has “self-taught” herself on.  ------  On top of juggling this, she is meticulous when it comes to details of meetings, overseeing and communicating issues like data that effect all departments, and thinking outside the box when issues arise."</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2022/Jen%20Costa%20Newsletter.jpg?ver=yJSRXCbxJM-a5f9hSZk96g%3d%3d" style="width: 300px; height: 383px;" /> <p class="bodytext"><br /> Congratulations Jen, and thank you for your many current and future contributions.</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"> </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a></span></p> <p class="bodytext"><span class="heading1">Job Opportunities:</span></p> <p class="bodytext">• ETL Specialist<br /> • Legal Assistant<br /> • Case Investigator<br /> • Customer Service Representative<br /> • Claim Analyst<br /> • Claim & Case Support Analyst<br /> • Senior Vice President of Sales</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext">• Alyssa Pisco has been promoted from Senior Claims Recovery Specialist to Claim Recovery Specialist IV</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Melinda Bellis was hired as the Associate General Counsel </p> <p class="bodytext">• Scott Byerley was hired as a VP, Recovery Services </p> <p class="bodytext">• Melanie DeMelin was hired as a Claim & Case Support Analyst </p> <p class="bodytext">• Haley McBroom was hired as a Sr. Claims Recovery Specialist </p> <p class="bodytext">• Soujana Gouriesetty was hired as an ETL Specialist </p> <p class="bodytext">• Jacqueline Davis was hired as a Plan Drafter </p> <p class="bodytext">• Brianna Coe was hired as a Customer Service Rep. </p> <p class="bodytext">• Jacob Falkof was hired as a Case Analyst </p> <p class="bodytext">• Melissa Mattingly was hired as a Sr. Claims Recovery Specialist </p> <p class="bodytext">• Sheyla Ortega-Perez was hired as a Customer Service Rep. </p> <p class="bodytext">• Scott Bennett was hired as a VP, Provider Relations </p> <p class="bodytext">• Connor Gillen was hired as a Subrogation Attorney </p> <p class="bodytext">• Elliot Logan was hired as a Subrogation Attorney</p> <p class="bodytext"> </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a></span></p> <p class="bodytext"><span class="heading1">Phia News:</span></p> <p class="boldtext">The Boston Globe Names The Phia Group as a Top Place to Work for 2021</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">It is with great honor and humility that The Phia Group announces it has been named by The Boston Globe as one of the Top Places to Work in Massachusetts. In its 14th annual employee-based survey, The Boston Globe – having assessed anonymous employee feedback and details about the company – determined that The Phia Group provides one of the most rewarding, meaningful employment experiences in the Commonwealth of Massachusetts.  </p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2022/globe.png?ver=svYiG0s-6SaKQwFgPkjP5Q%3d%3d" style="width: 600px; height: 150px;" /></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to announce that it has earned a Best Places to Work in Greater Louisville award, issued by Louisville Business First. The Best Places to Work program—administered in partnership with Quantum Workplace—surveys employees about workplace policies, office conditions, management styles, morale, and more. The Phia Group is humbled to be one of only 43 businesses and nonprofits, with at least 10 full-time employees and an office in the Louisville area, that scored high enough to be awarded.</p> <p class="bodytext" style="text-align: justify;">The Phia Group only recently opened its Louisville office, but it already houses some of the company’s most valuable team members. Thanks to the talent and passion found in Louisville, along with this recognition, The Phia Group plans to continue its steady growth in the Louisville area.</p> <p class="bodytext"><strong>COVID - Appeals, Subrogation, and Stop Loss Issues No One Saw Coming - Help is Here</strong></p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/covid.png?ver=1PYo1bACQA4zxTLKiRB-tA%3d%3d" style="width: 572px; height: 533px;" /></p> <p class="bodytext" style="text-align: justify;">COVID claims are coming - whether you pay or deny claims tied to COVID, you need The Phia Group.</p> <p class="bodytext" style="text-align: justify;">Claims tied to the treatment of COVID-19 are being submitted for payment and are passing through the claims process in record numbers. Many of these claims are substantial, with these considerable costs impacting our industry in both anticipated and unforeseen ways. As with any influx of new claims, we are also seeing growth in the number of denials and appeals arising from these COVID claims, as well as subrogation issues tied to the disease.</p> <p class="bodytext" style="text-align: justify;">COVID claims are routinely denied and/or paid incorrectly, due in large part to the inadequate time provided to consultants, administrators, and payers, to familiarize themselves with the ever changing rules, and thereby standardize appropriate handling of these claims in accordance with law and their plan documents. As a result, we are also seeing an increase in COVID related claim appeals, with heightened fiduciary liability issues also arising from these claim payment decisions.</p> <p class="bodytext" style="text-align: justify;">The Phia Group's PACE Service has existed for years and is the only service on the market where expert plan drafters, attorneys, and seasoned appeals professionals help you navigate these and other difficult appeals, thereby avoiding mistakes and costly liability. PACE ensures claim denials are legitimate, enforceable, and defended.</p> <p class="bodytext" style="text-align: justify;">As with claims processing and appeals, COVID has also created a new world for subrogation. When COVID claims are submitted, complex state law may be triggered regarding if and when COVID is "presumed" to be an occupational expense. The Phia Group was the first subrogation provider to build a custom process backed by its in-house legal team with a focus on identifying COVID related claims, determining whether the applicable geographic location and occupation are addressed by a regulation that presumes a link between the occupation and diagnosis, and quickly asserts a right to reimbursement against responsible parties if possible. The Phia Group has been applying this procedure to its existing process since June of 2020. Without an innovative subrogation solution like ours in place, plans not only lose money, but also fail in their obligation to stop-loss; a failure stop-loss carriers are increasingly unwilling to overlook.</p> <p class="bodytext" style="text-align: justify;">The stop-loss world has been handed a unique and difficult scenario. As it relates to claims arising from or tied to COVID-19, carriers are suspending reimbursement and asking questions such as: what is the Plan Participant's job description; is the Plan Participant a front line worker; what date did they test positive; are they an essential worker; did they file a workers' compensation claim; and so on. The Phia Group has the expertise to assist in these difficult stop-loss collaborations.</p> <p class="bodytext" style="text-align: justify;">Ensuring appeals are handled correctly, aligning plan documents with stop-loss policies, and fully understanding the bigger picture has never been more important. The Phia Group is uniquely positioned to help in this difficult time. With our unrivaled team and technology ready to help, there is no better partner to assist you now and in the days to come.</p> <p class="bodytext" style="text-align: justify;">Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com" target="_blank">ghunt@phiagroup.com</a> or <a href="mailto:info@phiagroup.com" target="_blank">info@phiagroup.com</a> to request more information and set a call to learn how The Phia Group can assist you with these COVID claim issues.</p> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.</p> <p class="bodytext"><strong></strong><br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter Q1 2018/footerlogo.png?ver=-c8yhuYtU1mPXJVxbXTW6A%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1120The Stacks – 1st Quarter 2022https://www.phiagroup.com/Media/Posts/PostId/1118/the-stacks-1st-quarter-2022NewslettersWed, 19 Jan 2022 20:16:22 GMT<p style="text-align:justify; margin:0in"><span style="color:#0071ce;"><span style="font-size:20px;"><span style="font-family:"Calibri",sans-serif"><b>A Rose by Any Other Name…</b></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:14px;"><span style="font-family:"Calibri",sans-serif">By: Ron E. Peck<br /> <br /> The year is 2009.  You are busy serving as a claims administrator for a self-funded health plan, on a lovely Monday morning in March.  On this day, a couple appeals roll into your office.  In one instance, a claim was denied due to a lack of medical necessity.  Nothing was paid; the claim was denied in full.  In the other instance, the appeal relates to an out-of-network provider’s bill.  The original claim that was submitted for payment exceeded $30,000.  At the time, the applicable benefit plan paid an amount it calculated to be “usual and customary” (or “U&C”); the process it applies when determining a maximum allowable payment when there is no pre-existing contractual rate. <br /> <br /> In the first case, the provider is filing an appeal, arguing that the treatment did meet the plan’s definition of medical necessity.  In the second case, the provider is filing an appeal arguing that the plan’s calculation of U&C is flawed. <br /> <br /> In both cases, less than 100% of billed charges was paid.  In both cases, the reduced payment (or no payment) constituted an adverse benefit determination.  In both cases, the provider – deeming itself to be a beneficiary of the plan (a completely separate discussion for another day) – has exercised its right to file an appeal.  In both cases, per the terms of the plan document and applicable law, the plan will have a fixed number of days to review the appeals and issue a decision… In both cases, they can uphold the original decision, or overturn the original decision and pay something additional.  In both cases, if the decision on appeal is to uphold the original decision, the beneficiary may then choose to appeal again (if a second appeal is available), and once the appeals are exhausted, seek to appeal the matter externally to a court of law.<br /> <br /> A year later, the “Affordable Care Act” (or “ACA”) was enacted in two parts: The Patient Protection and Affordable Care Act (signed into law on March 23, 2010) and The Health Care and Education Reconciliation Act (of March 30, 2010).  With the passage of what we call ObamaCare, rights to appeal were greatly strengthened.  New rights were bestowed upon beneficiaries, while new obligations were simultaneously imposed upon plans and carriers.  Strict timelines were bolstered by law, and access to binding external appeals before independent review organizations (or “IROs”) were legislated.  As providers and patients became more aware of these added rights and opportunities to push back against adverse benefit determinations, the number and complexity of appeals grew.  Both in response to denials and reduced payments, plan sponsors and administrators soon came to appreciate how important a well organized and defensible appeals process truly is.  They also came to realize how risky it is to make claims payment decisions and handle appeals without outside analysis.  Indeed – any seemingly arbitrary decision could, upon review, result in the decision maker being slapped with penalties for having breached their fiduciary duty.  Thus it was that both external review of appeals and protection against fiduciary liability found new value in the eyes of payers.  So it was, for more than a decade…<br /> <br /> On Dec. 27, 2020, The No Surprises Act (or “NSA”) was signed into law as part of the Consolidated Appropriations Act of 2021.  Amongst the many interesting rules and changes so introduced, the NSA seeks to prevent providers from balance billing patients in specific instances.  With that in mind, we are forced to wonder, when a patient can’t be held responsible for a balance, what – then – becomes of the balance?  Is the provider forced to waive it?  Is the applicable plan or carrier required to pay it?  Something in the middle?  Indeed, telling providers not to bill patients was the easy part; deciding who pays what to whom – less so.  The rule attempted to address this by stating that providers and payers would first be forced to negotiate.  Sadly, whomever devised this plan has apparently never negotiated before, since – any experienced negotiator knows – when entering a negotiation, you set a “cap” or maximum amount you are willing to pay (or accept).  That amount is in turn based on numerous factors.  Some important – if not the most important – factors are how likely you are to “win” if a matter can’t be resolved amicably, how much you’d win, and what it would cost to win.   The rule went on to explain that if a matter can’t be negotiated, it will proceed to arbitration.  The arbitrator – applying “baseball arbitration” rules – will need to pick between two offers; one made by the payer, and the other made by the provider.  There can be no “middle ground” selected by the arbitrator.  The issue, again, is that – until we know what rules or parameters the arbitrator will use to determine who “wins,” then no one knows who arbitration favors or how much to offer.  Without knowing what happens if a balance is NOT settled, we can’t enter negotiations with a plan; without knowing what happens in arbitration, we can’t engage in independent dispute resolution with a plan.   This left us clamoring for more information.<br /> <br /> Recently, we received an answer.  On September 30, 2021, the Departments of Health and Human Services, Labor, and Treasury, along with the Office of Personnel Management, released an interim final rule with comment period, entitled “Requirements Related to Surprise Billing; Part II.”  Here, they made clearer their stance on the use of objective pricing metrics – such as Medicare rates – and gave us some additional information to help us calculate how much is likely to be deemed the proper payment by an arbitrator.  Rather than delve more deeply into that aspect of the rule, however, I seek not to address the rules and parameters likely to determine how pricing disputes will be resolved, and rather, I seek to highlight one glaring issue… What happens to appeals?<br /> <br /> Recall, back on that sunny Monday in 2009 when you received those two appeals?  Recall how those appeals were handled in accordance with the terms of the plan document and law?  It was so simple, back then… Any reduced payment would be deemed an adverse benefit determination, and would be eligible for appeal.  Skip to 2021, and here we find ourselves dealing with a true issue – what is appealed, and what is not?  What adverse benefit determination must be appealed, and which triggers the NSA?<br /> <br /> Certainly, some adverse benefit determinations clearly fall into the bucket of appeals.  If a claim is denied outright – regardless of network status – because the service was (for instance) cosmetic, not medically necessary, and thus excluded by the plan… the provider, if they believe the payer to be mistaken, should appeal the denial.<br /> <br /> Likewise, looking at a situation that seems to fall cleanly under the NSA umbrella, an out-of-network specialist, providing services at an in-network facility, that treats a plan member… only to have their bill be paid based on a percent of Medicare rates (and leaving a balance behind)… is the type of scenario envisioned by the NSA.  If this provider believes that the plan didn’t misapply the terms of the plan document, and agrees that the amount paid by the plan matches the maximum allowable amount as defined by the plan document, then – we believe – this balance would not be eligible for appeal, and rather, would need to be disputed per the NSA.<br /> <br /> Yet… not all claims fall so neatly into these buckets.  What if a claim, submitted by such an out-of-network specialist (at an in-network facility), is denied in part due to a plan exclusion (such as experimental and investigational), and the remainder is paid using a Medicare-based pricing methodology?  Is one part (the denied part) of the claim appealed, whilst the other part (the reduced payment) is disputed under the NSA?  Does this happen simultaneously?  What if the denied portion of the bill is overturned, and paid – using the aforementioned Medicare-based pricing methodology?  Must this be disputed anew, or added to the other disputed payment?  What if the provider is willing to accept a payment based on a percent of Medicare rates, is pleased to accept the percent of Medicare described in the applicable plan document, but believes the plan simply miscalculated the Medicare-based amount to which that provider is entitled?  Is that clerical error grounds for an appeal, or dispute?<br /> <br /> This represents just the tip of the iceberg, when dissecting the breadth and scope of adverse benefit determinations.  The variety of reduced and denied payments we routinely handle in our office would shame Baskin Robbins and their mere 31 flavors.  With the creation of an alternative means to challenge a plan’s payment now being established by the NSA, in addition to the appeals process, we can expect an increase in appeal volume (as providers seek to trigger the NSA but mistakenly submit an appeal), complexity (as the players attempt to parse out what should be appealed, and what should trigger the NSA), and confusion (as matters go from an appeal of unpaid claims to a dispute over reduced payments of the same claim, following an overturned denial).<br /> <br /> In addition to creating ambiguity and confusion regarding which disputed adverse benefit determinations trigger the NSA versus those that are eligible for appeal, so too does this also create more opportunity for conflict between benefit plans and their stop-loss carriers.  Once, stop-loss carriers only needed to suspend reimbursement while a matter proceeded through an appeals process.  Now, stop-loss carriers will struggle to keep an eye on the claims as they bounce back and forth between appeals and NSA disputes.  Furthermore, while most stop-loss carriers agree to reimburse payments their policyholders are forced to pay (following an appeals process and order issues by an IRO or court of law to overturn an adverse benefit determination), will those same carriers also agree to cover additional payments made during an NSA negotiation period?  Following independent dispute resolution and arbitration?<br /> <br /> Adding to this quagmire, is the plan administrator’s fiduciary duty.  Plan administrators have learned over time to handle appeals in strict accordance with applicable law and the plan document.  The terms of the plan document regularly dictate what is payable, and how much is payable.  Now, are these plan administrators authorized to pay something additional during the NSA’s requisite “negotiation period,” without exceeding the authority granted to them by the plan document and Employee Retirement Security Act of 1974 (“ERISA”)?  Would an additional payment during negotiations constitute a payment in excess of the maximum allowable amount, and thus, constitute a breach of their fiduciary duty?<br /> <br /> In summary, it is safe to say that these new regulations and laws <span style="color:black">will increase the number of entities that may file appeals and broaden the</span><span style="color:black"> scope of issues about which appeals may be filed, as well as complicate the process applicable to handling adverse benefit determinations and appeals</span>.  Additionally, the other “dispute resolution” procedures established by law – separate and distinct from formal appeals – will result in confusion regarding which conflicts are meant to be appealed, versus those that should now be handled via an alternative methodology.<br /> <br /> As these rules and regulations continue to be released, we will continue to learn more.  Hopefully, which claims fall into which lane – appeals versus disputes – will further crystalize.  In the meantime, benefit plans and those that service them would be well advised to revisit their current appeals process.  Ensure the process clearly defines what can be appealed, when, and how.  Retain objective third parties to provide a de novo review of adverse benefit determinations, and share liability for complicated decisions.  Establish a process by which matters can be transferred to or from the appeals process if and when it is determined a matter should be appealed, or negotiated via the NSA.   Finally, stay abreast of the changing rules to ensure compliance.  Meanwhile, communicate with your stop-loss carrier to confirm what they need – before, during, and after both appeals and NSA based disputes – as well as define what is covered, when, and what documentation is required.  Together, we can overcome these new complexities, and hopefully emerge with a system that works.</span></span><br /> <span style="font-size:14px;"><span style="font-family:"Calibri",sans-serif"></span></span></p> <hr /> <p style="margin:0in"><span style="font-size:20px;"><span style="color:#0071ce;"><span style="font-family:"Calibri",sans-serif"><b>Ingredients for a Successful 2022: A Recipe for Self-Funded Plan Sponsors</b></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">By: Jen McCormick, Esq.<br /> <br /> With 2022 rapidly approaching, employers and plan sponsors of self-funded plans must act quickly to make important health benefit plan implementation decisions. Specifically, this upcoming plan year will create a puzzle for plans as they navigate compliance with the evolving regulatory landscape, complex COVID regulations, and the corresponding financial implications.<br /> <br /> Not dissimilar to plan years past, employers should have already at least <i>initiated </i>the plan design discussions. These conversations are crucial as annual benefit modifications are needed to address the changing employee and participant population needs. Plan vitality is no less important, so these revisions should be balanced against the potential economic factors. Additionally, prior to instituting these updates the employer must carefully and thoughtfully address the many regulatory requirements to ensure the plan’s foundation is compliant. </span></span><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><br /> <br /> The scope of this discussion is to highlight key plan document and design revisions for the plan year beginning on or after January 1, 2022.<br /> <br /> <b>Getting Started</b><br /> <br /> When contemplating plan document updates, the claims administrator and employer should approach renewal discussions mindful of pending risks and opportunities. The goal is to implement a plan design which addresses these considerations. To maximize the plan’s success for an upcoming plan year, an employer should review relevant plan materials in advance of any renewal meetings.