Phia GroupPhia Group Mediahttps://www.phiagroup.com/Media/PostsEmpowering Plans: P185 – Weighing the Optionshttps://www.phiagroup.com/Media/Posts/PostId/1318/empowering-plans-p185-weighing-the-optionsPodcastsThu, 14 Mar 2024 17:51:40 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/pjE_-C_W3RU?si=aL4aDJGDAum1O2F_" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span arial="" style="font-family:">Over the last twelve months we have seen major interest in GLP-1s  (Semaglutide- Ozempic / Wegovy and Tirzepatide – Mounjaro / Zepbound). Although GLP-1s have been around for years as a treatment for diabetes, the recent popularity is due to their use as a weight loss drug. Join Ron Peck and Corey Crigger as they discuss the impact this surge in demand has had on health plans and consumers. Are health plans and consumers informed about the benefits and drawbacks of this drug?  Are consumers too focused on the benefits? Are health plans too focused on cost? Find out as Ron and Corey discuss one of the hottest topics in the industry. </span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="margin: 0in; text-align: justify;"> </p> <p><span style="color:#000000;"></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span arial="" style="font-family:"><a href="https://youtu.be/pjE_-C_W3RU">Click here to check out the podcast!</a> (Make sure you subscribe to our <a href="https://youtu.be/pjE_-C_W3RU">YouTube</a> and <a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline">Apple Podcasts</a> Channels!)</span></span></span></span></p> <p style="margin: 0in; text-align: justify;"> </p> 1318The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Planshttps://www.phiagroup.com/Media/Posts/PostId/1317/the-indirect-but-significant-impact-of-a-recent-massive-healthcare-breach-on-benefit-plansBlog,Health InsuranceMon, 11 Mar 2024 19:06:24 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Andrew Silverio, Esq. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”  </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">At stake were over 14 billion yearly transactions and this attack has seriously disrupted provider billing, interfering with patient care, and even preventing some providers from paying their employees. On top of that, a massive amount of patient information, protected under HIPAA, has been compromised. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Most of the focus among news outlets has been on the impact to providers, which is of course enormous. Those using the affected claim systems have essentially no way to be paid for their services, and many have seen cash flow come to a prompt and complete halt. The government has advised Medicare plans and related entities to relax prior authorization and timely filing requirements and the entity involved has announced a program to actually offer loans to affected providers.  However, those of us in self-funding know that it’s no simple matter to simply waive requirements like prior authorization and timely filing limits, and we have heard no word from stop-loss carriers on what action it will take if plans provide some allowances to safeguard patient care.  Plans are still able to enforce timely filing limits and other plan terms, but most don’t want to leave patients in the lurch with unpaid claims due to system disruptions entirely outside their control.  A plan that chooses to accept a late claim or waive a preauthorization requirement will be at real risk, since the stop-loss carrier is always free to enforce the terms of the plan, and its own policy, strictly and as-written.  </span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The industry is still scrambling to get the system “working” again and establish something resembling a normal claim submission pipeline and cash flow.  But once the dust settles, we would expect in the coming months to see some regulatory relief for plans and providers alike, to account for concessions and audibles that had to be made to keep the ship afloat. Looking ahead, hopefully precautionary systemic measures can be taken to account for future incidents. After all, healthcare and technology promise to be forever intertwined and there’s no telling when the next cybersecurity breach will rock the industry as it did last month. </span></span></span></span></p> 1317Empowering Plans: P184 – State of the Union, 2024https://www.phiagroup.com/Media/Posts/PostId/1316/empowering-plans-p184-state-of-the-union-2024PodcastsFri, 08 Mar 2024 18:16:40 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/TIadlrwCGp4?si=JlILNcL2Mo8D9xrt" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="color:#000000;">In his third State of the Union address, President Biden touted his administration’s record and outlined the issues he and his team will likely be campaigning on heavily as the 2024 presidential race kicks off in earnest. Sprinkled throughout were a number of policy wish list items, including some key healthcare initiatives that we’ll be keeping a close eye on in the coming months. Attorneys Brady Bizarro and Nick Bonds bring you some of the highlights in this episode of the Empowering Plans podcast.  </span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span aptos=""></span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span aptos=""><a href="https://youtu.be/TIadlrwCGp4">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://youtu.be/TIadlrwCGp4">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1316How the Recent Industry Cyberattack Impacts Youhttps://www.phiagroup.com/Media/Posts/PostId/1315/how-the-recent-industry-cyberattack-impacts-youBlog,Health Insurance,HIPAAThu, 07 Mar 2024 15:09:26 GMT<p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Late last month, an apparent massive cybersecurity incident involving the potential theft of patient data – this could entail personally identifiable information, sensitive health information, and financial information -- and encrypted company files seemingly paralyzed one of the nation’s largest pipelines for healthcare payments and prior authorization processing. Impacting a substantial percent of Americans’ medical claims (billions of claims totaling over a trillion dollars per year), millions have been affected. But perhaps the worst part is that many don’t even know it – and won’t be aware until they need to visit their physician or refill a prescription and face new hurdles in getting their customary treatment. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Just this week, The Washington Post published stories of patients getting billed hundreds of dollars for prescriptions that had normally been fully covered by insurance. Meanwhile, others cannot get their prescriptions filled at all no matter how much they are willing to pay and still others have found that discount coupons are no longer effective (this can literally save a person hundreds of dollars per month on a given prescription). For Americans living on airtight budgets, which is certainly a great number of our fellow countrymen, they’ve had to forego taking medications for an untold number of physical and psychiatric conditions. While it’s by no means a long-term fix, some physicians have provided their patients with sample packs of pills or offered more affordable replacement prescriptions for those needing to pay out of pocket. But we all know this band-aid solution will only go so far. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As this horrific situation has been playing out across pharmacies throughout our country, physicians in both massive hospital networks and small clinics are struggling to obtain prior authorization for exams, medications, and procedures; subsequently, many patients have faced significant delays in receiving life-altering and/or life-prolonging medical care. Such delays have also been exacerbated by the unfortunate reality that some hospitals and medical providers have not received payments and thus lack the wherewithal to keep their employees. As it is, many medical practices throughout America do not carry significant cash reserves and entirely depend on healthy cash flow to execute claim submission and payment on a timely basis as well as keep up with payroll. For facilities that administer the most expensive services (i.e., chemotherapy and other forms of cancer drugs), burning through cash reserves can mean being unable to treat patients in dire need.  </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Simply put, the residual effects of this historically monumental data breach are endless – and, for many of the most vulnerable Americans who are already living on the margins of society, there appears to be no end in sight to physicians and hospitals not receiving adequate funding from private insurers, Medicare, and Medicaid. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As Molly Fulton, the chief operating officer of Arlington Urgent Care, a chain of urgent care centers around Columbus, Ohio, that’s currently carrying over $650,000 in unpaid insurance reimbursements, told the New York Times, “This is worse than when Covid hit because even though we didn’t get paid for a while then either, at least we knew there was going to be a fix. Here, there is just no end in sight.”</span></span></span></span></span></span></p> 1315Empowering Plans: P183 – The Therapeutic Equivalence Approach: A New “Pill”ar of Contraceptive Coveragehttps://www.phiagroup.com/Media/Posts/PostId/1314/empowering-plans-p183-the-therapeutic-equivalence-approach-a-new-pillar-of-contraceptive-coveragePodcastsThu, 29 Feb 2024 20:12:15 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yol0L4GWzN4?si=PbnGwcB6l784-ybp" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""><span calibri=""><span style="color:#000000;">The DOL recently issued new guidance on the long-standing contraceptive coverage mandate, and this time they took a different approach. Instead of clarifying prior guidance or issuing novel interpretations of the law, the DOL is giving health plans an alternative way to comply with the contraceptive coverage mandate: either follow the prior guidance issued in 2022… or don’t! The DOL introduced the “therapeutic equivalence” approach, whereby plans can comply with the law in a different, potentially less-burdensome way. Join The Phia Group’s Kendall Jackson and Jon Jablon as they discuss this “therapeutic equivalence” approach to compliance, what it means for consumers, and what it means for health plans.</span></span></span><br /> <span aptos=""><br /> <a href="https://youtu.be/yol0L4GWzN4">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://youtu.be/yol0L4GWzN4">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-size:11.0pt"><span calibri="" style="font-family:"></span></span></span></span></p> 1314Millions Saying Good-Bye to Medicaidhttps://www.phiagroup.com/Media/Posts/PostId/1313/millions-saying-good-bye-to-medicaidBlog,MedicaidThu, 22 Feb 2024 20:02:29 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">That millions of Americans have been losing Medicaid coverage over the past year may be unsurprising, but it doesn’t make it any less heartbreaking. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Some historical context: Normally, Medicaid recipients who receive federally funded health insurance due to disabilities or low incomes undergo eligibility reviews every year to see if they are eligible for renewed coverage. But, of course, March 2020 was far from a normal time and the feds froze the checks due to it being a public health emergency. Subsequently, Medicaid recipients would retain their enrollment for the following three years . . . until this past spring when President Biden terminated the public health emergency and an “unwinding” process soon ensued whereby millions have thus far been disenrolled from Medicaid. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">According to KFF, the renowned non-profit organization that bills itself as an independent source for health policy research, polling, and journalism, <span style="background:white">as of December 20, 2023, over thirteen million Americans had been taken off Medicaid since the spring.</span> Texas, perhaps understandably given its mammoth size, has been at the epicenter of this gargantuan development. Since the COVID-era coverage protections were stripped last spring, over two million Texans have been cut off from their state’s Medicaid program. For reference, Houston, Texas’ largest city population-wise, has 2.3 million residents. It also should be noted that Texas hasn’t finished assessing eligibility information for all Medicaid enrollees, meaning more residents will likely forfeit coverage. Nationwide, an untold number of Medicaid beneficiaries will be receiving such disheartening notifications through May, after which the pre-pandemic status quo is slated to resume.  </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">While there is not exactly a universal way to categorize the tens of millions who receive Medicare funds, some common profiles include: </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">--Single parents working multiple low-paying jobs while struggling to stay above the Federal Poverty Level </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">--Parents with children who have serious, perhaps even terminal, illnesses that require incredibly expensive, drawn-out treatment</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">--Americans who may be unable to work in a full or part-time capacity due to incurring sudden debilitating injuries </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The harsh reality is that for many of these Medicare recipients who lack robust employer-sponsored health benefits, being denied coverage – even for just a few weeks – can represent a life-or-death scenario (i.e., no longer having access to chemotherapy, radiation, and/or round-the-clock medical care.)</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In fairness, Texas officials have been responsive to outreach efforts on behalf of the Center for Medicaid and Children’s Health Insurance Program Services (CHIP) as they convened to review Texas’ eligibility evaluation procedures and examine cases of state residents becoming disenrolled. Ultimately, Texas reinstated over 90,000 people who were deemed falsely disenrolled from Medicaid. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In a statement to NBC News, the <span style="background:white">Texas Health and Human Services Commission said it “planned this massive unwinding effort for more than a year,” and that if issues surfaced, the commission “works systematically to resolve any issues and reinstate recipients’ coverage if necessary.” And even for those who do not get coverage reinstated, it’s not Medicaid or nothing – there is also potential to </span><span style="background:white">qualify for no or low-cost premiums in the health insurance marketplace</span><span style="background:white"> or obtain coverage from a new employer. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Also in fairness, for virtually every single American alive, this decade’s pandemic was an unprecedented time in our country’s history with many systems, including Medicaid, being thrown out of whack. From spring 2020 to spring 2023, Medicaid enrollment spiked to historic highs (as in over ninety-seven million Americans) – a situation that may very well have been unsustainable going forward. This spring, meanwhile, state agencies will have their hands full playing catch-up in examining cases to determine who should and should not retain Medicaid coverage. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">On another level, this historic purge of Medicaid recipients has exposed longstanding administrative and technical problems in the systemic framework that covers the most vulnerable Americans. As New York Medicaid director Amir Bassiri recently told a national board of Medicaid advisers: “It would be a failure if we come out of this with the same old standards and processes we had in place prior to the public health emergency.” These antiquated standards and processes very well prevent many from enrolling (and re-enrolling) in Medicaid in the first place. </span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">For now, such shortcomings – not to mention persistent staffing challenges -- are also making it significantly harder for states to redetermine who is Medicaid eligible. </span></span></span></span></p> 1313The Skinny on Weight Loss Drugshttps://www.phiagroup.com/Media/Posts/PostId/1312/the-skinny-on-weight-loss-drugsWebinarsWed, 21 Feb 2024 16:05:50 GMT<p style="text-align:justify; margin:0in 0in 10pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="" style="font-family:">From Contrave to Saxenda to Wegovy and beyond, society is being bombarded with messaging about weight loss drugs.  