<br /> <br /> Items an employer should compile include:</span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <ol> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> The past year’s claim data; </span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> A list of the plan sponsor and/or plan participant’s desired benefit changes and improvements; </span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Any relevant supplemental options to support the plan’s success;</span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> An outline of the pending compliance requirements; and</span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> All corresponding agreements and materials potentially needing modification. </span></span><br /> <span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></li> </ol> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">A non-exhaustive list of documentation that must be reviewed includes the stop loss policy, Plan Document and Summary Plan Description (PD/SPD), plan amendments, relevant administrative services agreements, vendor contracts, employee handbook, and the Summary of Benefits and Coverage (SBC).<br /> <br /> Once the documentation is compiled, the next step is developing an action plan to mitigate the identified risks and improvement opportunities. To simplify this process, the plan might consider analyzing modifications for the upcoming plan year as they would generally fall in one of three categories – must, may, and should. This approach will ensure that employers adopt the most attractive, yet compliant and cost-effective plan design for plan participants.<br /> <br /> <b>Must</b><br /> <br /> An annual review of the employer’s plan design is necessary. This step must not be skipped and to have the most impact, the review must address both compliance updates and cost containment issues.<br /> <br /> <i>Compliance</i><br /> <br /> Over the course of 2021 the regulations created new baseline requirements and the plan provisions must be revised accordingly. This section is not intended to serve as a complete list, but to highlight significant compliance considerations for plan sponsors for the 2022 plan year.<br /> <br /> On an annual basis, the US Department of Health and Human Services (HHS) adjusts the Affordable Care Act (ACA) in-network out of pocket maximum amounts. For plan years in 2022 these limitations apply for essential health benefits under non-grandfathered group health plans. The maximum for self-only coverage is $8,700 and the maximum for coverage other than self-only is $17,400. Note that certain qualified high deductible health plans have different limits as well. An employer must review and adjust the benefits to ensure compliance with the 2022 federally allowed out of pocket maximums.<br /> <br /> In addition to potential modifications to the plan’s cost-sharing maximums, the employer must revise employee contributions if they do not coincide with the applicable ACA Employer Mandate affordability threshold for 2022. Pursuant to IRS Revenue Ruling Procedure 2021-36, for plan years beginning on or after January 1, 2022, employer sponsored self-only coverage may not exceed 9.61% of an employee’s household income. This is significant as it represents a decrease from the 9.83% affordability threshold in 2021. An employer, subject to the Employer Mandate, offering coverage greater than the 9.61% threshold could be subject to penalties. Plan sponsors should continue to monitor this, however, as pending regulations may further decrease the affordability threshold in the future. <br /> <br /> During the 2020 and 2021 plan years regulators issued urgent relief to assist individuals and employers through the COVID-19 pandemic. Much of this temporary relief, however, has either since changed or expired. As a result, many of these optional and required compliance provisions must now be removed from plan materials.<br /> <br /> For example, employers must address the following with respect to previously issued amendments:</span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <ol> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Did the plan adopt any optional, temporary relief with respect to the Health Flexible Savings Account or Dependent Care Assistance Plan benefits? If so, have the changes been documented with the appropriate timeframes and expiration dates? </span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Did the plan adopt a COVID amendment to comply with the regulations? Was that COVID amendment revised as the regulations edited the extended timelines?  Note that the national emergency and public health emergency will likely continue for the foreseeable future. </span></span></li> <li style="text-align:justify; margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Did the plan issue an amendment to address COBRA premium relief assistance under the American Rescue Plan Act of 2021? If so, did the language appropriately address the relevant timing and interaction between other regulations? </span></span></li> </ol> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The Consolidated Appropriations Act of 2021 (CAA) mandates plan language changes as well for the 2022 plan year. The CAA enhanced existing mental health parity protections by mandating a written, documented comparative analysis to demonstrate compliance regarding the plan’s non-quantitative treatment limitations (NQTLs). Plan sponsors must have, readily available, relevant information to demonstrate the NQTLs within the plan design imposed upon mental health and substance use disorder benefits are in parity with those imposed upon medical and surgical benefits. For example, plan sponsors must review the NQTLs specific to the requirements for medical and prescription pre-authorization, the reimbursement strategy for out of network claims, the medical management and medical necessity standards, and any provider definitions containing unique licensure requirements.<br /> <br /> The CAA also contains expansive surprise medical billing protections. Pursuant to the No Surprises Act (NSA), plans will need to add and revise certain plan provisions to protect plan participants. NSA presents new terms such as certified IDR entity, qualifying payment amount and recognized amount which should be defined for plan participants. Further, the NSA expands the scope of emergency services and as a result the existing plan definition will require revision to ensure compliance.<br /> <br /> The required NSA revisions created new protections for plan participants covered under a grandfathered health plan. Prior to the NSA, retaining grandfathered status would have exempted the plan from certain ACA requirements. For example, only non-grandfathered plans were required to comply with the revised ACA appeals process and emergency service protections. Significantly, the NSA expands the scope of claims subject to external review to include adverse benefit determinations involving consideration of the plan’s compliance with the NSA protections for both non-grandfathered and grandfathered plans. These expanded protections necessitate urgent plan revisions. <br /> <br /> <i>Cost Containment</i><br /> <br /> With so many required compliance changes, the plan must not overlook implementation of cost containment strategies. Upon review of the available claims data the plan sponsor may identify exposures that can be mitigated by alternative benefits. Employers should consider whether any particular benefit revisions could create plan savings without decreasing available benefits.<br /> <br /> For example, important questions should be discussed: </span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <ol> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Did the plan encounter issues with any high-cost specialty drugs where a generic drug may have been appropriate? </span></span></li> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Does the plan have a program to ensure participants are properly guided, when requested and appropriate, to alternative drugs? </span></span></li> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Does the plan encourage or mandate second opinions for any procedures? </span></span></li> <li style="text-align: justify; margin: 0in 0in 0in 0.5in;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"> Does the plan offer compliant mental health and substance use disorder benefits that will ensure the necessary support for plan participants?  </span></span></li> </ol> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><b>May</b><br /> <br /> Beyond compliance and cost containment updates employers may wish to consult their employees regarding plan design. The health plan is an important employee benefit and may be used as a recruitment tool. By taking the employee benefit desires into consideration it may help assure the package remains attractive and available as a retention tool. <br /> <br /> While this step should be balanced against the financial implications of such changes, it is an important part of the renewal discussions. Every employee suggestion may not be implemented, but the feedback may help the employer understand the benefits their employees value the most. For example, are employees inquiring about Lasik eye surgery, massage benefits, acupuncture benefits or chiropractic benefits? Could the addition of these benefits not only improve employee morale but potentially offset the need for other more expensive benefits? Are employees asking about expanded categories of eligible dependents? Could the additional classification generate increased employee satisfaction?<br /> <br /> Even if the employer does not intend to adopt a broader scope of benefits, listening to employee desires and needs can inspire conversations and a deeper understanding of the employer’s plan benefit design.<br /> <br /> <b>Should</b><br /> <br /> After contemplating the compliance, cost containment and other benefit changes the employer should devise a detailed implementation plan. Not only will materials need to be revised to reflect the updated benefits, but the employer should have a plan for communicating this information to plan participants.<br /> <br /> As multiple documents will need to be updated a thorough gap review of the various plan materials should be performed to ensure that a change to one document will not create a conflict within another. As the regulations for 2022 outline process related changes, the employer and administrator must review processes, systems, and work flows to ensure they are up to date.<br /> <br /> Importantly, since many of these changes are new requirements, they might not be neatly outlined within existing agreements. As a result, the documents governing the plan’s relationships should be reviewed to ensure the regulatory requirements are addressed and duties clearly outlined by the appropriate party.<br /> <br /> <b>Next Steps</b><br /> <br /> Plan year 2022 will present complexities for plan sponsors. To preempt these issues an employer must be prepared with the proper ingredients to make sure they have a recipe for success. The best preparation mandates an in-depth understanding of the regulatory requirements, strategies tailored to the plan population, and an action plan for implementation. This year will be crucial for plans to coordinate, collaborate, and communicate with relevant plan stakeholders to ensure the upcoming plan year will be a positive one.</span></span></p> 1118The Phia Group's 4th Quarter 2021 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1099/the-phia-groups-4th-quarter-2021-newsletterNewslettersWed, 27 Oct 2021 15:14:00 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/phiaheader2021.jpg?ver=cPXT-OQ2nUoOqvo57jvVxw%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q4 2021/icons68.png?ver=Ouerj_Q06_ofiNcvdCGCcw%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo44"><img src="/Portals/phiagroup/Newsletters/Q4 2021/block10021.png?ver=Ouerj_Q06_ofiNcvdCGCcw%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#russo55"><img src="/Portals/phiagroup/Newsletters/Q4 2021/block11021.png?ver=Ouerj_Q06_ofiNcvdCGCcw%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td valign="top" width="47%"> <p><br /> <img src="/Portals/phiagroup/Newsletter 2019 Q1/adam9.jpg?ver=d5VGoFOPUXcIVu6YdsX-0Q%3d%3d" style="width: 264px; height: 255px;" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"> </p> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">‘Tis the season! No… not the Holiday Season. It’s renewal season, and everyone is scrambling to retain current business as well as attract some new lives for 2022. One of the ways with which we at The Phia Group can assist you is by identifying unique ways to ensure both client retention and securing some new business. We can help you accomplish these lofty goals by offering innovative solutions – meant to stop (and reverse) the costly trends with which most plans are dealing – and impress employers and brokers alike. Indeed, when we speak with those entities, they are almost universally dissatisfied with their current offerings, and one of the most important things they want to see from their administrator partners are new tools and services that will make their plans more attractive to their employees… all while remaining cost effective.</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Sadly, we all lose when employers give up on self-funding, and recent rules and regulations seem to be dead-set on making our plans less effective and more costly. Staying ahead of these trends and leveraging both data and consumer behavior will be what separates the winners from the losers, and ensures you keep (and retain) clients long term. </p> <p class="bodytext" style="text-align: justify;">It has come to my attention that many industry members “believe” that they know exactly what we do at The Phia Group, and they jump to conclusions about what we can or can’t do together. Yet, as the saying goes, when you assume… well… you know the rest. There is not a single entity in our industry that cannot benefit from some collaboration; together we learn and do more than any of us could on our own. Recognizing that every situation is different, the bottom line is that your clients need our combined expertise in their corner, especially in light of the ever changing legal landscape. With this as our mission, our services are often “white labeled” by clients, who seek to utilize us like a subcontractor. Other times, clients openly advertise our relationship and tout the tools and partnerships they bring to the table on behalf of their customers. Either way, there exist opportunities that can and will contribute to your success, while benefiting customers as well; lowering the overall cost of health benefits while ensuring better access to quality care.</p> <p class="bodytext" style="text-align: justify;">For those who don’t work with us, reach out and let’s see what – if anything – we can do together. For those that already partner with us, let’s diagnose our current status, see if there is anything we can add or adjust, and confirm you are getting the most from our collaboration. It breaks my heart when a current partner of ours is not enjoying added revenue or success, all because they don’t understand our services or can’t communicate the value-add to their customers. Let’s work together to ensure that doesn’t happen! We want to make sure that you have all of the tools you need, at your disposal, to not only survive… but lead. </p> <p class="bodytext" style="text-align: justify;">When I started this company over 20 years ago I did so with the goal of inspiring change and fixing what I felt was a broken model. I have seen how, with amazing technology and legal prowess, our partners have succeeded in growing their client base by offering tools that are desperately needed in an ever changing environment. Let us partner with you to ensure a bright future for all. </p> <p class="bodytext" style="text-align: justify;">- Happy reading.</p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p class="tocbkgd"><img src="/Portals/phiagroup/Newsletter Q1 2018/inthisissue.png?ver=n5HSLKiVNAfWV5tv5BtrZA%3d%3d" style="width: 101px; height: 18px;" /><br /> <a href="#russo44"><span style="color:null;">Services of the Quarter</span></a><span style="color:null;"> - Plan Appointed Claim Evaluator (PACE) </span><br /> <a href="#pftp"><span style="color:null;">Phia Fit to Print</span></a><span style="color:null;"></span><br /> <a href="#pblog"><span style="color:null;">From the Blogosphere</span></a><span style="color:null;"></span><br /> <a href="#pwebinars"><span style="color:null;">Webinars</span></a><span style="color:null;"></span><br /> <a href="#ppodcast"><span style="color:null;">Podcasts</span></a><span style="color:null;"></span><br /> <a href="#pcharity"><span style="color:null;">The Phia Group’s 2021 Charity</span></a><span style="color:null;"></span><br /> <a href="#pstacks"><span style="color:null;">The Stacks</span></a><span style="color:null;"></span><br /> <a href="#pemployee"><span style="color:null;">Employee of the Quarter</span></a><span style="color:null;"></span><br /> <a href="#pnews"><span style="color:null;">Phia News</span></a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a name="russo44"></a> <p class="heading1"> </p> <p class="heading1">A Teaser and the Service of the Quarter: Plan Appointed Claim Evaluator (PACE) – Now More Than Ever!<strong><a id="russo2" name="russo"></a> </strong></p> <p class="bodytext"><strong>A Teaser! A Rose by Any Other Name…</strong></p> <p class="bodytext">By: Ron E. Peck, Esq. </p> <p class="bodytext" style="text-align: justify;">I am very excited to let you know that my recent article, regarding the No Surprises Act and its impact on appeals and disputes, will be published in the upcoming issue of The Self-Insurer magazine, published by the Self-Insurance Institute of America (“SIIA”). Here I provide you with an overview of the topic that will be discussed, why this is so important, and how it all impacts our own Plan Appointed Claim Evaluator (“PACE”) service. </p> <p class="bodytext" style="text-align: justify;">One upon a time, if a plan beneficiary felt their claim was underpaid – either fully denied, or partially paid – it was fodder for an appeal. Appeals were the only way to secure a review of a disputed plan decision. </p> <p class="bodytext" style="text-align: justify;">With the “Affordable Care Act” (or “ACA”) being signed into law in 2010, the volume and complexity of appeals increased. More entities could appeal about more things. Additionally, if they weren’t happy with the results of said appeal, an external review option was added. This all meant more work, tougher work, and a lot more fiduciary risk for entities that were responsible for receiving, reviewing, and making decisions in response to appeals. </p> <p class="bodytext" style="text-align: justify;">That’s why, following the passage of the “ACA, we witnessed growing industry concerns over the volume, sensitivity, and complexity of appeals. This, along with the risk associated with fiduciary duties arising from the handling of those appeals, caused The Phia Group to create the <strong>Plan Appointed Claim Evaluator (PACE)</strong> service. </p> <p class="bodytext" style="text-align: justify;">Now, with the passage of the Consolidated Appropriations Act of 2021, the number and difficulty of appeals – as well as risk associated with handling them – will increase even more. Not only will there be more appeals, but the No Surprises Act will also result in providers appealing claims that should be disputed under the “NSA,” (and disputing under the NSA claims that should be appealed). </p> <p class="bodytext" style="text-align: justify;">Amongst the many interesting rules and changes so introduced, the NSA seeks to prevent providers from balance billing patients in specific instances. Balance billing happens when a payer pays to a payee less than the amount to which that payee thinks they are entitled. Historically, the payee would file an appeal, and if the appeal fails, they would then balance bill the patient. In other words, providers generally balance bill patients only when they know they can’t get anything else from the plan. Most providers learn that the plan won’t pay anything else after they file an appeal and lose. Indeed, in the past, any reduced payment would be deemed an adverse benefit determination, and would be eligible for appeal. Skip to 2021, however, and here we find ourselves dealing with a true issue – what is appealed, and what is not? What adverse benefit determination must be appealed, and which triggers the NSA? </p> <p class="bodytext" style="text-align: justify;">Certainly, some adverse benefit determinations clearly fall into the bucket of appeals. Yet… not all claims fall so neatly into these buckets. We deal with a vast variety of reduced and denied payments, arising from a tremendous variety of causes. With the creation of an alternative means to challenge a plan’s payment now being established by the NSA, in addition to the appeals process, we can expect an increase in appeal volume (as providers seek to trigger the NSA but mistakenly submit an appeal), complexity (as the players attempt to parse out what should be appealed, and what should trigger the NSA), and confusion (as matters go from an appeal of unpaid claims to a dispute over reduced payments of the same claim, following an overturned denial). </p> <p class="bodytext" style="text-align: justify;">In addition to added volume and complexity, there is added fiduciary risk. Plan administrators have learned over time to handle appeals in strict accordance with applicable law and the plan document. The terms of the plan document regularly dictate what is payable, and how much is payable. Now, are these plan administrators authorized to pay something additional during the NSA’s requisite “negotiation period,” without exceeding the authority granted to them by the plan document and Employee Retirement Security Act of 1974 (“ERISA”)? Would an additional payment during negotiations constitute a payment in excess of the maximum allowable amount, and thus, constitute a breach of their fiduciary duty? </p> <p class="bodytext" style="text-align: justify;">In summary, it is safe to say that these new regulations and laws will increase the number of entities that may file appeals and broaden the scope of issues about which appeals may be filed, as well as complicate the process applicable to handling adverse benefit determinations and appeals. Additionally, the other “dispute resolution” procedures established by law – separate and distinct from formal appeals – will result in confusion regarding which conflicts are meant to be appealed, versus those that should now be handled via an alternative methodology. </p> <p class="bodytext" style="text-align: justify;">This is why the time for PACE is now. PACE is a fiduciary transfer service addressing final-level internal appeals. It is designed solely to help health plans ensure that they have made correct determinations in response to an appeal, as well as insulate the plan from liability, allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations. </p> <p class="bodytext">PACE includes: </p> <p class="bodytext" style="text-align: justify; margin-left: 40px;">• Assessment of eligible final internal appeals via written directive as a fiduciary; </p> <p class="bodytext" style="text-align: justify; margin-left: 40px;">• Plan Document and stop-loss policy “Gap Reviews” ensure compliance, eliminate coverage gaps, and ensure PACE readiness; </p> <p class="bodytext" style="text-align: justify; margin-left: 40px;">• Advanced-level webinars exclusively for PACE clients; and, </p> <p class="bodytext" style="text-align: justify; margin-left: 40px;">• Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (and PACE covers all external review costs!) </p> <p class="bodytext" style="text-align: justify;">We also offer PACE Certification, through which your organization can enhance your PACE understanding and utilization, improve your internal appeals processes, ensure regulatory compliance, and improve your business as a whole. </p> <p class="bodytext" style="text-align: justify;">To learn more about PACE or PACE Certification, contact Garrick Hunt, at <a href="mailto:Ghunt@phiagroup.com">Ghunt@phiagroup.com</a> or 781-535-5644.</p> <a name="russo5"></a> <p class="bodytext"><strong>Success Story of the Quarter: Proactive Problem-Solving</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group’s Provider Relations team was presented with a situation where a self-funded health plan attempted to “carve out” dialysis from its plan, as well as from its network. Their hope was to instead pay all dialysis benefits at a percentage of Medicare. This particular health plan also contained an exclusion, excluding from coverage any dialysis claims incurred once the patient became Medicare-eligible (regardless of whether the patient actually signed up for Medicare). </p> <p class="bodytext" style="text-align: justify;">The dialysis provider engaged a law firm to recoup nearly $350,000. It is worth noting that we have dealt with this law firm in the past, and they do not shy away from litigation. </p> <p class="bodytext" style="text-align: justify;">Phia analyzed the issues, and opined that the plan’s practices were prohibited by applicable law and the network contract; the plan was neither permitted to pay dialysis claims at an amount less than the network rate, nor deny all dialysis claims for individuals who have not actually enrolled in Medicare. We provided to the plan administrator a detailed explanation as to why this was the case, and what was missing from their arrangement that – if it had been handled properly prior to their incurring the claims – would have enabled them to carve dialysis out of the plan and network. </p> <p class="bodytext" style="text-align: justify;">Phia suggested that the plan get out in front of the issue rather than wait for the law firm to make its next move (which we worried may be a drastic one). The plan agreed, and when we reached out to start negotiating, the law firm told us that this dialysis provider was in fact preparing to file suit against multiple plans for similar offenses, but due to this plan’s proactive resolution efforts, the provider would remove this plan from the complaint and negotiate rather than file a lawsuit. Phia was able to leverage the nature of the employer group (a non-profit organization that provided various social services to low-income and indigent individuals), and ultimately achieved a reduction from the already network discounted price (additionally savings exceeding $127,000 off of the discounted rate they were contractually and legally obligated to pay). Had this case gone to court, there is a very good chance that the provider would have been owed the full contractual amount, and perhaps even attorney’s fees as well. </p> <p class="bodytext" style="text-align: justify;">With our help, the plan has also since adjusted it’s document and network arrangement to enable a legal and enforceable carveout program.</p> <p class="bodytext"> </p> <hr class="horiz" /> _<a name="russo4"></a> <p class="bodytext" style="text-align: justify;"><strong>Phia Case Study: Gap-Free Analysis Reveals Dangerous Plan Change</strong></p> <p class="bodytext" style="text-align: justify;">A broker client of The Phia Group’s Independent Consultation and Evaluation (ICE) service engaged us to perform a “Gap-Free Analysis” on an employer’s new stop-loss policy, since the employer had just changed stop-loss carriers. Included at no extra cost as part of our ICE service, this review compares the stop-loss policy against a plan document to identify “gaps” – or areas where the plan may have to pay certain amounts that the stop-loss carrier may deny. </p> <p class="bodytext" style="text-align: justify;">Our consulting team noticed that the new policy (which had already gone into force) contained a broad and alarming exclusion for any amounts paid by the plan in excess of 150% of Medicare… but this particular plan utilized a PPO, and didn’t pay claims based on Medicare at all! The result is a significant gap in coverage where the employer may be contractually required to pay the network rate, in this case 85% of billed charges, but the stop-loss carrier is not required to reimburse above 150% of Medicare, (despite the plan being contractually obligated to pay more than that amount). </p> <p class="bodytext" style="text-align: justify;">For instance, on a $100,000 claim, if the contracted rate is $85,000, but the stop-loss carrier calculates 150% of Medicare as $30,000, then the stop-loss policy excludes the difference of $55,000 – and the employer is left in the lurch! </p> <p class="bodytext" style="text-align: justify;">Fortunately, we spotted the issue before an impacted claim was paid. Now – since there is no massive reimbursement hanging in the balance – the employer, broker, and TPA have reached out to the carrier to see what, if anything, can be done about this matter. Had Phia been asked to review the policy prior to its effective date, this could potentially have been avoided – but in any event, spotting this issue early on can still help avoid surprises and give the employer time to find a solution. </p> <p class="bodytext" style="text-align: justify;">At the end of the day, this is just one alarmingly common example of a stop-loss gap, which come in all shapes and sizes. To help avoid or mitigate these types of issues with your groups, be sure to have Phia perform Gap-Free Analysis prior to stop-loss renewal! </p> <p class="bodytext" style="text-align: justify;">To learn more about The Phia Group’s Independent Consultation and Evaluation service or a Gap-Free Analysis, contact Garrick Hunt, at <a href="mailto:Ghunt@phiagroup.com">Ghunt@phiagroup.com</a> or 781-535-5644.</p> <a name="russo55"></a> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: No Surprises Act Compliance</strong></p> <p class="bodytext" style="text-align: justify;">Although most relevant provisions don’t go into effect until January 1, 2022, now is the time when health plans must prepare to comply with the No Surprises Act (or NSA). The NSA contains a broad framework of health plan requirements, many of which are brand new, and some are even downright weird. From a practical perspective, plans (or, realistically, TPAs) will need to revamp certain longstanding processes, such as information present on ID cards and EOBs, and even the most basic payment amount calculations for certain claims. </p> <p class="bodytext" style="text-align: justify;">One issue in particular is in the area of emergency services. Pursuant to the No Surprises Act, health plans are prohibited from systematically classifying emergency claims based on CPT or other data, and must instead use the “prudent layperson” standard. This means that on a case-by-case basis, the health plan must determine whether a “prudent layperson” – that is, a person of average medical knowledge – would reasonably believe the situation to be one which, if gone untreated, would result in one’s health or life being in serious jeopardy. </p> <p class="bodytext" style="text-align: justify;">The “prudent layperson” standard is far from a brand new concept, but until now it has not been applied on such a sweeping scale. Health plans and their TPAs may now need to engage additional resources in order to make these determinations. Having to examine the specific circumstances of each claim, and even factors specific to each patient, may add an unprecedented layer of complexity to what might have previously been simpler and more systematic claim determinations.</p> <a name="pdef"></a> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a><br /> Webinars:</p> <p class="bodytext" style="text-align: justify;">• On September 21, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/stories-from-the-front-lines-a-collection-of-recent-relevant-case-studies-covid-19-vaccine-mandate">Stories from the Front Lines – A Collection of Recent Relevant Case Studies</a>,” where we share cautionary tales meant to enlighten, and ensure you don’t make the same mistakes or fall into the same traps. </p> <p class="bodytext" style="text-align: justify;">• On August 24, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-provider-perspective-analysis-and-response-to-how-providers-are-reacting-to-recent-rule-changes-and-reform">The Provider Perspective – Analysis and Response to How Providers are Reacting to Recent Rule Changes and Reform</a>,” where we assess how providers are – presently, and in the future – likely to react (or not react) to the new healthcare pricing rules, as well as address best practices to fight back against abusive provider billing tactics. </p> <p class="bodytext" style="text-align: justify;">• On July 12, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/surprise-surprise-analyzing-the-no-surprises-act-part-deux">Surprise, surprise! Analyzing the No Surprises Act Part Deux</a>,” where we dive into the world of surprise bills and dissect this important law. From discussing what we know, to outlining what is yet to come, anyone who will be impacted by this law (and – spoiler alert – that includes you). </p> <p class="bodytext">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p> <p class="bodytext"><strong>Breakout Sessions</strong></p> <p class="bodytext" style="text-align: justify;">• Following our August webinar, The Phia Group presented two breakout sessions, “<a href="https://us02web.zoom.us/rec/share/Br8UZAOMhfzJ55NeJeiN9bbmtj06uAzFUr5E3PBYzi3O0xIIrbSb13qbFFYmnj0r.F0wZ31iJr9tg7h7S">A Failure to Negotiate</a>” and “<a href="https://us02web.zoom.us/rec/share/thDyridtWjGGg7luz-4Thtyoy6g-gVHg1WCm2RweB8Y_WMniKZl5OOe89BUCaBTy.LO-TurbDB9WH-iwj">Ready, Set, Comply</a>.” </p> <p class="bodytext" style="text-align: justify;">If you would like a copy of the slide deck, please reach out to, Matthew Painten, at <a href="mailto:mpainten@phiagroup.com">mpainten@phiagroup.com</a>. </p>   <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a><br /> Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On September 30, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p119-workers-compensation-covid-19-claims">Workers' Compensation & COVID-19 Claims</a>,” where our hosts, Rebekah McGuire-Dye and Cindy Merrell, discuss how current Workers’ Compensation regulations impact health plans, and who is responsible for employee’s Covid-19 related claims. </p> <p class="bodytext" style="text-align: justify;">• On September 17, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p118-you-cant-always-get-what-you-want">You Can’t Always Get What You Want</a>,” where our hosts, Chris Aguiar and Cindy Merrell, discuss what happens when limited settlement funds force Plans to consider a reduction. </p> <p class="bodytext" style="text-align: justify;">• On September 1, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p117-boost-your-covid-19-vaccine-knowledge">Boost Your COVID-19 Vaccine Knowledge</a>,” where our hosts, Brady Bizarro and Kelly Dempsey, discussed what employers and their plans need to know about important COVID-19 vaccine updates. </p> <p class="bodytext" style="text-align: justify;">• On August 20, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p116-right-to-repair-and-healthcare">Right to Repair and Healthcare</a>,” where our hosts, Andrew Silverio and Nick Bonds, discussed President Biden’s recent executive order on right to repair. </p> <p class="bodytext" style="text-align: justify;">• On August 6, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p115-a-lightning-round-of-healthcare-updates">A Lightning Round of Healthcare Updates</a>,” where our hosts, Nick Bonds and Brady Bizarro, discussed a number of healthcare topics to keep you updated on the latest topics buzzing around the industry. </p> <p class="bodytext" style="text-align: justify;">• On July 23, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p114-time-to-vent">Time to Vent!</a>,” where our hosts, Ron Peck and Jen McCormick, discussed key mistakes and false beliefs dominating the media, politics, and the general public, before dissecting how those errors have impacted recent rulemaking. </p> <p class="bodytext" style="text-align: justify;">• On July 9, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p113-ahlborn-revisited">Ahlborn Revisited</a>,” where our hosts, Rebekah McGuire-Dye and Lisa Hill, discussed whether or not the term “medical expenses” covers ALL medical expenses, or only past medical expenses, for purposes of subrogation & reimbursement.</p> <p class="bodytext">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" style="width: 491px; height: 121px;" /></a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a><br /> Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/09/24/how-will-the-federal-vaccinetesting-mandate-impact-self-funded-group-health-plans/">How will the federal vaccine/testing mandate impact self-funded group health plans?</a> – September 24, 2021 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Who_is_on_First__by_Tim_Callendar.pdf">Who is on First? Operational Hurdles and Holes Found in Portions of the NSA</a> – September 4, 2021 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/08/23/2022-coverage-of-preventive-services-in-non-grandfathered-group-health-plans/">2022 Coverage of Preventive Services in Non-Grandfathered Group Health Plans</a> – August 23, 2021 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/The_Liability_Landmine-The_Surprising_Decision_In_Doe_V__UBH_by_Jon_Jablon.pdf">The Liability Landmine: The Surprising Decision In Doe V. UBH</a> – August 7, 2021 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/07/30/plan-representatives-as-fiduciaries-how-far-down-the-totem-pole-does-the-designation-apply/">Plan Representatives as Fiduciaries: How Far Down the Totem Pole does the Designation Apply?</a> – July 30, 2021 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/New_Administration_Cast_Doubt_On_Trump's_Importation_Plan_by_Andrew_Silverio%2C_Esq.pdf">New administration cast doubt on Trump's Importation Plan</a> – July 2, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/07/01/the-covid-long-hauler-dynamic/">The COVID Long-hauler Dynamic</a> – July 1, 2021 </p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a><br /> From the Blogoshpere:</span><span class="heading1"></span></p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/covid-19-vaccine-boosters-are-they-ethical">Covid-19 Vaccine Boosters – Are they Ethical?</a> COVID-19 vaccine boosters discussed. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/biden-administration-announces-sweeping-new-vaccine-mandates">Biden Administration Announces Sweeping New Vaccine Mandates</a>. On September 9, 2021, President Biden announced his COVID-19 Action Plan. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-status-of-major-legal-challenges-to-the-aca">The Status of Major Legal Challenges to the ACA</a>. The Supreme Court dismissed the latest challenge to the Affordable Care Act (“ACA”) in a 7-2 decision. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/a-failure-to-communicate">A Failure to Communicate</a>. The time has come to explain in terms everyone can understand what insurance is, and what it is not. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/canadian-drug-importation-back-on-track-but-not-for-everyone">Canadian Drug Importation – Back on Track (but not for everyone)</a>. Look into the future of fully legal foreign drug importation programs. </p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a><br /> The Stacks:</span></p> <p class="bodytext" style="text-align: justify;"><strong>Who Is On First? Operational Hurdles and Holes Found in Portions of The NSA</strong></p> <p class="bodytext" style="text-align: justify;">By: Tim Callender, Esq. – September 2021 – <a href="https://www.sipconline.net/files/Who_is_on_First__by_Tim_Callendar.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">The Consolidated Appropriations Act (“CAA”) did many things and has created obligations, questions, and confusion for many stakeholders in the healthcare space. This article could cover COBRA topics, mental health parity topics, surprise billing, or any other number of pandora’s boxes opened by the CAA. But no one wants to read a 1M word article filled with legal jargon and uncertain statements on how a pending rule or vague regulation should be interpreted. Instead, this piece aims to spend some brief time focused on some specific obligations that have been handed down in the CAA and throw a few questions against the wall, so to speak, in the interest of starting a dialogue toward understanding how our industry might meet the obligations of the CAA. We will not be looking at all of the obligations within the CAA but will pick out a few of my favorites as examples of the things we need to be considering as the CAA rolls out. The CAA requirements discussed below are in no particular order and, again, have randomly been picked by me as some that seemed to have a few issues glaring right at the top. I tend to be very guilty of finding glee in identifying logistical problems, so, the requirements I decide to write about all have this in common – they will create some headaches – let’s figure out how to get past those headaches. </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2021" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext" style="text-align: justify;"><strong>The Liability Landmine: The Surprising Decision in Doe v. UBH</strong></p> <p class="bodytext" style="text-align: justify;">By: Jon Jablon, Esq. – August 2021 – <a href="https://www.sipconline.net/files/The_Liability_Landmine-The_Surprising_Decision_In_Doe_V__UBH_by_Jon_Jablon.pdf">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="text-align: justify;">The industry is buzzing. Congress and the Department of Labor are shaking things up with the Consolidated Appropriations Act – including, of course, the No Surprises Act and new requirements for compliance with the Mental Health Parity and Addiction Equity Act. Even though the fiduciary liability standards we have all come to understand have been relatively static for a long time, a recent Mental Health Parity-related federal court decision has sent a shockwave across the self-funded industry, potentially changing the way TPAs and other entities will need to view fiduciary liability. The decision in question is in response to a motion in Jane Doe v. United Behavioral Health, in the U.S. District Court for the Northern District of California (Case No. 4:19-cv-07316-YGR), decided March 5, 2021. The dispute in this case centered around the health plan’s blanket exclusion of Applied Behavioral Analysis and Intensive Behavioral Therapy – two of the primary treatments for Autism Spectrum Disorders. </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2021" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext" style="text-align: justify;"><strong>New Administration Casts Doubt on Trump’s Importation Plan </strong></p> <p class="bodytext" style="text-align: justify;">By: Andrew Silverio, Esq. – July 2021 – <a href="https://www.sipconline.net/files/New_Administration_Cast_Doubt_On_Trump's_Importation_Plan_by_Andrew_Silverio%2C_Esq.pdf">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="text-align: justify;">In July of 2019, then president Trump’s HHS announced a “<a href="https://public3.pagefreezer.com/browse/HHS.gov/31-12-2020T08:51/https:/www.hhs.gov/about/news/2019/07/31/hhs-new-action-plan-foundation-safe-importation-certain-prescription-drugs.html">New Action Plan to Lay Foundation for Safe Importation of Certain Prescription Drugs</a>” Much of this release was reiterating and repackaging previous policies and rulemaking authority, but a significant development was the announcement of that the HHS and FDA would review and approve pilot programs organized by the states to facilitate the importation of prescription drugs from Canada. </p> <p class="bodytext" style="text-align: justify;">An awful lot has happened in the country and the world during the almost two years since this guidance, and we did not see any development at a federal level before the election and hand-off of the presidency. Now, the Biden administration has touched on the issue for the first time.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2021" target="_blank">Click here to read the rest of this article</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2021 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2021 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/boysgirls%20Metro%20South.png?ver=0M1lUSd1NKu0K-P3NC57EQ%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8-18, signed up as club members. In the 25 years since, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.</p> <p><span class="bodytext"><strong>Back to School</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our friends from the Boys & Girls Club of Metro South are going back to school, and the Phia Family wanted to send them some school supplies to go back to school with. The Phia family donated a total of $5,000 in school supplies! The kids were able to pick out a backpack, markers, glue sticks, pens, pencils, notepads, and so much more to help them succeed in school. We hope all of the amazing children are enjoying their new school supplies!</p> <strong><img alt="" height="363" src="/Portals/phiagroup/Newsletters/Q4 2021/kids.jpg?ver=LkA0BzSPqcgCiUmz3a2yIw%3d%3d" width="356" /></strong> <p><span class="bodytext"><strong>Translating Forms & Letters for the B&GCMS</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South has come up with a great initiative to promote inclusivity among their membership and families. They will now be offering their Membership Application, Financial Assistance Application, and Member Handbook in five languages: </p> <p class="bodytext" style="font-weight: normal">• English </p> <p class="bodytext" style="font-weight: normal">• Cape Verdean Creole </p> <p class="bodytext" style="font-weight: normal">• Haitian Creole </p> <p class="bodytext" style="font-weight: normal">• Portuguese </p> <p class="bodytext" style="font-weight: normal">• Spanish </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">This was made possible by The Phia Group raising and donating $5,000 to cover the translation firm’s fee required to convert all three documents. We hope that this will help a large number of families with enrolling their children in The Boys & Girls Club of Metro South!</p> <p class="bodytext" style="font-weight: normal"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a></span></p> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter:<br /> Elizabeth Pels</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Elizabeth Pels, The Phia Group’s 2021 Q4 Employee of the Quarter! </p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Elizabeth: “Liz has impressed everyone she has come in contact with, while taking on a new role of subro CST liaison. Her knowledge has impressed our new clients and she has taken her knowledge of processes, to implementations, to make sure that clients’ expectations are accurate when they come on board. Having her on the team has saved CH unnecessary work and cut down on any surprises we have as new clients are onboarded.”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Q4 2021/employee.jpg?ver=SkGUwgVxkQHPpydjG2Z7QQ%3d%3d" style="width: 400px; height: 506px;" /></p> <p class="bodytext">Congratulations Elizabeth, and thank you for your many current and future contributions.</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"> </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Job Opportunities:</span></p> <p class="bodytext"> </p> <p class="bodytext">• Claim Analyst </p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• Subrogation Attorney </p> <p class="bodytext">• Training and Development Specialist </p> <p class="bodytext">• Claim Recovery Specialist </p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext" style="text-align: justify;">• Ben Mooney has been promoted from Claim Analyst to Team Leader, Claim Analysis </p> <p class="bodytext" style="text-align: justify;">• Sue Bivins has been promoted from Senior Data Architect to Manager, Data Qualty & Architecture – Data Services Group </p> <p class="bodytext" style="text-align: justify;">• Michael Vaz has been promoted from Senior Customer Success & Account Manager to Manager, Intake - Data Services Group</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Lindsay Stewart was hired as a Customer Service Rep. </p> <p class="bodytext">• Jueyao Fadrigalan was hired as a Claim & Case Support Analyst </p> <p class="bodytext">• Malcolm Rymer was hired as a Claim Analyst </p> <p class="bodytext">• Kaitlyn MacLeod was hired as a Consulting Attorney </p> <p class="bodytext">• Micah Iberosi-Parnell was hired as a Consulting Attorney </p> <p class="bodytext">• Emily Rodriguez was hired as an Intake Specialist </p> <p class="bodytext">• Shannon Glover was hired as a Case Investigator </p> <p class="bodytext">• Saurabh Patil was hired as an ETL Specialist </p> <p class="bodytext">• Melinda Bellis was hired as an Associate General Counsel </p> <p class="bodytext">• Melanie DeMelin was hired as a Claim & Case Support Analyst </p> <p class="bodytext">• Haley McBroom was hired as a Sr. Claims Recovery Specialist </p> <p class="bodytext">• Soujana Gouriesetty was hired as an ETL Specialist </p> <p class="bodytext">• Jacqueline Davis was hired as a Plan Drafter<br />  </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a><br /> Phia News:</span></p> <p class="boldtext">COVID - Appeals, Subrogation, and Stop Loss Issues No One Saw Coming - Help is Here!</p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2021/covid4.png?ver=DtLJ22Q5SlpyGPYdg6tGpQ%3d%3d" style="width: 572px; height: 533px;" /></p> <p class="bodytext" style="text-align: justify;">COVID claims are coming - whether you pay or deny claims tied to COVID, you need The Phia Group.</p> <p class="bodytext" style="text-align: justify;">Claims tied to the treatment of COVID-19 are being submitted for payment and are passing through the claims process in record numbers. Many of these claims are substantial, with these considerable costs impacting our industry in both anticipated and unforeseen ways. As with any influx of new claims, we are also seeing growth in the number of denials and appeals arising from these COVID claims, as well as subrogation issues tied to the disease.</p> <p class="bodytext" style="text-align: justify;">COVID claims are routinely denied and/or paid incorrectly, due in large part to the inadequate time provided to consultants, administrators, and payers, to familiarize themselves with the ever changing rules, and thereby standardize appropriate handling of these claims in accordance with law and their plan documents. As a result, we are also seeing an increase in COVID related claim appeals, with heightened fiduciary liability issues also arising from these claim payment decisions.</p> <p class="bodytext" style="text-align: justify;">The Phia Group's PACE Service has existed for years and is the only service on the market where expert plan drafters, attorneys, and seasoned appeals professionals help you navigate these and other difficult appeals, thereby avoiding mistakes and costly liability. PACE ensures claim denials are legitimate, enforceable, and defended.</p> <p class="bodytext" style="text-align: justify;">As with claims processing and appeals, COVID has also created a new world for subrogation. When COVID claims are submitted, complex state law may be triggered regarding if and when COVID is "presumed" to be an occupational expense. The Phia Group was the first subrogation provider to build a custom process backed by its in-house legal team with a focus on identifying COVID related claims, determining whether the applicable geographic location and occupation are addressed by a regulation that presumes a link between the occupation and diagnosis, and quickly asserts a right to reimbursement against responsible parties if possible. The Phia Group has been applying this procedure to its existing process since June of 2020. Without an innovative subrogation solution like ours in place, plans not only lose money, but also fail in their obligation to stop-loss; a failure stop-loss carriers are increasingly unwilling to overlook.</p> <p class="bodytext" style="text-align: justify;">The stop-loss world has been handed a unique and difficult scenario. As it relates to claims arising from or tied to COVID-19, carriers are suspending reimbursement and asking questions such as: what is the Plan Participant's job description; is the Plan Participant a front line worker; what date did they test positive; are they an essential worker; did they file a workers' compensation claim; and so on. The Phia Group has the expertise to assist in these difficult stop-loss collaborations.</p> <p class="bodytext" style="text-align: justify;">Ensuring appeals are handled correctly, aligning plan documents with stop-loss policies, and fully understanding the bigger picture has never been more important. The Phia Group is uniquely positioned to help in this difficult time. With our unrivaled team and technology ready to help, there is no better partner to assist you now and in the days to come.</p> <p class="bodytext" style="text-align: justify;">Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com" target="_blank">ghunt@phiagroup.com</a> or <a href="mailto:info@phiagroup.com" target="_blank">info@phiagroup.com</a> to request more information and set a call to learn how The Phia Group can assist you with these COVID claim issues.</p> <p class="bodytext"><strong>Hispanic Heritage Month Celebration</strong></p> <p class="bodytext" style="text-align: justify;">As some of you may know, El Mes de la Hispanidad (Translation: Hispanic Heritage Month) is celebrated from September 15th through October 15th, aligning with the Independence Days of some Latin American countries such as Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Mexico, Chile, and Belize. This is an important celebration in the U.S., as Latinx and Hispanic Americans make up the largest minority group in the country. </p> <p class="bodytext" style="text-align: justify;">In honor of Phia’s Latinx and Hispanic American employees, family members, and to enhance our diversity inclusion efforts, The Phia Group and the Diversity Inclusion Committee hosted a Hispanic Heritage Month. </p> <p class="bodytext" style="text-align: justify;">The event included Hispanic food, refreshments, and cultural music!</p> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.</p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter Q1 2018/footerlogo.png?ver=-c8yhuYtU1mPXJVxbXTW6A%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1099The Stacks – 4th Quarter 2021https://www.phiagroup.com/Media/Posts/PostId/1098/the-stacks-4th-quarter-2021NewslettersWed, 27 Oct 2021 14:46:00 GMT<p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#0071ce;"><span style="font-size:18px;"><strong>Who Is On First?  Operational Hurdles and Holes Found in Portions of The NSA</strong></span></span><br /> <em><strong>By: Tim Callender, Esq.</strong></em><br /> <br /> <span style="color:#000000;">The Consolidated Appropriations Act (“CAA”) did many things and has created obligations, questions, and confusion for many stakeholders in the healthcare space.  This article could cover COBRA topics, mental health parity topics, surprise billing, or any other number of pandora’s boxes opened by the CAA. But no one wants to read a 1M word article filled with legal jargon and uncertain statements on how a pending rule or vague regulation should be interpreted.  Instead, this piece aims to spend some brief time focused on some specific obligations that have been handed down in the CAA and throw a few questions against the wall, so to speak, in the interest of starting a dialogue toward understanding how our industry might meet the obligations of the CAA.  We will not be looking at all of the obligations within the CAA but will pick out a few of my favorites as examples of the things we need to be considering as the CAA rolls out.  The CAA requirements discussed below are in no particular order and, again, have randomly been picked by me as some that seemed to have a few issues glaring right at the top.  I tend to be very guilty of finding glee in identifying logistical problems, so, the requirements I decide to write about all have this in common – they will create some headaches – let’s figure out how to get past those headaches. <br /> <br /> Please note – as annoying as it might be, I may not offer big solutions to the logistical questions posed herein.  But, by raising the questions, hopefully this will get us all thinking and working together to make sure our industry is poised to handle these new duties and we can find opportunity therein.<br /> <br /> <strong>Requirement 1</strong> – The Advanced EOB Requirement of The No Surprises Act<br /> <br /> The No Surprises Act is everyone’s favorite portion of the CAA.  That is, unless you are really excited by COBRA, then there are other portions of the CAA that might tickle your fancy a little more.  But most of us in this increasingly complicated healthcare space find balance billing, surprise billing, and pricing transparency to be pretty juicy – hence our interest in the No Surprises Act.  Contained within the NSA is a provision that requires a health plan to provide an advanced EOB any time the plan receives notice from a provider of a scheduled procedure and/or a request from a plan participant seeking an explanation of benefits regarding an upcoming procedure.  The advanced EOB is required to contain quite a swath of information, including, whether the provider is in-network or out-of-network; information on how to seek out an in-network provider, if needed; contracted rates for the relevant in-network provider; good faith cost estimates as furnished by the provider; a good faith estimate of the plan’s obligation (what the plan will pay); a good faith estimate of the plan participant’s cost share; deductible and out-of-pocket information related to the participant; medical management information if relevant; and a statement that the numbers provided are merely estimates.<br /> <br /> In terms of timelines, the plan is obligated to provide this advanced EOB in 1 business day when the plan receives notice of a proposed procedure, from a provider, and 3 business days when the plan receives a notice/request from a plan participant.<br /> <br /> This is clearly going to be an obligation that falls to the plan sponsor’s contracted, third-party payer.  Of course.  Payers already handle the EOB work for their plan clients, typically, so it is a fair assumption this new obligation will be handled at that level as well.  Knowing this obligation will fall to the third-party payer, some questions arise:</span></span><span style="color:#000000;"></span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;">Will payers have to increase their administrative fees to account for this new operational lift?</span></span></li> <li style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;">What about 3rd party EOB production vendors & their relationship with the payer community – will these stakeholders be able to handle these tight turnarounds?</span></span></li> <li style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;">What processes will a payer put in place to account for the intake of these requests whether from a provider or a member?  How will plans and/or payers alert plan members to the availability of this information & that participants have a right to request this information?</span></span></li> <li style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;">What if the contracted rates for the in-network provider are not known by the payer (I understand this should be known, but I also understand that network contracts are a bit like narwhals – we know they exist but only a few people have ever seen one).</span></span></li> <li style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;">How will the payer go about getting a good faith cost estimate from the provider, especially with such a tight turnaround time to provide the info!</span></span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><strong>Requirement 2 </strong>– Plans Must Provide Balance Billing Information on Their Websites Along With a Web-Based, Price Comparison Tool<br /> <br /> This requirement will be live as of January 1, 2022, unless the regulators decide otherwise.  Additionally, it should be noted that this requirement applies to both grandfathered and non-grandfathered plans alike.  No getting out of this one! <br /> <br /> Interestingly, it is not clear who will actually handle the logistics in fulfilling this requirement.  Clearly the regulatory obligation falls onto a “plan,” but does a plan even have the ability to comply with this requirement?  It is hard to imagine that a self-funded, plan sponsor, is going to literally place balance billing support information and/or balance billing education tools on its website.  Trying to picture a random employer who makes widgets, in a factory, coordinating its HR department with its IT department to make sure that their company’s website contains balance billing information and a web-based price comparison tool for health plan participants is laughable at best.  Will the insurance broker / consultant advise the plan sponsor to do this?  Likely not.  Where will this obligation end up then?  Does it fall to the payer (TPA / ASO) to put this information on their website?  How would the payer go about accomplishing this task on behalf of a plan it administers? <br /> <br /> It seems that the contracted payers’ contractual duties will be getting thicker and thicker come 2022.<br /> <br /> <strong>Requirement 3</strong> – Continuity of Care<br /> <br /> This requirement is a truly interesting one in that it states that plans are now obligated to provide in-network coverage to participants who access care from a provider that is no longer a part of the network.  Said another way, when an in-network provider leaves a network, a plan participant who was seeing that provider can continue to see that provider and the plan is obligated to provide the benefit as though the provider were still in-network, for 90 days.  The plan is also obligated to provide notice to the plan member when the plan learns of this provider network change.  Now, there are obviously many more details than I’ve outlined here – for example, the patient must be seeking serious and complex care – the care cannot be a routine physical.  But for this discussion, we will just focus on the concept of in-network versus out-of-network, for whatever reason.<br /> <br /> On its face, this requirement makes a great deal of sense.  Patients should not be financially punished because their favorite doctor chooses to leave a network.  However, how can we guarantee that the plan does not become the bearer of that punishment – have we simply shifted the financial burden of paying for an out-of-network provider from the plan member to the plan?  To be more specific, what happens when the provider leaves Network A and does not contract with any network so the provider can bill at a higher rate?  Suppose the provider does exactly that & begins billing at a higher rate on a number of patients seeing the provider within the 90-day continuity of care timeline.  The claims are submitted to the payer, as before, only now the third-party payer, on behalf of the health plan, must adjudicate the claims and apply the old, Network A, payment structure to the claims.  But this will leave a balance, correct?  And this will cause the provider to seek reimbursement on that balance, correct?  From whom?  It is clear from the intent of the CAA that this balance cannot fall onto the plan member, which means the plan itself, and/or the plan’s third-party administrator, will be forced to invent mechanisms that will capture these balances – perhaps direct provider negotiations with plan funds at risk? <br /> <br /> <strong>Requirement 4 (my favorite)</strong> – Removal of Gag Provisions<br /> <br /> The gag provision requirement prohibits plans from entering into service contracts with an entity where the contract restricts the plan from providing provider specific cost information, among other details, through a transparency tool or through other means, to plan members or those eligible to enroll in the plan.  The provision goes on to also state that a plan cannot enter into service contracts where certain detailed claim information is restricted from disclosure to the plan.<br /> <br /> This requirement seems incredibly logical – clearly, it is set up to promote transparency and assure that cost information is readily available to plan members and the plan alike.  Of course, this is a great thing!  But once you start thinking of the unintended, collateral impacts, the sense behind the way this requirement was put together becomes questionable. <br /> <br /> You will note that it is the PLAN who is prohibited, by this requirement, from entering into these restricted contracts.  The provision does not require networks, providers, or other third parties to remove these gag provisions from their contracts. Instead, it has shifted the burden of fighting these gag provisions onto actual health plans by outlawing a plan’s ability to agree to a gag provision.  This seems to put a plan in a bit of a weird situation in that the plan is now the government’s policeman and will be forced to try and negotiate gag provisions out of service contracts.  What if a network, or a provider, or other third-party refuses to remove a gag provision?  There is no remedy readily available to the plan other than to say, “well, ummmm… I guess we can’t sign that contract then.  Ok.  See ya later.”  Although the third party might be motivated to remove gag provisions in the interest of gaining business, there is not guarantee this will happen.  Unless there is a critical mass of business being lost, third parties who value their gag provisions will likely stand firm and let some business go by in favor of protecting the information that they do not wish to share.  Or will the various, contracting parties find a way to sneak around this requirement and ruin the intended spirit?  Could a TPA enter into a network contract full of gag provisions and then sell the network access to a plan, via their administrative services agreement, so long as the administrative services agreement does not incorporate the terms of the network contract, thus circumventing the gag provision requirement entirely?  Someone should ask a lawyer.<br /> <br /> In closing, it is important to note that the CAA and, more specifically, the NSA, work toward some great goals that I think we all believe in.  There is much more to the CAA than discussed in this brief article and it really does deserve a more detailed treatment whenever possible.  Today’s goal was to raise a few questions about a very few provisions of the CAA in the hope that we will all look through the CAA, in its entirety, with questioning eyes.  Not for the sake of poking holes necessarily, but for the sake of asking questions so that we can find opportunity and solutions, together, and continue to move our industry forward.</span></span></p> <hr /> <p style="text-align:justify; margin:0in"><span style="font-size:18px;"><span style="color:#0071ce;"><span calibri="" style="font-family:"><b>The Liability Landmine: The Surprising Decision in <i>Doe v. UBH</i></b></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#222222"></span></span></span></p> <p style="text-align:justify; margin:0in"><strong><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#222222">By: Jon Jablon, Esq. </span></span></span></strong><br /> <br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#222222">The industry is buzzing. Congress and the Department of Labor are shaking things up with the Consolidated Appropriations Act – including, of course, the No Surprises Act and new requirements for compliance with the Mental Health Parity and Addiction Equity Act.<br /> <br /> Even though the fiduciary liability standards we have all come to understand have been relatively static for a long time, a recent Mental Health Parity-related federal court decision has sent a shockwave across the self-funded industry, potentially changing the way TPAs and other entities will need to view fiduciary liability.<br /> <br /> The decision in question is in response to a motion in <i>Jane Doe v. United Behavioral Health</i>, in the U.S. District Court for the Northern District of California (Case No. 4:19-cv-07316-YGR), decided March 5, 2021. The dispute in this case centered around the health plan’s blanket exclusion of Applied Behavioral Analysis and Intensive Behavioral Therapy – two of the primary treatments for Autism Spectrum Disorders.<br /> <br /> The facts of the case demonstrate that the SPD excluded these two services, and the claims administrator – United Behavioral Health, or UBH – administered the exclusion that was written in the SPD, and denied a medical claim pursuant to that SPD language as written. UBH moved to dismiss the suit under the theory that even assuming the truth of all facts alleged, applicable law would not classify UBH as a fiduciary.<br /> <br /> The relevant case law generally indicates that if <i>the Plan</i> makes the rules via the Plan Document, and if the TPA is just following the literal written terms without exercising discretion, the TPA has not rendered itself a fiduciary. Based on case law and regulatory guidance, that’s the prevailing sense of the fiduciary rules. The court’s decision started out very much as we tend to expect from cases like this: the court recited the facts of the case, iterated the general rules of fiduciary duties, and cited to lots of cases that have indicated that rule, apparently using those cases to guide its decision.<br /> <br /> Then, though, the court’s decision changed course, and things got a little strange.</span><br /> <br /> <b><span style="color:#222222">Who’s a Fiduciary?</span></b><br /> <br /> <span style="color:#222222">Department of Labor (DOL) guidance has made it clear that the intended interpretation of ERISA’s fiduciary duty designation is fairly broad, but still well-established through an explicit set of exceptions to the “general” rule that an entity that makes decisions for a health plan is a fiduciary.<br /> <br /> According to the DOL, there is an eleven-item list of actions that explicitly do <i>not</i> render an individual or company a TPA, including applying established rules (as opposed to <i>making</i> the rules), processing claims pursuant to established rules (as opposed to <i>adjudicating</i> claims), and calculating benefits (as opposed to <i>determining</i> benefits). With respect to this list, the DOL has stated that “a person who performs purely ministerial functions such as [these] for an employee benefit plan within a framework of policies, interpretations, rules, practices and procedures made by other persons is <i>not</i> a fiduciary.” (Emphasis added).<br /> <br /> The distinctions may seem small, but the regulators and courts have been clear that if an entity performs <i>only</i> those broad functions listed in the exceptions, that entity is not a fiduciary. Of course, a TPA or other entity can become a fiduciary if it performs any of these eleven items in <i>addition</i> to other actions – but limiting its actions to solely these eleven items does not cause the TPA to assume a fiduciary designation.<br /> <br /> The court appeared to agree, making the point multiple times: <i>a purely ministerial act does not in itself rise to the level of a fiduciary act</i>. This court did not show any evidence of a desire to change that well-established law; in fact, its language tends to indicate that the court agreed and embraced these principles.</span><br /> <br /> <b><span style="color:#222222">So, Was UBH a Fiduciary?</span></b><br /> <br /> <span style="color:#222222">According to UBH, when acting as the TPA, they did exactly what the SPD said, and they didn’t exercise discretion in doing it. The Plan Document excluded ABA and IBT services, and the TPA read the SPD and applied it as written. To an onlooker, UBH’s conduct seems like a textbook definition of a purely ministerial decision; denial of the ABA or IBT claim is indisputable. All indications are that UBH performed “purely ministerial functions…for an employee benefit plan within a framework of policies, interpretations, rules, practices and procedures made by other persons…” and therefore “is not a fiduciary.”<br /> <br /> Interestingly enough, the court apparently didn’t disagree with that premise, but still concluded nonetheless that UBH <i>did</i> act as a fiduciary. The logic employed is unexpected, given all the precedent cited: the court reasoned that even though UBH did exactly what the Plan Document provided, UBH still <i>made a decision</i>, and the simple act of making a coverage decision is enough to render UBH a fiduciary.<br /> <br /> Recall, however, that the eleven explicit exceptions to the general fiduciary rule include applying established rules and processing claims pursuant to those established rules; the facts suggest that UBH meets those exceptions and is therefore <i>not</i> a fiduciary. For a reason the court did not quite explain, however, it disagreed.</span><br /> <br /> <b><span style="color:#222222">The Supreme Court’s <i>General</i> Rule</span></b><br /> <br /> <span style="color:#222222">In reaching its conclusion, the court placed a great deal of reliance on the United States Supreme Court’s decision in <i>Aetna Health Inc. v. Davila.</i> According to the Supreme Court, “A benefit determination under ERISA . . . is <i>generally</i> a fiduciary act”. <i>Aetna Health Inc.  v. Davila</i>, 542 U.S. 200, 218-19 (2004) (Emphasis added; internal quotations omitted). Despite all the iterations of the “purely ministerial” standard that the court cited in reviewing UBH’s conduct, the court nonetheless relied on the Supreme Court’s quotation above, and concluded that the TPA was necessarily a fiduciary, since <i>all</i> <i>benefit determinations are fiduciary in nature</i>.<br /> <br /> Hang on a minute, though: are <i>all</i> benefit determinations fiduciary in nature? Is that really what the Supreme Court wrote? A plain reading of the quote casts some doubt on this court’s interpretation.<br /> <br /> Despite quoting the Supreme Court’s <i>general</i> rule, including the very telling word “generally”, this court interpreted the Supreme Court’s rule as an absolute one. The difference is that a general rule is subject to exceptions (recall that case precedent and regulatory guidance suggests that UBH <i>is</i> subject to an exception) while, to contrast, an absolute rule has <i>no</i> exceptions (and this is what the court ultimately concluded).<br /> <br /> The Supreme Court’s rule can be read as: <i>benefit determinations are generally fiduciary acts, unless they are purely ministerial in nature and the decision-maker exercised no discretion in making the determination.</i> Instead, the court in Doe v. UBH read the Supreme Court’s rule as <i>benefit determinations are fiduciary acts, period.</i> That doesn’t seem right, though – especially based on <i>everything else</i> the court in <i>Doe v. UBH</i> wrote.<br /> <br /> In other words, the text of this decision shows that the court added 2 and 2 and got 5.<br /> <br /> Sometimes a court will reimagine or reinterpret existing law, but this court showed no evidence of doing that. Instead, the court went through all the premises, but then disregarded those premises and reached a different conclusion entirely.<br /> <br /> An analogy would be to say that if oranges are <i>generally</i> round, then <i>all</i> oranges must be round.</span><br /> <br /> <b><span style="color:#222222">The Literal Fiduciary Duty</span></b><br /> <br /> <span style="color:#222222">On the topic of general versus absolute rules, the fiduciary duty within ERISA to strictly abide by the terms of the SPD is a <i>general</i> rule, an important exception to which being if the terms of the SPD do not comply with applicable law. It is therefore possible to violate a fiduciary duty by choosing to enforce noncompliant plan language over contradictory law, but in order to <i>violate</i> a fiduciary duty, the entity must first be determined to <i>be</i> a fiduciary.<br /> <br /> As it happens, the court did go on to determine that the plan language in this case did violate federal law and was therefore unenforceable – but again, the question isn’t whether UBH violated a fiduciary duty, but whether UBH owed one in the first place. An act performed by a <i>non</i>-fiduciary wouldn’t give rise to fiduciary liability, after all.</span><br /> <br /> <b><span style="color:#222222">Begging the Question</span></b><br /> <br /> <span style="color:#222222">At one point, after it had already analyzed the expected premises and reached the unexpected conclusion, the court iterated the fiduciary duty to apply plan terms as written except to the extent inconsistent with ERISA. The court write that UBH “cannot hide behind plan terms” since applicable law conflicts with those terms, which is unquestionably accurate – but this statement or the single paragraph explaining, which appears to be an afterthought, it still does not explain why UBH should be deemed a fiduciary to begin with.<br /> <br /> It’s possible that the court’s intended logic was that UBH exercised discretion by choosing to follow the SPD over the conflicting law, thereby rendering it a fiduciary on <i>that</i> basis. The court did not iterate that connection, but giving the court the benefit of the doubt, perhaps that was the intended meaning. In any event, the court performed this ancillary one-paragraph analysis of whether UBH violated a fiduciary duty only because it had <i>already</i> decided that the TPA is a fiduciary; in other words, this single paragraph discussing how UBH can’t “hide behind plan terms” <i>already</i> assumes that the TPA is a fiduciary, which means that this discussion can’t be relevant to the analysis of whether the TPA is a fiduciary to begin with.<br /> <br /> In a logical fallacy known as “begging the question”, the court used its conclusion (that UBH is a fiduciary) to form one of its premises (that UBH’s conduct violated a fiduciary duty) – the only premise that even comes close to explaining why UBH might be a fiduciary (which, again, is the conclusion). Put more simply, the court apparently used its conclusion to justify its conclusion. From a logic perspective, this doesn’t track.</span><br /> <br /> <b><span style="color:#222222">Proof of a Negative</span></b><br /> <br /> <span style="color:#222222">At one point in this decision, the court indicated that UBH was a fiduciary because UBH did not sufficiently prove it was <i>not</i> a fiduciary. Interestingly, the old adage “innocent until proven guilty” does not always apply in the civil court setting.<br /> <br /> Without getting too far down the rabbit hole on this particular point, it is worth noting that any allegation that a TPA has acted as a fiduciary could prompt the need for the TPA to defend itself – and as a good portion of the self-funded industry has experienced first-hand, plan participants and their attorneys often opt for a “kitchen sink” approach, suing everyone possible, sometimes resulting in an apparently baseless suit against a TPA, broker, consultant, or other entity.<br /> <br /> As this case makes clear, though, court is sometimes like the wild west, where anything can happen.<br /> <br /> As discussed, the court’s logic is not quite clear, and hopefully an appeals court will shed some light on this so we can at least get some closure one way or the other – but one thing is for sure: if this case doesn’t get reversed, or even if other courts start to rely on this case prior to appeal, TPAs across the country may be in for a paradigm shift when it comes to their ability to strictly follow the clear, literal terms of an SPD without fear of reprisal.<br /> <br /> Strengthening plan language is always a good idea, but health plans (and their TPAs!) need to ensure that strong language isn’t stronger than the law permits, since there could be liability landmines even where we least expect them.</span></span></span></p> <hr /> <p style="margin-bottom:0in; margin:0in 0in 8pt"><span style="color:#0071ce;"><span style="font-size:18px;"><span style="line-height:normal"><span calibri="" style="font-family:"><b>New Administration Casts Doubt on Trump’s Importation Plan</b></span></span></span></span></p> <p style="margin-bottom:0in; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b>By: Andrew Silverio, Esq. </b></span></span></span></p> <p style="margin-bottom:0in; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 8pt;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="color:#000000;">In July of 2019, then president Trump’s HHS announced a “New Action Plan to Lay Foundation for Safe Importation of Certain Prescription Drugs” (archived and available at</span> <a href="https://public3.pagefreezer.com/browse/HHS.gov/31-12-2020T08:51/https:/www.hhs.gov/about/news/2019/07/31/hhs-new-action-plan-foundation-safe-importation-certain-prescription-drugs.html" style="color:#0563c1; text-decoration:underline">https://public3.pagefreezer.com/browse/HHS.gov/31-12-2020T08:51/https://www.hhs.gov/about/news/2019/07/31/hhs-new-action-plan-foundation-safe-importation-certain-prescription-drugs.html</a>).  <span style="color:#000000;">Much of this release was reiterating and repackaging previous policies and rulemaking authority, but a significant development was the announcement of that the HHS and FDA would review and approve pilot programs organized by the states to facilitate the importation of prescription drugs from Canada.<br /> <br /> An awful lot has happened in the country and the world during the almost two years since this guidance, and we did not see any development at a federal level before the election and hand-off of the presidency.  Now, the Biden administration has touched on the issue for the first time.</span></span></span></span></p> <p style="text-align: justify; margin: 0in 0in 8pt 40px;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="color:#000000;">In a court filing calling for the dismissal of a lawsuit against HHS by a pharmaceutical industry organization (available at</span> <a href="https://www.politico.com/f/?id=00000179-b4ee-db57-abfd-b7fe4db60000" style="color:#0563c1; text-decoration:underline">https://www.politico.com/f/?id=00000179-b4ee-db57-abfd-b7fe4db60000</a>), <span style="color:#000000;">the administration claimed that the plaintiff’s claims are moot and their alleged damages far too speculative (the lawsuit against HHS claims that the importation rule impermissibly damages drug manufacturers and oversteps federal authority).  In the filing, HHS outlines that there is “no timeline” for the approval of any state programs, and that states still have numerous hurdles to get past before any such program could be approved begin operation (at this time, six states have passed laws providing for the formation of these programs, and two have actually submitted programs to the FDA for review).  Interestingly, HHS cites hostility to the proposed program(s) from Canada itself, noting that “Canada’s interim order injects uncertainty into whether and to what extent the Rule could be implemented.” This is actually closely in line with what we predicted when the rule was first released:</span></span></span></span><span style="color:#000000;"></span></p> <p style="margin-right:.5in; text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="">It is worth noting that when the proposed rule came out, it was met with harsh criticism from our northern neighbors, many of whom discussed potential action by the Canadian government to counter any such importation efforts in order to protect their own drug supply.  As such, action taken by the United States in regard to Canadian drug importation won’t be the only factor in whether the practice ultimately becomes both legal and practical.</span></span></span><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""><br /> <br /> Of course, proponents of these programs shouldn’t lose all hope just yet – this is an interesting situation where the posture of HHS is such that they must argue in order to defend the program against challenge that it may very well never actually get off the ground.  That said, any optimism for imminent program approvals is essentially quashed with this filing.</span></span></span></span></p> 1098The Phia Group's 3rd Quarter 2021 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1079/the-phia-groups-3rd-quarter-2021-newsletterNewslettersTue, 13 Jul 2021 20:03:00 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/phiaheader2021.jpg?ver=cPXT-OQ2nUoOqvo57jvVxw%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2021/icons66.png?ver=QOrtolwsSSVL_DniGLtmzA%3d%3d" style="width: 650px; height: 149px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2021/block12021.png?ver=QOrtolwsSSVL_DniGLtmzA%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#russo"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2021/block22021.png?ver=DtLJ22Q5SlpyGPYdg6tGpQ%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td valign="top" width="47%"> <p><br /> <img height="327" src="/Portals/phiagroup/Newsletter Q1 2018/adam.jpg?ver=KAJlFem5DERRpjAI9hFfew%3d%3d" width="264" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">Well… Here we are; in the middle of another Boston summer … Except, this July has not been a typical New England one. Temperatures are in the 90’s one day, and in the 60’s the next. I wasn’t allowed to water my lawn due to a drought yesterday but today I received warnings about flash floods. Indeed, it seems like it’s been raining almost every day and my fingers are crossed that we get back to typical summer weather soon, or else I may need to pack up and move the family to some warmer climate.</p> <p class="bodytext" style="text-align: justify;">For that reason – above all others – I am praying for the sun to shine, because I am not ready to move four kids, my wife and our wonderful French Bulldog Bella. That, and I need to be near a Dunkin Donuts at all times. Staying nimble, and being able to adjust to unusual circumstances is the name of the game.</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Whether it’s keeping kids entertained on cold, rainy days, or adjusting plan processes in response to ongoing regulatory changes… As you all know, we here at The Phia Group are always attempting to stay ahead of the curve when it comes to industry developments, challenges and opportunities.</p> <p class="bodytext" style="text-align: justify;">For instance, one of the biggest industry issues that we have been laser focused on is the design and application of Non-Quantitative Treatment Limitations (NQTLs). If you haven’t been paying attention to this issue, you better start soon, as every plan may need to show their compliance work as it relates to this new regulatory requirement. As we have shared with you previously, starting on February 10, 2021, and pursuant to the Consolidated Appropriations Act of 2021 (the “CAA”), group health plans are required to perform and document comparative analyses relating to NQTLs. This means that, upon request, plans would need to disclose their comparative analysis, have a detailed explanation of the specific plan terms and practices involved, and the rationale for the plan's determination that the NQTL is compliant with the Mental Health Parity Addition Equity Act of 2008 (MHPAEA). This is not an easy exercise by any means, but we are ready to serve you and your clients to ensure compliance with these new, complicated regulations. We have multiple service options for plans and administrators to comply with the comparative analysis process. Well, it looks like it’s raining again … but that doesn’t mean you can’t enjoy our latest newsletter – happy reading!</p> <p class="bodytext" style="text-align: justify;"> </p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p class="tocbkgd"><img src="/Portals/phiagroup/Newsletter Q2 2017/inthisissue.png?ver=MccyVIGCQMCOF4LSnwUjkQ%3d%3d" style="width: 101px; height: 18px;" /><br /> <a href="#russo">Enhancements of the Quarter: Bundled NSA Consulting, And Patient Defender</a> "Levels"<br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2021 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#pemployee">Employee of the Quarter</a><br /> <a href="#pnews">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><strong><a id="russo" name="russo"></a></strong></p> <p class="heading1"><br /> Enhancement of the Quarter: Bundled No Surprises Act Consulting, and Patient Defender “Levels”<strong> </strong></p> <p class="bodytext"><strong>No Surprises Act Consulting</strong></p> <p class="bodytext" style="text-align: justify;">From COVID claims to expanded timeframes for providers to submit claims to the impending provisions of the No Surprises Act, few can deny that these are trying times for health plans and those that provide administrative and consulting services to them. Amidst this all, though, help is available. The Phia Group has been Empowering Plans since 2000, and twenty-one years later we continue our quest to do so by providing Phia Unwrapped clients with No Surprises Act consulting included at no extra cost.</p> <p class="bodytext" style="text-align: justify;">You may already know Phia Unwrapped as a leading out-of-network claims management solution. We’re enhancing Phia Unwrapped, however, to make sure our clients are able to comply with the No Surprises Act’s requirements, as well as understand how to manage the impending Independent Dispute Resolution (or IDR) process.</p> <p class="bodytext" style="text-align: justify;">IDR is still a mystery to providers and health plans, and the supplemental regulatory guidance issued on July 1, 2021 doesn’t even attempt to help unravel that mystery. Congress has laid out certain factors that may or may not be taken into account by the IDR arbiter, but still confusion abounds as to what will actually happen – and, perhaps more urgently, what a health plan will need to do to properly defend its payment offer.</p> <p class="bodytext" style="text-align: justify;">This offer to include No Surprises Act consulting at no additional cost is extended to all current Phia Unwrapped clients, as well as those that become clients on or before September 1, 2021. For more information on Phia Unwrapped, please contact our Senior VP of Provider Relations, Jason Davis, at <a href="mailto:jdavis@phiagroup.com">jdavis@phiagroup.com</a>. Of course, if you’re not a Phia Unwrapped client, you can still get all the help you need by contacting <a href="mailto:PGCReferral@phiagroup.com">PGCReferral@phiagroup.com</a> – or, for clients of our Independent Consultation and Evaluation (ICE) service, via your dedicated ICE intake address.</p> <a name="russo5"></a> <p class="bodytext"><strong>Patient Defender “Levels”</strong></p> <p class="bodytext" style="text-align: justify;">In response to feedback from you – our valued clients and friends – we have revised our Patient Defender pricing model, to allow health plans to choose what “level” of service they would like, on a case-by-case basis. As a refresher, Patient Defender entitles a group, for a flat PEPM fee, to an attorney to represent patients in certain balance-billing scenarios. The Phia Group covers the attorney’s fee, so health plans and patients can feel secure in their reference-based pricing models.</p> <p class="bodytext" style="text-align: justify;">We now offer three different levels, each with a different PEPM fee and each with a different threshold of balance-bill that will be handled by the pre-paid attorney. A TPA doesn’t need to decide up-front, either; an individual group can elect the option that is best tailored to its needs, and that option can even be changed at any time. This enhancement is designed solely to tailor the Patient Defender service to an individual group’s needs, and has been met with very positive feedback thus far.</p> <p class="bodytext" style="text-align: justify;">To explore your Patient Defender options, please contact our Sales Manager, Garrick Hunt, at <a href="mailto:GHunt@phiagroup.com">GHunt@phiagroup.com</a>.</p> <p class="bodytext"> </p> <hr class="horiz" /><a name="russo4"></a> <p class="bodytext"><strong><br /> Service Focus of the Quarter: The MHPAEA NQTL Analysis</strong></p> <p class="bodytext" style="text-align: justify;">The Mental Health Parity and Addiction Equity Act (or MHPAEA) now requires health plans to “show their work” and perform a comprehensive NQTL analysis of the health plan itself. The analysis is no small task; even just knowing what information is needed is a chore.</p> <p class="bodytext" style="text-align: justify;">At a high level, the MHPAEA does not require health plans to cover treatment for mental health or substance abuse disorders. If the health plan does cover that treatment, though, the MHPAEA requires generally that benefits not be more restricted for mental health and substance abuse disorder benefits than benefits provided for medical and surgical benefits. It’s not the honor system; the purpose of the NQTL analysis is to have health plans affirmatively demonstrate their compliance (or their non-compliance).</p> <p class="bodytext" style="text-align: justify;">Whether the Department of Labor or a plan participant will request a copy of the analysis is anyone’s guess – but all health plans subject to the MHPAEA are required to perform the analysis nonetheless. In keeping with our perpetual goal of “Empowering Plans”, The Phia Group can help perform the NQTL analysis for your health plan, or those you service! Contact <a href="mailto:PGCReferral@phiagroup.com">PGCReferral@phiagroup.com</a> today to learn more.</p> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong>Success Story of the Quarter: The $300k+ Balance Bill</strong></p> <p class="bodytext" style="text-align: justify;">One of The Phia Group’s balance-billing support clients had a member who suffered a stroke and was treated at a New Jersey hospital to the tune of $359,000. The Plan adjudicated its benefits of 140% of Medicare, which totaled just about $46,500. The member was balance-billed for the remainder, and the claim was then referred to The Phia Group.</p> <p class="bodytext" style="text-align: justify;">In a case like this, where the billing is so much higher than a reasonable amount, our strategy is to start out with a forceful negotiation; the attorney handling this case offered $5,000 additional to settle (which totaled about 155% of Medicare). The provider didn’t respond for a couple of weeks, and the attorney working the file from Phia’s end was eventually given contact information for the individual in charge of negotiations at the hospital. The original offer of $5,000 was rejected, which was not unexpected for a first offer, but after establishing a positive rapport and having friendly but meaningful discussions about the claim, the plan’s rights, and the provider’s recourse, our attorney was able to settle the claim for additional payment of $17,343, or a total payment of about 192% of Medicare.</p> <p class="bodytext" style="text-align: justify;">Through this negotiation, our attorney kept his cool, and he was able to discern that the provider would be receptive to a good attitude rather than a fight. Sometimes we do have to fight, of course – but an amicable relationship can often lead to the same or even better results, and this is a great example of that.<a name="pdef"></a></p> <p class="bodytext"><strong>Phia Case Study: The Dialysis Overpayment</strong></p> <p class="bodytext" style="text-align: justify;">After a lack of clarity regarding which contract applied to a particular claim, one of The Phia Group’s clients discovered that one of its health plans had tendered payment to a DaVita dialysis facility in an amount far above the health plan’s allowable amount. When the TPA requested that the facility return the overpayment, DaVita refused. Phia was asked to attempt to recoup the overpayment; we knew from experience how difficult it can be to recover money from DaVita, especially once they had involved their attorneys, but we went into it with an open mind.</p> <p class="bodytext" style="text-align: justify;">At first, we had very little luck. We argued the merits back and forth with the attorney, but no one would give an inch. Eventually, DaVita’s attorney made the plan a meager offer, which was better than the legally-required zero reimbursement, but still a pittance compared to the amount of the total overpayment. Phia advised its client of the offer, of course, but the plan decided to reject it.</p> <p class="bodytext" style="text-align: justify;">One of the additional arguments Phia suggested had to do with considering DaVita to be a fiduciary with respect to the overpaid plan assets. The concept was a bit rough around the edges, since it isn’t quite supported by case law, but we had attorneys from multiple areas within Phia put their heads together, and we came up with an argument that at least sounded good. We presented the arguments to DaVita’s counsel, and without making any new counterarguments, we were able to reach a settlement figure that was acceptable to the plan.</p> <p class="bodytext" style="text-align: justify;">We will likely never know what exactly spurred the ultimate overpayment recovery in this case (whether it was the persistence, or the creative fiduciary argument, or some combination of the two) – but this case study goes to show that even when a favorable outcome seems unlikely, some combination of persistence, a show of strength, and creativity can change the winds.</p> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong>PACE Certification</strong></p> <p class="bodytext" style="text-align: justify;">Appeals and fiduciary requirements are a hot topic with all of the Consolidated Appropriation Act of 2021 mandates that are rolling out. You may want a better understanding of ERISA’s Claim and Appeals requirements, best practices, and the fiduciary role you might be playing unknowingly, we have created the PACE Certification course. You can take the course to become PACE Certified in the following areas. This course covers topics such as:</p> <p class="bodytext">• The Growth of Self-Funding – The Good, The Bad and The Risky<br /> • First Time Self-Funders; What You Need to Know<br /> • Applicable Laws • Applicable Duties<br /> • Trends in the Industry<br /> • Fiduciaries and Appeals<br /> • Types of Appeals<br /> • Appeals 101<br /> • Clerical Issues vs. Substantiative Issues<br /> • Appeals Process and Best Practices</p> <p class="bodytext">If you want to learn more about these topics, please contact us at: <a href="mailto:PACECertification@phiagroup.com">PACECertification@phiagroup.com</a></p> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Cross-Plan Offsetting</strong></p> <p class="bodytext" style="text-align: justify;">Whether you are a TPA, broker, health plan, stop-loss carrier, or even a hospital, you are well aware that hospitals usually do not bill reasonably. In keeping with this habit, hospitals often refuse to return overpayments made by health plans; widespread common law support of a provider’s right to keep an overpayment (except in certain limited cases, such as a contractual overpayment or fraud) has proven very detrimental to payors.</p> <p class="bodytext" style="text-align: justify;">In response, some health plans have begun to offset unreimbursed overpayments against future claims payable to that medical provider. This is fine if it is a claim for the same member as was involved in the overpaid claim (so long as the SPD supports it, that is). Some TPAs have taken it a step further, however, by having a different health plan deny a future claim for that same provider to account for the unreimbursed overpayment – a practice known as “cross-plan offsetting”. There is a bit of law on the topic, but not much; in general, courts do not take kindly to the practice when it comes before them, but we are yet to receive a sweeping general prohibition, nor do we have concrete guidance that the practice violates ERISA.</p> <p class="bodytext" style="text-align: justify;">One major problem with cross-plan offsetting is that by denying future claims in response to an unreturned overpayment, the plan is making the assumption that the overpayment is legally recoupable. Unfortunately, with respect to the majority of overpayments, this country’s courts have been clear that that is not actually the case. Absent some dishonesty, fraud, or an incorrectly-paid contract rate, for instance, providers are legally entitled to keep overpaid plan funds, provided the payment is at or below the provider’s billed charges. Courts hold that the overpayment was actually made to the patient, since the money allegedly overpaid would have been the patient’s responsibility if it had not been paid by the plan. As a result, withholding future payment to the provider for a different patient, whether on the same or different health plan, is generally not a proper practice, since that different patient experiences a claim denial that is unrelated to his or her actual claim!</p> <p class="bodytext" style="text-align: justify;">We have provided guidance on this many times in a consultative capacity, and one of our attorneys has <a href="https://www.phiagroup.com/Media/Posts/robbing-peter-to-pay-paul-the-trouble-with-cross-patient-offsetting">blogged about it</a>. The DOL itself has opined that cross-plan offsetting violates ERISA, and we tend to agree. In any event, we strongly caution TPAs and health plans against this practice. If you have any questions about a health plan’s or provider’s rights in a given scenario, please don’t hesitate to contact us at <a href="mailto:PGCReferral@phiagroup.com" target="_blank">PGCReferral@phiagroup.com</a>.<br />  </p> <hr class="horiz" /> <p> </p> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On June 22, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/back-on-track-plan-sponsor-priorities-for-the-second-half-of-2021" target="_blank">Back on Track: Plan Sponsor Priorities for the Second Half of 2021</a>,” where we discussed some simple cost-containment solutions and plan document changes, as well as a few cutting-edge techniques to prepare you for the second half of the year.</p> <p class="bodytext" style="text-align: justify;">• On May 25, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-light-at-the-end-of-the-covid-tunnel-pandemic-fallout-and-permanent-changes" target="_blank">The Light at the End of the COVID Tunnel – Pandemic Fallout and Permanent Changes</a>,” where we discussed pandemic era regulations – such as ARPA and the American Families Plan, analyze employer “return to work” policies, as well as predict how the past year will impact the future – and cost – of health care.</p> <p class="bodytext" style="text-align: justify;">• On April 27, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/face-the-change-plan-design-administrative-claims-processing-and-payment-changes-needed-in-light-of-covid-19-and-new-regulatory-obligations" target="_blank">Face the Change – Plan Design, Administrative Claims Processing and Payment Changes Needed in Light of COVID-19 and New Regulatory Obligations</a>,” where we shared with you the information you need to remain compliant, while also predicting what the provider industry will look like in the months and years to come.</p> <p class="bodytext">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p> <p class="bodytext"><strong>Breakout Sessions</strong></p> <p class="bodytext" style="text-align: justify;">• Following our June webinar, The Phia Group presented two breakout sessions, “<a href="https://www.phiagroup.com/Media/Posts/back-on-track-plan-sponsor-priorities-for-the-second-half-of-2021" target="_blank">Mental Health Parity – A Litigation Survey</a>” and “<a href="https://www.phiagroup.com/Media/Posts/back-on-track-plan-sponsor-priorities-for-the-second-half-of-2021" target="_blank">FAQs on Prescription Drug Importation</a>.” If you would like a copy of the recording or slide deck, please reach out to, Matthew Painten, at mpainten@phiagroup.com.</p> <p class="bodytext" style="text-align: justify;">• Following our May webinar, The Phia Group presented two breakout sessions, “<a href="https://www.phiagroup.com/Media/Posts/the-light-at-the-end-of-the-covid-tunnel-pandemic-fallout-and-permanent-changes" target="_blank">The Future Cost of COVID-19</a>” and “<a href="https://www.phiagroup.com/Media/Posts/the-light-at-the-end-of-the-covid-tunnel-pandemic-fallout-and-permanent-changes" target="_blank">Welcome Back; Not So Fast.</a>” If you would like a copy of the recording or slide deck, please reach out to, Matthew Painten, at <a href="mailto:mailto:mpainten@phiagroup.com" target="_blank">mpainten@phiagroup.com</a>.</p> <p class="bodytext" style="text-align: justify;">• Following our April webinar, The Phia Group presented two breakout sessions, “<a href="https://www.phiagroup.com/Media/Posts/face-the-change-plan-design-administrative-claims-processing-and-payment-changes-needed-in-light-of-covid-19-and-new-regulatory-obligations" target="_blank">New Regulations Impose Additional MHPAEA Compliance Requirements – Act Now!” and “COBRA Changes Under ARPA – What You Need to Know</a>.” If you would like a copy of the recording or slide deck, please reach out to, Matthew Painten, at <a href="mailto:mailto:mpainten@phiagroup.com" target="_blank">mpainten@phiagroup.com</a>.</p> <p> </p> <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On June 25, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p112-healthcare-subrogation-the-comeback-post-covid-edition" target="_blank">Healthcare Subrogation, The Comeback!</a> Post-Covid Edition,” where our hosts, Cindy Merrell and Maribel Echeverry McLaughlin, discussed healthcare subrogation in the post-Covid environment, and the difficulties faced during the international pandemic.</p> <p class="bodytext" style="text-align: justify;">• On June 11, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p111-breaking-down-drug-importation" target="_blank">Breaking Down Drug Importation!</a>,” where our hosts, Chris Aguiar and Andrew Silverio, discussed some evolving issues and recent developments, including whether a participant can be deemed a plan fiduciary after a third party recovery, and the current state-run of state drug importation programs.</p> <p class="bodytext" style="text-align: justify;">• On May 27, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p110-nqtl-mhpaea-omg-idk" target="_blank">NQTL? MHPAEA?! OMG, IDK!</a>,” where our hosts, Nick Bonds and Jon Jablon, discussed one of the most mysterious topics of the CAA: the Non-Quantitative Treatment Limitation analysis now required by the Mental Health Parity and Addiction Equity Act.</p> <p class="bodytext" style="text-align: justify;">• On May 14, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p109-the-unanticipated-costs-of-covid-19-testing" target="_blank">The Unanticipated Costs of COVID-19 Testing</a>,” where our hosts, Kelly Dempsey and Kevin Brady, revisited a subject quite popular at the beginning of the pandemic; testing for COVID-19.</p> <p class="bodytext" style="text-align: justify;">• On May 11, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p108-a-winwin-proposition-better-quality-for-patients-real-roi-for-plans" target="_blank">A Win/Win Proposition – Better Quality for Patients, Real ROI for Plans</a>,” where our hosts, Tim Callender and Linda Pestant, are joined by the CEO and Co-Founder of Rightway Healthcare, Jordan Feldman, to discuss how Rightway is making an impact!</p> <p class="bodytext" style="text-align: justify;">• On April 30, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p107-updates-employers-need-to-know-about-the-covid-19-vaccines" target="_blank">Updates Employers Need to Know About the COVID-19 Vaccines</a>,” where our hosts, Brady Bizarro and Philip Qualo, had a conversation about compliance considerations implicated when considering mandating vaccination.</p> <p class="bodytext" style="text-align: justify;">• On April 16, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p106-a-no-surprises-party-the-no-surprises-act-dissected" target="_blank">A No-Surprises Party – The No Surprises Act Dissected</a>,” where our hosts, Ron Peck and Jen McCormick, discussed the No Surprises Act, its likely impact on both the payer and provider industries, and provide listeners with guidance on what they need to do now, to ensure compliance when it goes live.</p> <p class="bodytext" style="text-align: justify;">• On April 6, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p104-the-mystery-surrounding-covid-19-long-haulers-employment-benefit-considerations" target="_blank">The Mystery Surrounding COVID-19 Long Haulers: Employment & Benefit Considerations</a>,” where our hosts, Phil Qualo and Kelly Dempsey, explored the phenomena surrounding COVID-19 long haulers.</p> <p class="bodytext">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletter 2019 Q1/Apple%20Podcasts.jpg?ver=goypGkLDYbWCGYXontbItA%3d%3d" style="width: 491px; height: 121px;" /></a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Pension_Ruling_Limits_Health_Plan_Mismanagement_Cases_by_Brady_Bizarro%2C_Esq.pdf" target="_blank">Pension Ruling Limits Health Plan Mismanagement Cases</a> – June 4, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/06/02/vaccine-patent-waivers-a-roadblock-on-the-path-to-normalcy/" target="_blank">Vaccine patent waivers: A roadblock on the path to normalcy</a> – June 2, 2021</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/The_Pandemic_May_Be_On_The_Back_Nine__But_What_About_Its_Impact_by_Christopher_M__Aguiar_Esq.pdf" target="_blank">The Pandemic May Be On The Back Nine; But What About its Impact</a> – May 7, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/04/20/no-surprises-act-practical-effects-of-independent-dispute-resolutions/" target="_blank">No Surprises Act: Practical effects of independent dispute resolutions</a> – April 20, 2021</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Are_Your_ICS_Really_EES__A_Look_At_Who's_Who_On_An_Employee_Benefit_Plan_The_Saga_Continues_by_Philip_Qualo_and_Kelly_E__Dempsey.pdf" target="_blank">Are Your ICS Really EES? A look at who's who on an employee benefit plan...The Saga Continues</a> – April 2, 2021</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1"></span><br />  </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/good-to-be-back" target="_blank">Good to Be Back!</a> Getting back into the swing of things.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/mhpaea-compliance-the-dreaded-nqtl-analysis" target="_blank">MHPAEA Compliance: The Dreaded NQTL Analysis.</a> The Mental Health Parity and Addiction Equity Act (or MHPAEA) now requires health plans to “show their work.”</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-new-normal-same-as-the-old-normal" target="_blank">The New Normal… Same as the Old Normal?</a> The halfway mark of 2021 is a great time to examine the last year and a half.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/revisiting-ppo-contracts-stop-loss-gaps" target="_blank">Revisiting PPO Contracts & Stop-Loss Gaps.</a> Stop-loss policy gaps can arise anywhere – even from basic policy definitions.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/doe-v-united-behavioral-health-a-fiduciary-twist" target="_blank">Doe v. United Behavioral Health – A Fiduciary Twist.</a> A lawsuit brought against a TPA could have a fiduciary ripple effect on TPAs in California and beyond.</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a>The Stacks:</span></p> <p class="bodytext"><strong>Pension Ruling Limits Health Plan Mismanagement Cases</strong><br />  </p> <p class="bodytext">By: Brady Bizarro, Esq. – June 2021 – <a href="https://www.sipconline.net/files/Pension_Ruling_Limits_Health_Plan_Mismanagement_Cases_by_Brady_Bizarro%2C_Esq.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="text-align: justify;">In the complex world of ERISA litigation, court rulings can often impact both retirement and health and welfare benefit plans. When a crossover occurs in a case primarily involving retirement plans, the impact on health and welfare plans is typically limited. Every so often, though, a case centers around a threshold question which impacts every federal case, and as such, the ruling has significant consequences for all employee benefits cases.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2021" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>The Pandemic May Be On The Back Nine; But What About its Impact</strong></p> <p class="bodytext">By: Christopher Aguiar, Esq. – May 2021 – <a href="https://www.sipconline.net/files/The_Pandemic_May_Be_On_The_Back_Nine__But_What_About_Its_Impact_by_Christopher_M__Aguiar_Esq.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="text-align: justify;">What a year; 2020 was one for the history books - the year almost everything changed (except aggressive, polarizing, political rhetoric)! Presidential Administrations changed as we witnessed an historic election, the results of which were not determined for over a week and disputed for several more. Live shows became live streams and drive ins. Movie theatres turned into ghost towns. Remote working became the norm. City dwellers fled in droves in search of more space and cheaper housing costs. Iconic/historic hotspots became relics of the past. Supply in the housing market, nationally, reached never-before seen lows while the future of the commercial real estate market spiraled into question. Parents doubled as financial providers and teachers. Finally, and perhaps most upsetting of all, remote learning became a norm that virtually all school systems were forced to learn to implement, cementing that future generations of children may never again experience the magic of a snow day!</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2021" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>Are Your ICS Really EES? A look at who's who on an employee benefit plan...The Saga Continues </strong></p> <p class="bodytext">By: Philip Qualo, J.D., and Kelly Dempsey, Esq. – April 2021 – <a href="https://www.sipconline.net/files/Are_Your_ICS_Really_EES__A_Look_At_Who's_Who_On_An_Employee_Benefit_Plan_The_Saga_Continues_by_Philip_Qualo_and_Kelly_E__Dempsey.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="text-align: justify;">Last time we addressed the issue of classifying workers in March of 2020, the world was a totally different place. Face masks were only worn by doctors during surgery, quarantine was a term almost exclusively used in sci-fi and horror movies, and the blurry rules applicable to classifying workers had remained relatively unchanged for decades. What a difference a year can make! Facemasks have become the hottest new accessory, “Zoom fatigue” is a real thing, a new administration, and an entirely new framework for classifying employees and independent contractors is on the horizon.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2021" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2021 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2021 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8-18, signed up as club members. In the 25 years since, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.</p> <p><span class="bodytext"><strong>Youth of the Year</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Each year, the Boys & Girls Clubs of Metro South holds a competition to award the most prestigious honor that a teenager can receive as a member of their local Boys & Girls Club. The Youth of the Year award is the Boys & Girls Club signature effort to foster a new generation of leaders, fully prepared to live and lead in a diverse, global and integrated world economy.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">One lucky teen was awarded a $5,000 scholarship and a new laptop, courtesy of The Phia Group. The Boys and Girls Clubs of Metro South has announced the Boys & Girls Clubs of Metro South’s 2021 Youth of the Year winner, Victoria Rodriguez! Best of luck in your future endeavors.</p> <p><span class="bodytext"><strong>Phia Group Great Futures Scholarship</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group joined the Boys & Girls Club community in 2016 as a way to enhance great futures. The Great Futures Scholarship was established in 2018 by Adam V. Russo, Esq, co-founder and CEO, of The Phia Group. Once a Boys & Girls Club kid himself, Adam has set his mind and heart on supporting the ambitions of our club kids and their amazing potential. Adam realizes first-hand the struggles and challenges to overcome obstacles, facing adverse circumstances, and the determination for self-perseverance.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Great Futures Scholarship recognizes one graduating senior annually for their commitment to education and dedication to a better future. With Adam’s vision, the club annually awards a $10,000 scholarship to assist one student in their pursuit of their educational dreams, development of strong work ethic, and development of self-appreciation. The Boys and Girls Clubs of Metro South has announced The Phia Group Great Futures Scholarship winner, DeeJay Lamarre! Congratulations and best of luck in College!<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Get to Know Our Employee of the Quarter: Brittany Farr</span></p> <p class="bodytext" style="text-align: justify;">To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.</p> <p class="bodytext" style="text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Brittany Farr, The Phia Group’s 2021 Q3 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Brittany: “Every single time I reach out to CSD, not only is Brittany usually the first person to say they can help me out, but she is SUPER helpful, responsive, and very professional. This isn’t to say that most of the new people haven’t been helpful or responsive, but I just think that Brittany has always gone the extra mile for me since she started.”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2021/brittany.jpg?ver=QOrtolwsSSVL_DniGLtmzA%3d%3d" style="width: 475px; height: 506px;" /></p> <p class="bodytext"> </p> <p class="bodytext">Congratulations Brittany, and thank you for your many current and future contributions.</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"> </p> <hr class="horiz" /> <p><strong><span style="color:#000000;">Job Opportunities:</span></strong></p> <p class="bodytext">• ETL Specialist<br /> • Legal Assistant<br /> • Case Investigator<br /> • Customer Service Representative<br /> • Claim Analyst<br /> • Claim & Case Support Analyst<br /> • Senior Vice President of Sales</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext" style="text-align: justify;">• Andrew Fine has been promoted from Team Lead of Intake to Consulting Data Analyst</p> <p class="bodytext" style="text-align: justify;">• Ron E. Peck has been promoted from Executive VP & General Counsel to Chief Legal Officer</p> <p class="bodytext" style="text-align: justify;">• Nicole Capozzoli has been promoted from Case Investigator to Claim Recovery Specialist III</p> <p class="bodytext" style="text-align: justify;">• Francesca Russo has been promoted from Claims Recovery Specialist IV to Senior Claims Recovery Analyst</p> <p class="bodytext" style="text-align: justify;">• Kevin Brady has been promoted from Staff Attorney to Attorney II</p> <p class="bodytext" style="text-align: justify;">• Kelsey Dillon has been promoted from Sr. Claim & Case Support Analyst to Team Leader – Claim & Case Support</p> <p class="bodytext" style="text-align: justify;">• Kaitlyn Lucier has been promoted from Customer Care Representative to Team Leader – Customer Service</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Peter Kotsifas was hired as the Chief Financial Officer<br /> <br /> • Katie Duke was hired as a Legal Intern<br /> <br /> • Adam Czyrklis was hired as a Case Investigator<br /> <br /> • Samantha Crawford was hired as a Case Investigator<br /> <br /> • Nicole Hunt was hired as a Case Analyst<br /> <br /> • Amanda Watts was hired as a Customer Service Rep.<br /> <br /> • Tika Green was hired as a Customer Service Rep.<br /> <br /> • Veronica Marcos was hired as a Contracts Intern<br /> <br /> • Caitlin Lankston was hired as an IT Consultant<br /> <br /> • Sandra Croteau was hired as a CST Manager<br /> <br /> • Petra Holder was hired as a Customer Service Rep.<br /> <br /> • Michael Guthrie was hired as a DSG Consultant<br /> <br /> • Anna Montalto was hired as a Marketing Intern</p> <hr class="horiz" /> <p><span class="heading1"><a id="pnews" name="pnews"></a><span class="heading1"><a id="pnews" name="pnews"></a></span></span></p> <p class="bodytext"><span class="heading1">Phia News:</span></p> <p class="boldtext">Best Place to Work in Greater Louisville</p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2021/bptw.png?ver=JhY3nMyXQl4wgI6-IWjvDg%3d%3d" style="width: 572px; height: 533px;" /></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to announce that it has earned a Best Places to Work in Greater Louisville award, issued by Louisville Business First. The Best Places to Work program—administered in partnership with Quantum Workplace—surveys employees about workplace policies, office conditions, management styles, morale, and more. The Phia Group is humbled to be one of only 43 businesses and nonprofits, with at least 10 full-time employees and an office in the Louisville area, that scored high enough to be awarded.</p> <p class="bodytext" style="text-align: justify;">The Phia Group only recently opened its Louisville office, but it already houses some of the company’s most valuable team members. Thanks to the talent and passion found in Louisville, along with this recognition, The Phia Group plans to continue its steady growth in the Louisville area.</p> <p class="bodytext"><strong>COVID - Appeals, Subrogation, and Stop Loss Issues No One Saw Coming - Help is Here</strong></p> <p class="bodytext"> </p> <p class="boldtext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/covid.png?ver=1PYo1bACQA4zxTLKiRB-tA%3d%3d" style="width: 572px; height: 533px;" /></p> <p class="bodytext" style="text-align: justify;">COVID claims are coming - whether you pay or deny claims tied to COVID, you need The Phia Group.</p> <p class="bodytext" style="text-align: justify;">Claims tied to the treatment of COVID-19 are being submitted for payment and are passing through the claims process in record numbers. Many of these claims are substantial, with these considerable costs impacting our industry in both anticipated and unforeseen ways. As with any influx of new claims, we are also seeing growth in the number of denials and appeals arising from these COVID claims, as well as subrogation issues tied to the disease.</p> <p class="bodytext" style="text-align: justify;">COVID claims are routinely denied and/or paid incorrectly, due in large part to the inadequate time provided to consultants, administrators, and payers, to familiarize themselves with the ever changing rules, and thereby standardize appropriate handling of these claims in accordance with law and their plan documents. As a result, we are also seeing an increase in COVID related claim appeals, with heightened fiduciary liability issues also arising from these claim payment decisions.</p> <p class="bodytext" style="text-align: justify;">The Phia Group's PACE Service has existed for years and is the only service on the market where expert plan drafters, attorneys, and seasoned appeals professionals help you navigate these and other difficult appeals, thereby avoiding mistakes and costly liability. PACE ensures claim denials are legitimate, enforceable, and defended.</p> <p class="bodytext" style="text-align: justify;">As with claims processing and appeals, COVID has also created a new world for subrogation. When COVID claims are submitted, complex state law may be triggered regarding if and when COVID is "presumed" to be an occupational expense. The Phia Group was the first subrogation provider to build a custom process backed by its in-house legal team with a focus on identifying COVID related claims, determining whether the applicable geographic location and occupation are addressed by a regulation that presumes a link between the occupation and diagnosis, and quickly asserts a right to reimbursement against responsible parties if possible. The Phia Group has been applying this procedure to its existing process since June of 2020. Without an innovative subrogation solution like ours in place, plans not only lose money, but also fail in their obligation to stop-loss; a failure stop-loss carriers are increasingly unwilling to overlook.</p> <p class="bodytext" style="text-align: justify;">The stop-loss world has been handed a unique and difficult scenario. As it relates to claims arising from or tied to COVID-19, carriers are suspending reimbursement and asking questions such as: what is the Plan Participant's job description; is the Plan Participant a front line worker; what date did they test positive; are they an essential worker; did they file a workers' compensation claim; and so on. The Phia Group has the expertise to assist in these difficult stop-loss collaborations.</p> <p class="bodytext" style="text-align: justify;">Ensuring appeals are handled correctly, aligning plan documents with stop-loss policies, and fully understanding the bigger picture has never been more important. The Phia Group is uniquely positioned to help in this difficult time. With our unrivaled team and technology ready to help, there is no better partner to assist you now and in the days to come.</p> <p class="bodytext" style="text-align: justify;">Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com" target="_blank">ghunt@phiagroup.com</a> or <a href="mailto:info@phiagroup.com" target="_blank">info@phiagroup.com</a> to request more information and set a call to learn how The Phia Group can assist you with these COVID claim issues.</p> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.<br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter Q1 2018/footerlogo.png?ver=-c8yhuYtU1mPXJVxbXTW6A%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1079The Stacks – 3rd Quarter 2021https://www.phiagroup.com/Media/Posts/PostId/1078/the-stacks-3rd-quarter-2021NewslettersTue, 13 Jul 2021 15:08:00 GMT<p style="text-align: justify;"><span style="font-size:20px;"><span style="color:#0071ce;"><b><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Are Your ICs Really EEs? A Look at Who’s Who on an Employee Benefit Plan … The Saga Continues</span></span></b></span></span><b><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="color:null;"></span></span></span></span></b><br /> <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="color:null;">By: Kelly Dempsey, Esq. & Philip Qualo, J.D.</span></span></span></span></p> <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">Last time we addressed the issue of classifying workers in March of 2020, the world was a totally different place. Face masks were only worn by doctors during surgery, quarantine was a term almost exclusively used in sci-fi and horror movies, and the blurry rules applicable to classifying workers had remained relatively unchanged for decades. What a difference a year can make! Facemasks have become the hottest new accessory, “Zoom fatigue” is a real thing, a new administration, and an entirely new framework for classifying employees and independent contractors is on the horizon. </span></span></span></p> <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></span></span></p> <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">For most laymen, the question of whether a worker is an employee or an independent contractor is simple…an independent contractor is compensated by Form-1099, and an employee is compensated by Form W-2 as well as subject to federal and state tax withholding. Many are surprised to find out that the analysis is far more complicated than which tax form is provided annually. For employers, this is a far more complex undertaking (whether they realize it or not). Employee status triggers employer obligations under various federal and state laws that do not apply to independent contractors, and the responsibility for classifying a worker correctly falls squarely on the employer. The implications are even larger for employers that sponsor self-insured health plans - correctly classifying workers is an extremely important undertaking as offering coverage to independent contractors can create significant compliance issues for their health plans as well as issues with stop-loss reimbursement. </span></span></span></p> <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></span></span></p> <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">No bright-line test exists to determine when a worker should be classified as an employee rather than as an independent contractor. In September 2020, the U.S. Department of Labor (DOL) issued proposed rules aimed at simplifying classification of workers. Final rules were published on January 7, 2021 with a March 8, 2021 effective date; however, actions taken by the Biden administration delayed the effective date of the final rule to May 7, 2021. To further complicate matters, on March 11, 2021, proposed rules to withdraw the final rules published on January 7 were issued. While it is likely these rules will be withdrawn without much objection, it is important to understand what was being proposed as it is possible future rules may arise as the concept of employee vs. independent contractor is a very hot topic, especially in California. Prior to the DOL issuing final rules, California had previously placed California Proposition 22 on the November 2020 ballot. California Proposition 22 established more stringent classification standards for certain workers and it is likely the lobbying entities will seek similar legislation in other states. Changes to state law and the impending federal rules make this a good time for employers to start reviewing their own internal processes for classifying workers (that is if employers did not heed Kelly’s prior article - see The Self-Insurer March 2020 edition). </span></span></span></p> <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></span></span></p> <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">Before we dive into the final rules that are now pending withdrawal, it is important to emphasize why this classification matters. Employers are required to withhold income taxes based on information employees provide on IRS Form W-4. If an employer fails to withhold income taxes on behalf of a worker improperly classified as an independent contractor, and the individual has failed to pay the taxes, the employer may be liable for federal or state taxes that were required to be withheld but were not. Furthermore, independent contractors are not eligible to receive tax-free benefits from an employer - such as an offer of coverage to participate in a self-insured health plan. If an employer chooses to offer health care benefits to an independent contractor, the contractor must pay income taxes on the value of the benefit. Additionally, if the company includes an independent contractor in its defined benefit pension plan, it risks losing the tax-exempt status of the plan. Employers offering self-insured health coverage to independent contractors are especially vulnerable to compliance risks for the plan, including inadvertently creating a Multiple Employer Welfare Arrangement (MEWA) plan subject to state law and no longer protected by ERISA preemption mandates. </span></span></span></p> <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">Historically, the DOL, Internal Revenue Services (IRS), and federal courts have interpreted the Fair Labor Standards Act (FLSA) to consist of a broad general rule that a worker was an independent contractor, and not a bona fide employee, if the employer had the right to control or direct only the result of the work of an individual, as opposed to what will be done and how it will be done. To determine how to properly classify workers and assess the degree of control and independence in the employer/worker relationship, the agencies and the courts have focused on three broad categories, which consist of a total of 20 factors for employers to consider when determining whether a worker was a bona fide employee of the employer, or an independent contractor. The 20 factor list is fairly exhaustive and can be overwhelming, however, the categories are seemingly straightforward. The first category is behavioral control - a worker is an employee when the business has the right to direct and control the work performed by the worker, even if that right is not exercised. The second category focuses on financial control - whether the business has a right to direct or control the financial and business aspects of the worker's job. The third category focuses on the relationship between the parties. Essentially, an expectation that the relationship will continue indefinitely, rather than for a specific project or period, is generally seen as evidence that the intent was to create an employer-employee relationship. Ultimately, whether a worker was an independent contractor or employee depended on the facts in each situation.</span></span></span></p> <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></span></span></p> <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">Towards the end of 2020, however, the DOL published a proposed rule revising its interpretation of the FLSA's classification provisions to determine whether a worker is an employee or independent contractor. Subsequently the rules were finalized very early in 2021, but are now subject to withdrawal. With that said, it is important to understand what these rules would have changed. Under the “economic reality test”, the DOL would consider whether a worker is in business for themselves and thus is an independent contractor, or if the worker is economically dependent on an entity for work and is an employee.</span></span></span></p> <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></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="font-family:"Calibri",sans-serif">In making this determination, the DOL would identify two core factors: (1) the nature and degree of the worker's control over the work (2) the worker's opportunity for profit or loss based on initiative or investment. It also will identify three other factors that may serve as additional guides in the analysis. These factors include the amount of skill required for the work, the degree of permanence of the working relationship between the worker and the potential employer, and whether the work is part of an integrated unit of production.</span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="font-family:"Calibri",sans-serif">The DOL noted that the first two core factors are entitled to greater weight than the other factors. The first factor would suggest that an individual is an independent contractor to the extent that he or she exercises substantial control over key aspects of the performance of the work. Examples of an individual's substantial control include setting his or her own work schedule, choosing assignments, working with little or no supervision, and being able to work for others, including a potential employer's competitors.</span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="font-family:"Calibri",sans-serif">In contrast, the control factor would weigh in favor of classification as an employee to the extent that a potential employer, rather than the worker, exercises substantial control over key aspects of the work, such as imposing requirements that the individual work for the employer exclusively during the working relationship. The second factor would suggest that an individual is an independent contractor if he or she has an opportunity for profit or loss on either the exercise of personal initiative, including managerial skill or business acumen or the management of investments in or capital expenditure on (for example, helpers, equipment, or materials). </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="tab-stops:list .5in"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> <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">As for the skill factor, the DOL proposed focusing on the amount of skill required. Because the worker's ability to work for others is already analyzed as part of the control factor, the final rule articulates the permanence factor without reference to the exclusivity of the relationship between the worker and potential employer. The permanence factor would weigh in favor of an individual's being classified as an independent contractor when the working relationship is definite in duration or sporadic. By contrast, the factor would suggest someone is an employee if the working relationship is indefinite in duration or continuous.</span></span></span></p> <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></span></span></p> <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">The "integrated unit" factor would focus on whether an individual works in circumstances similar to a production line. This factor weighs in favor of employee status where a worker is a component of a potential employer's integrated production process, whether for goods or services. The overall production process must be an integrated process that requires the coordinated function of interdependent subparts working toward a specific unified purpose. This may happen when the worker depends on the overall process to perform work duties.</span></span></span></p> <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></span></span></p> <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">According to the DOL, if the first two core factors—control and opportunity for profit or loss—point toward the same classification, their combined weight is substantially likely to outweigh the other factors. This differs from the original test supported by the agencies as the actual practice of the parties involved will be considered more relevant than what may be contractually or theoretically possible.</span></span></span></p> <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></span></span></p> <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">The proposed withdrawal of the final rules outlines various reasons the rule should not become effective. In short, based on over 1,500 comments received, the DOL now believes the final rules create more confusion and potential inconsistency in application as opposed to providing clarity and certainty as intended. While these rules now face even greater uncertainty than just delayed application, one state has already implemented their own set of stringent rules for worker classifications that have been making headlines since the November elections. </span></span></span></p> <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></span></span></p> <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"><i>California’s Proposition 22</i></span></span></span></p> <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"><i></i></span></span></span></p> <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">As mentioned above, California’s Proposition 22 was on the ballot in November 2020 and passed with a relatively narrow majority at 58%. Several key requirements now apply to “gig companies” – sometimes referred to as “on-demand companies” and better known by their names including Uber, Lyft, DoorDash, and Instacart. These on-demand companies must provide (1) an hourly wage equal to 120% of local or state minimum wage requirements for time spend on rides; (2) a stipend for health insurance for individuals working 15 hours or more per week; and (3) access to accident insurance. The catch-22 (pun intended) is that Proposition 22 also solidifies an exemption under state law for these same on-demand ride-hail and delivery companies to treat workers as independent contractors. This means these workers are not protected by California’s generous employee protections, including paid sick leave laws. Many following these developments in California have observed that California has essentially created a third category of workers. Aside from the general controversy surrounding the new requirements and permanent independent contractor status, the success in California means the door to additional states having similar laws has been kicked open. </span></span></span></p> <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></span></span></p> <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"><i>New Jersey Classification Penalties</i></span></span></span></p> <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></span></span></p> <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">Faithful readers may recall the March 2020 discussion of New Jersey’s modifications to worker classification laws. Some rules took effect in late 2019 and additional requirements began in April 2020. As a quick refresher, one very notable change was the addition of monetary penalties for misclassification of employees and independent contractor. Penalties include an administrative penalty for misclassifying an employee beginning at $250 per misclassified employee and increasing for subsequent violations to a maximum of $1,000 per misclassified employee. The second penalty is a monetary amount that is to be no more than 5% of the worker’s gross earnings over the past 12 months. The limitation applies to the earnings from the employer that actually misclassified the individual – meaning a new employer that has contracted to work with the independent contractor cannot be held accountable for the prior employer’s mistake. Given the radical turn 2020 took with the pandemic, it is likely to be some time before information on violations make their way to the surface. </span></span></span></p> <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></span></span></p> <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"><i>Final Considerations for Self-Insured Plans</i></span></span></span></p> <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></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Those familiar with self-funding will know that private self-insured employers are generally used to enjoying ERISA preemption of state law; however, as classification of workers is a rule directed to employers, the lines begin to blur and as discussed, these rules can have an impact on how an employer is offering a self-insured benefit plan. Classification of workers is certainly an area of regulation that will continue to develop at a state and federal level. In addition to the various federal laws that include testing requirements (such as the Mental Health Parity Addiction Equity Act, Code Section 125, and Code Section 105(h)), employers will need to remain acutely aware of how they are classifying workers regardless of whether or not the final rules take effect. While the future always carries a fair amount of uncertainty, being proactive and assessing the status of their current workforce is something that employers should not ignore.</span></span></span></p> <hr /> <p><span style="color:#0071ce;"><b><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:20px;">The Pandemic May be On the Back Nine; but What About Its Impact?</span></span></span></span></b></span><br /> <span style="color:null;"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Christopher M. Aguiar, Esq.</span></span></span></span></p> <div> <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">What a year; 2020 was one for the history books - the year almost everything changed (except aggressive, polarizing, political rhetoric)!  Presidential Administrations changed as we witnessed an historic election, the results of which were not determined for over a week and disputed for several more. Live shows became live streams and drive ins. Movie theatres turned into ghost towns. Remote working became the norm. City dwellers fled in droves in search of more space and cheaper housing costs. Iconic/historic hotspots became relics of the past. Supply in the housing market, nationally, reached never-before seen lows while the future of the commercial real estate market spiraled into question. Parents doubled as financial providers and teachers. Finally, and perhaps most upsetting of all, remote learning became a norm that virtually all school systems were forced to learn to implement, cementing that future generations of children may never again experience the magic of a snow day! </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">As vaccinations ramp and millions of Americans march towards “herd immunity”, many are starting to feel that we are reaching the home stretch. What exactly, though, does life after COVID, the so-called “new norm”, look like? Even after the pandemic is behind us, we will be experiencing its effects, and perhaps some newly established behaviors, well into the future. Whether it be an increase in virtual meetings and remote work, a change in the way we greet each other upon meeting, an increase in mask usage during peak viral seasons, or as society deals with some of the financial consequences of a year of lock downs and fear, people and organizations will need to find ways to address some of the financial concerns that came with this pandemic. </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">Benefit plans, for example, may need to find new innovative ways to cut costs as they deal with what some are projecting to be a greater than normal increase in medical spend. Some projections, like those made by the American Institute of Certified Public Accountants, indicate that national health spending projections are showing a per year increase over the next decade at 450% of the inflation rate seen between 2014 – 2018 (from 1.2% to 5.4%). This COVID surcharge is no doubt intended to make up some of the losses suffered by hospitals who, according to healthaffairs.org, saw a 35.8% decrease in hospital spending in March and April of 2020 alone – thanks in large part to a decrease in non-critical services, those among the most profitable delivered by hospitals. </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">Luckily, regulators across the country are seeking ways to make cost containment for benefit plans a bit more possible. A perfect example of this is with potential changes in worker’s compensation coverage – an area of insurance traditionally heavily regulated by state government. Why are changes necessary in the worker’s compensation arena? Proving someone contracted the virus at work can be very difficult, even in situations where the person has a high-risk job. For example, a nurse assigned to a COVID unit is much more likely to contract the virus than, say, a grocery store cashier. Yet, both may be considered essential employees and, by the very nature of their employment, contract the virus while working. Both could also easily contract the virus at the grocery store on the way home from their shift while running errands after work. How, then, do you prove causation - the most important element of an injury claim?  Causation is the element that ultimately establishes an employee contracted the virus while dealing with an infected person rather than getting too close during a walk and breathing in that person’s droplets. </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">Every state treats the key legal concept differently, that of ‘Presumptive Illness’. This presumption, often used for firefighters who contract certain diseases such as lung disease or cancer that were likely caused by their time on the job, requires the insurance company to presume causation while allowing them to prove otherwise. So, the nurse assigned to a COVID unit would be presumed to have contracted the virus there; the insurance carrier then has the burden to prove otherwise. Causation, then, becomes a significantly lesser barrier to benefits. </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">As of March 22, 2021 - 16 states have some type of presumption that would cover COVID-19 already on the books; the remaining 34, however, do not. 20 of those states either have no activity considering a change to their presumptive illness practices as it relates to worker’s compensations benefits, or bills have been introduced but not passed. </span></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">All entities providing or administering health benefit plans in America should be evaluating all their cost containment options in a post COVID world and preparing for what could be a significant increase of medical bills both, directly and indirectly related to this pandemic. The potential cost to health benefit plans as a result of this virus will no doubt be significant. We have all heard the stories, COVID treatment itself is very expensive; the other charges, however, are also likely primed to see increases as hospitals review their charge masters and attempt to remedy a black hole of non-emergent care caused by lock downs and folks unwilling to trek to the hospital. After months of record losses, it is only natural that they will find ways to recoup them. If benefit plans, too, are going to stem the tide, they must seek options to account, budget, and wherever possible, mitigate this surge of inevitable costs.</span></span></span></p> <hr /> <p><span style="color:#0071ce;"><strong><span style="font-size:20px;">Pension Ruling Limits Health Plan Mismanagement Cases</span></strong></span><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Brady Bizarro, Esq.</span></span></span></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></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">In the complex world of ERISA litigation, court rulings can often impact both retirement and health and welfare benefit plans. When a crossover occurs in a case primarily involving retirement plans, the impact on health and welfare plans is typically limited. Every so often, though, a case centers around a threshold question which impacts every federal case, and as such, the ruling has significant consequences for all employee benefits cases. Last summer, the Supreme Court of the United States decided <u>Thole v. U.S. Bank N.A.</u>, a case principally about pension plans.<a href="#_ftn1" name="_ftnref1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[1]</span></span></span></span></span></a> The 5-4 ruling was considered extremely consequential in this area because it limited beneficiaries’ right to sue plan fiduciaries. Now, attorneys representing health plan fiduciaries are finding success in utilizing the Court’s ruling in <u>Thole</u> to dismiss cases brought against them.<br /> <br /> The <u>Thole</u> case involved one of the most fundamental legal doctrines in America law: the standing requirement. Standing is the determination of whether a specific person is the proper party to bring a matter to a court for adjudication. To establish constitutional standing, a plaintiff must prove (1) that she suffered an injury in fact that is concrete, particularized, and actual or imminent, (2) that the injury was caused by the defendant, and (3) that the injury would likely be redressed by the requested judicial relief.<a href="#_ftn2" name="_ftnref2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[2]</span></span></span></span></span></a> Here, the plaintiffs, Thole and Smith, were two retired employees who participated in U.S. Bank’s retirement plan. They filed a class-action suit against the plan fiduciaries, alleging that they mismanaged more than $748 million, causing them harm. The Court ruled that because the plan participants had suffered no monetary injury, they lacked standing to sue the plan fiduciaries.<br /> <br /> To understand why this case is having a major effect on health plan litigation, it is essential to dig into the facts, the Court’s majority opinion, and its lengthy dissent authored by Justice Sonia Sotomayor. The plaintiffs in this case were part of a defined-benefit plan, not a defined-contribution plan. In defined-benefit plans, retirees receive a fixed payment each month, and those payments do not change with the value of the plan or because of plan fiduciaries’ good or bad investment decisions. Compare that to a defined-contribution plan, most commonly a 401(k) plan, in which benefits are usually tied to the value of their accounts, and those benefits can fluctuate depending on plan fiduciaries’ investment decisions. Thole and Smith, as pensioners, receive $2,198.38 and $42.26 per month, respectively, despite the plan’s value at any given moment or any of the investment decisions made by the plan fiduciaries. They have received all of the money due to them and are legally and contractually entitled to receive those amounts for the rest of their lives.<br /> <br /> While the plaintiffs did not sustain a monetary injury, they brought suit against the plan fiduciaries under ERISA, claiming that the defendants violated ERISA’s duties of loyalty and prudence by poorly investing plan assets some ten years ago, to the tune of a $748 million loss. They asked the Court to force the fiduciaries to repay the losses to the plan, to replace the plan fiduciaries, and to award them $31 million in attorney’s fees. The district court in Minnesota found that the plaintiffs had sufficient standing to proceed with the case, and after that determination, U.S. Bank made a substantial contribution to the pension plan, bringing it above the statutory minimum. The district court ultimately dismissed the case, and on appeal, the U.S. Court of Appeals for the Eighth Circuit found that the plaintiffs lacked statutory standing.<br /> <br /> Justice Brett Kavanaugh authored the Supreme Court’s majority opinion, joined by the Court’s other conservative justices. He noted that the pensioners had thus far received all of the money due to them and that the outcome of this suit would have no impact on the plaintiffs’ future monthly benefit benefits. If they lost the case, they would still receive the exact same monthly payment. If they won the case, they would not receive any additional benefit payments. The majority went on to dismiss four alternative arguments advanced by the plaintiffs, concluding that they lacked a sufficient stake in the case to have standing to sue.<br /> <br /> First, the plaintiffs argued that a plan fiduciary’s breach of a trust-law duty of prudence or duty of loyalty itself causes harm, even if the plan participants have not and will not suffer any monetary losses. The Court disagreed, noting that this argument would be proper if the plan at issue were a defined-contribution plan or a trust. In a defined-benefit plan, the Court does not recognize a plan participant’s equitable or property interest in the plan. Then, the Court determined that the plaintiffs did not have standing as representatives of the plan itself because they did not suffer an injury in fact.<br /> <br /> Third, the plaintiffs argued that language in ERISA itself grants plan participants a statutory right to sue for breach of fiduciary duty and other equitable relief. In response, the majority noted that a statutory right to sue does not itself satisfy the constitutional standing requirement. Finally, the plaintiffs asserted that if beneficiaries are unable to bring fiduciary breach claims against plan fiduciaries, no one will meaningfully regulate plan fiduciaries. Here, the Court noted that employers have strong incentives to avoid fiduciary misconduct because they are on the hook for plan shortfalls. ERISA authorizes the Department of Labor (“DOL”) to enforce fiduciary obligations, and the Court explained that since the federal government is required by law to pay vested pension benefits of retirees, the DOL has a strong incentive to police plan fiduciaries. Further, certain claims of fiduciary misconduct can be bought directly against individual plan fiduciaries (for example, if using plan assets for personal gain). Justice Kavanaugh sums up oversight of ERISA plan fiduciaries as a “regulatory phalanx.”<a href="#_ftn3" name="_ftnref3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[3]</span></span></span></span></span></a><br /> <br /> Justice Sotomayor wrote a lengthy dissent, joined by Justices Ginsburg, Breyer, and Kagan. For the dissent, there is no meaningful difference in the rights afforded to participants of defined-benefit plans from those of defined-contribution plans or trusts. Without affording plan participants in these cases an equitable interest in the plan, no one would hold that title, leaving about 35 million people with defined-benefit plans vulnerable to fiduciary misconduct in the eyes of the dissent. Justice Sotomayor also found the majority’s argument that a financial injury is necessary to establish standing exceedingly unpersuasive. For example, the Supreme Court has long recognized that a breach of fiduciary duty claim exists regardless of the beneficiary’s personal gain or loss. It is for this reason, the dissent observes, that the majority declares that this case has no bearing on those alleging failure to provide plan information (which would support standing). The majority did not persuade the dissenting justices that a beneficiary’s noneconomic right to loyalty and prudence from fiduciaries is meaningfully different.<br /> <br /> The dissent also presents two arguments for standing based in contract law. First, they observe that the Plan Document itself confers upon the beneficiaries an equitable stake in the financial integrity of the plan. Second, they cite to the majority’s claim that the plaintiffs have a contractual right to receive monthly payments for life and note that a breach of contract always creates a right of action, even when no financial harm was caused. Essentially, the dissent recognizes an equitable interest based in trust law for defined-benefit plans while the majority views beneficiaries’ rights under these arrangements as largely contractual.<br /> <br /> Since the <u>Thole</u> decision, over one hundred cases have cited to its holding. Out of those, at least three cases involved health and welfare benefit plans and claims of health plan mismanagement. They were all dismissed by courts for lack of standing. At first glance, this should seem unusual because unlike pension plans, self-funded health plans are not defined-benefit plans. The Court’s ruling in <u>Thole</u> did not contemplate health and welfare benefit plans. If anything, self-funded health plans are most like defined-contribution plans since the “benefit” received is not defined and the contribution, the amount contributed by a plan participant to the plan, is typically defined.<br /> <br /> Nevertheless, the strategy being utilized by attorneys representing self-funded plans is to analogize the facts of their cases with <u>Thole</u>. In particular, they assert that the alleged fiduciary misconduct never had or will have a material impact on the benefits due to plan participants. In <u>De Fuente v. Preferred Home Care of N.Y. LLC</u>, the plaintiffs were home health aides enrolled in a self-funded health plan.<a href="#_ftn4" name="_ftnref4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[4]</span></span></span></span></span></a> The plan was part of a captive arrangement in which the employer paid premiums to the captive insurer, which then used the premium to establish a reserve to pay covered medical claims. The plaintiffs alleged the employer breached its fiduciary duties and engaged in prohibited transactions under ERISA by receiving profits and excess premiums from the captive insurer. The district court found that the plaintiffs, like those in <u>Thole</u>, had received all of the benefits to which they were entitled and winning or losing would not increase their health benefits. As such, the district court found that the plaintiffs lacked standing to sue.<br /> <br /> In <u>Crosby v. Cal. Physicians’ Serv.</u>, the plaintiffs alleged that their health plan improperly considered age and therapy history in medical necessity determinations for children with autism. The district court cited <u>Thole</u>, noting that the plaintiffs had received all of the benefits due to them, and that the plaintiffs must show they have been injured beyond their need to pursue administrative appeals. In the district court’s view, they did not, and the case was dismissed for lack of standing.<a href="#_ftn5" name="_ftnref5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[5]</span></span></span></span></span></a> Finally, in <u>Bryant v. Wal-Mart Stores, Inc.</u>, the plaintiff brought suit against Wal-Mart’s health plan for alleged failure to provide timely COBRA notices. The district court, however, found that the plaintiff was not injured by a lapse in coverage, and cited to <u>Thole</u> when it dismissed for lack of standing.<a href="#_ftn6" name="_ftnref6" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[6]</span></span></span></span></span></a><br /> <br /> Taken together, these cases, with their reliance on the holding in <u>Thole</u>, reveal that the Supreme Court has paved the way to limit suits against health plan fiduciaries alleging mismanagement of plan assets. It will now be much more difficult for plan participants to satisfy the constitutional standing requirement in ERISA cases where they are alleging breach of ERISA’s duties of loyalty and prudence by poorly investing or utilizing plan assets. The Court made clear that in such cases, the plaintiff would have to show that they received fewer benefits due to them, or will receive fewer benefits due to them, as a result of the alleged fiduciary breach.<br /> <br /> One unanswered question in the <u>Thole</u> case involves extreme situations. The majority left open the question of whether a plaintiff would have standing to sue when “the mismanagement of the plan was so egregious that it substantially increased the risk that the plan and the employer would fail and be unable to pay the participants’ future pension benefits.”<a href="#_ftn7" name="_ftnref7" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[7]</span></span></span></span></span></a> In today’s economy, given the volatility of the post-pandemic market and risky investment opportunities such as cryptocurrency, I would caution plan fiduciaries to continue to handle plan assets with the skill and prudence which is typical in our industry.</span></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 style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[1]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>Thole v. U.S. Bank N.A.</u>, 140 S. Ct. 1615 (2020).</span></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 style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[2]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>Lujan v. Defenders of Wildlife</u>, 504 U. S. 555, 560-561 (1992).</span></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 style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[3]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>Thole</u>, at 1621.</span></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 style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[4]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>De Fuente v. Preferred Home Care of N.Y. LLC</u>, 2020 U.S. Dist. LEXIS 187681, at *1 (E.D.N.Y. Oct. 9, 2020).</span></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 style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[5]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>Crosby v. Cal. Physicians’ Serv.</u>, 2020 U.S. Dist. LEXIS 210654, at *1 (C.D. Cal. Nov. 2, 2020)</span></span></span></p> </div> <div id="ftn6"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref6" name="_ftn6" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[6]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>Bryant v. Wal-Mart Stores, Inc.</u>, 2020 U.S. Dist. LEXIS 125266, at *10 (S.D. Fla. July 15, 2020)</span></span></span></p> </div> <div id="ftn7"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref7" name="_ftn7" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-family:"Times New Roman",serif"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">[7]</span></span></span></span></span></span></a><span style="font-family:"Times New Roman",serif"> <u>Thole</u>, at 1621-1622.</span></span></span></p> </div> </div> </div> 1078