While many publicly debate their efficacy and long term viability, far fewer are openly asking who will pay for them – and how.  For those of us that sponsor and service health benefit plans, the costs arising from this trend are very real.  While we want to help people lose weight, get fit, and improve their overall health – the best way to approach this matter is still uncertain.  Join The Phia Group for another free webinar!  Our team will discuss this very relevant topic, including related issues such as off-label drug usage, international drug importation, defining medical necessity, plan drafting and exclusions.  Likewise, the importance of educating plan membership about the costs of healthcare, and what it means to be self-funded.   </span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 10pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 10pt"><a href="https://attendee.gotowebinar.com/recording/4261639336946821292"><span style="color:#0071ce;"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="">Click Here to View Our Full Webinar</span></span></span></span></a></p> <p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="" style="font-family:"><span style="color:#000000;">To obtain a copy of our webinar slides, please reach out to</span> <a href="mailto:mpainten@phiagroup.com" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> 1312Empowering Plans: P182 – Navigating Post-Settlement Fund Pursuitshttps://www.phiagroup.com/Media/Posts/PostId/1311/empowering-plans-p182-navigating-post-settlement-fund-pursuitsPodcastsThu, 15 Feb 2024 21:11:27 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/fRX_QUf4ox8?si=Q7yOlslKZpT6jHk5" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;"> <span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""> Attorneys Andrew Silverio and Cindy Merrell discuss a newly decided case which provides a roadmap for pursuing settlement funds after disbursement. Who has the burden of proof when the funds have been dissipated? What is lowest intermediate balance rule? </span></span></span></span><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""><a href="https://youtu.be/fRX_QUf4ox8">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://youtu.be/fRX_QUf4ox8">YouTube </a><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1311Welcome to the Subrogation Spherehttps://www.phiagroup.com/Media/Posts/PostId/1310/welcome-to-the-subrogation-sphereBlog,Health Insurance,Healthcare Costs,SubrogationFri, 09 Feb 2024 14:43:40 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">By: Cindy Merrell, Esq. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The Subrogation Sphere Is a Place Where Opponents Become Allies  </span></span></b></span></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Las Vegas does not have the only sphere that can provide an extraordinary experience for its participants. Let me introduce you to the subrogation sphere where participants may first appear to have conflicting interests but can become allies. When a health plan member is injured because of a third-party action it sets into motion a dance involving many players, potentially including the plan participant, at-fault party, medical providers, stop loss carrier, and the health plan. Each player is trying to determine which player is the proper payor of the plan participant’s medical expenses. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The Alliance Begins </span></span></b></span></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">My primary duty as a subrogation attorney is to identify the proper payor of the health plan participant’s medical expenses. To successfully perform my job, I have regular contact with attorneys for both stop loss carriers, facilities, and plan participants’ attorneys. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Just the other week, one of our third-party administrator clients reached out to us because they were having difficulty getting a group’s stop loss carrier to process a $500,000.00 trauma bill. When we took a deep dive into the facts, we found out the member had been involved in a motor vehicle wreck caused by a third party. In this case, the auto policy limits were minimal. The hospital lien and health plan reimbursement amount far exceeded the available auto policy limits. Given the size of the trauma bill, the hospital retained an attorney to pursue their interest. The injured plan participant retained an attorney. The general counsel for the stop loss carrier was involved and The Phia Group was pursuing the subrogation/reimbursement interest on behalf of the health plan. Everyone was at a stalemate. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">I knew that no one could “win” on this case. The plan participant was stressing over the $500,000.00 unpaid trauma bill. The self-funded health plan employer group was stressing over the same bill, not only because their valued employee was stressed and injured, but because this large of a claim without the stop loss reimbursement could be financially catastrophic to the health plan. The plan participant’s attorney could not resolve the plan participant’s claim against the auto carrier given the size of the provider lien and the health plan’s reimbursement interest. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">No One Wins, but Everyone Wins</span></span></b></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">When I talked to the plan participant’s attorney, I could hear the desperation in his voice as he simply did not know what to do. His client who had suffered a catastrophic injury was more worried about the large trauma bill than his own recovery. I asked the plan participant’s attorney if his client would consider entering into a pre-settlement agreement in which the health plan and the plan participant could both get at least some portion of the minimal limits. After the plan participant agreed to my proposal, I had to get the stop loss carrier on board. I quickly realized the stop loss carrier simply did not have all the facts and I was able to provide the missing information and get the trauma bill processed. Once the trauma bill was processed and paid, the hospital lien was withdrawn. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Why Does the Alliance Matter? </span></span></b></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The subrogation sphere can provide a meaningful impact for many people. In my example, the plan participant did not face the financial hardship of a $500,000.00 trauma bill. The hospital that provided the medical care received compensation for the services it provided. Finally, the health plan could remain self-funded. The health plan’s self-funded status allows its employees and their dependents to have comprehensive health care with lower premiums.</span></span></span></span></p> 1310Empowering Plans: P181 – Chevron Deference in Peril – What It Could Mean for Healthcare Regulationshttps://www.phiagroup.com/Media/Posts/PostId/1309/empowering-plans-p181-chevron-deference-in-peril-what-it-could-mean-for-healthcare-regulationsPodcastsThu, 01 Feb 2024 20:24:33 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/6CTWtTQNv1E?si=YLXHenv_4tukQhkj" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-size:11.0pt">In this episode of the Empowering Plans podcast, attorneys Brady Bizarro and Brian O’Hara discuss the legal doctrine involved in two cases now before the Supreme Court – <u>Chevron</u> deference. They’ll explain what it means, why it is important for federal agency action, and how it impacts the entire healthcare industry. With a decision expected by this summer, you do not want to miss our take on how the NSA, the Medicare drug price negotiations, and the ACA itself could be at stake.</span></span></span><br /> <span style="font-size:11.0pt"><span aptos="" style="font-family:"><br /> <a href="https://www.youtube.com/watch?v=6CTWtTQNv1E">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=6CTWtTQNv1E">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></p> 1309Are Measles Making a Comeback?https://www.phiagroup.com/Media/Posts/PostId/1308/are-measles-making-a-comebackBlog,Health Insurance,Healthcare CostsWed, 31 Jan 2024 14:52:22 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">When Dr. Michael Osterholm speaks, people listen – even if many do so begrudgingly. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">The ever-serious epidemiologist out of Minnesota, who forewarned of a global pandemic years ago and has garnered the not-so-flattering nickname “Bad News Mike,” has a new dire message about the recent measles outbreak, one to which children are most susceptible, that has started to trickle through pockets of Europe and, more recently, the US:</span></span></span></span></span></span></span></p> <p class="gntarbp" style="margin: 10.5pt 0in; text-align: justify;"><span style="font-size:12pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="color:black">“We're going to start seeing more and more of these outbreaks,” Osterholm told <i>USA TODAY</i> last month. “We're going to see more kids seriously ill, hospitalized and even die. And what's so tragic about this, these are all preventable.”</span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">In late January, the World Health Organization (WHO) reported that measles cases spiked more than 40-fold in 2023 compared with 2022. Approximately 30 percent of those cases were in Kazakhstan, where there is an exceptionally high number of children who aren’t vaccinated. In England, there were 250 confirmed measles cases, most impacting children younger than ten. Although last year in the US, the number of measles cases reported was lower compared to most pre-COVID years, there have been ominous signs of trouble: Philadelphia has thus far recorded nine cases of measles, Washington State has identified three cases and investigated three others, while several other states have been tracing contacts of a single case. From a global perspective, 49 countries are experiencing what the WHO calls “large or disruptive outbreaks.”</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">As Osterholms noted, an uptick in severe illnesses, hospitalizations, and even deaths will follow. Per the Centers for Disease Control and Prevention (CDC), approximately a fifth of those who contract measles will be hospitalized due to a range of issues including uncontrollable diarrhea, dehydration, fever, conjunctivitis, skin rash, pneumonia triggering long-term respiratory issues, and possibly even brain inflammation sparking neurological issues. More alarmingly, it is estimated that out of every thousand children who come down with measles, one to three will inevitably die. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">But, most maddeningly, as Osterholm also referenced, the vast majority of recent measles cases, which are incredibly contagious as the virus can drift in the air for a couple hours, could have been prevented. A single dose of the measles vaccine is 93 percent effective at stopping the virus, according to the CDC. For that reason alone, nearly every single parent alive has their children vaccinated (in the US, the measles vaccine is given twice, at 12-15 months old and then again at 4-6 years of age); but there’s always a small minority that doesn’t – and that is precisely what appears to be the root cause of the current problem. Generally speaking, for measles to remain in check, at least 95 percent of a given population needs to be immunized; in Europe, the percentage of people who had received a first dose dipped from 96 percent in 2019 to 93 percent in 2022. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">“We actually knew this was going to happen, so it’s not news for us,” Dr. Natasha Crowcroft told the <i>New York Times</i> in regard to Europe’s current rise in measles cases. “There are times when there’s absolutely no pleasure in being right, and this is one of those.” </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">In terms of the aforementioned stateside cases, <span style="background:white">most unsurprisingly involved young children and adolescents who didn’t receive the measles, mumps and rubella (MMR) vaccine, despite being eligible. (Undoubtedly, </span><span style="background:#fcfcfc">measles is far from the only vaccine-preventable disease that looms as a major public health threat; other such diseases include polio, mumps, diphtheria, tetanus, whooping cough, and hepatitis B.)</span><span style="background:white"> But it is important to note that the rising number of unvaccinated children may not solely be attributed to an increasing body of parents reluctant to comply with vaccine recommendations for their children – a problem that only becomes magnified when their children have returned from international travel. Another chief culprit may be the larger, socioeconomic force in play: the unfortunate reality that broad swaths of the American population, naturally those uninsured and living below the Federal Poverty Level, (never mind millions living in impoverished communities around the globe) simply don’t have access to proper healthcare, a dynamic more broadly known as health inequity. Even more so, it has been well documented that childhood vaccination rates have been on the decline in America since the onset of COVID, further broadening pre-existing gaps in vaccine participation. </span></span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">This unjust situation speaks to many issues, not least of which is that health insurance remains prohibitively expensive for many Americans who are unemployed, self-employed, employed by companies that provide substandard coverage, or ineligible for Medicare and/or Medicaid. While immunizations, including those for measles, are considered preventive care and thus covered without cost-sharing under private health plans, millions of tax-paying Americans remain without adequate access to such plans. When will that change for the betterment of society?</span></span></span></span></span></p> 1308Empowering Plans: P180 – The Continuing Evolution of MHPAEAhttps://www.phiagroup.com/Media/Posts/PostId/1307/empowering-plans-p180-the-continuing-evolution-of-mhpaeaPodcastsThu, 18 Jan 2024 15:45:30 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/jcruONvPkxk?si=LL_VB5k3ZPnE_9_F" title="YouTube video player" width="560"></iframe></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 aptos="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:">One might think they’re listening to a broken record when hearing Jennifer McCormick and Kelly Dempsey discuss the ever-shifting landscape of the Mental Health Parity and Addiction Equity Act (MHPAEA), but alas, this is a brand new podcast! As we start 2024, we are reframing our mindset and are making some changes to address the evolving MHPAEA regulations and insights we have received from regulating bodies through the NQTL Comparative Analysis Process. In addition to highlighting the significance of how these issues should be addressed within an employer’s PD/SPD, there are three main changes discussed to create visibility for employers creating new 2024 PD/SPDs.</span></span></span></span></span></span></span></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=jcruONvPkxk"><span style="color:#0071ce">Click here to check out the podcast!</span></a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=jcruONvPkxk"><span style="color:#0071ce;">YouTube</span></a><span style="color:#0071ce;"> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1307A New Year Brings New (Higher) Prescription Drug Priceshttps://www.phiagroup.com/Media/Posts/PostId/1306/a-new-year-brings-new-higher-prescription-drug-pricesBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 18 Jan 2024 15:32:49 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">It must be January. W-2 forms are hitting the mail. Fitness centers are packed to the brim. The NFL playoffs are in full force. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">And, yes, pharmaceutical companies are hiking prices on their drugs. This time of year,<span style="background:white"><span style="color:black"><span style="letter-spacing:.3pt"> when insurance plans turnover,</span></span></span> Big Pharma unveils its list of new (aka elevated) prices for drugs, which, particularly concerning newly launched ones, sparks sticker shock for consumers. Certainly, January 2024 does not appear to be an exception to this unpleasant trend. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">On December 29 -- as many were making last-minute New Year’s Eve plans – the unsettling news dropped: globally recognized drugmakers, including Pfizer, Sanofi, and Takeda Pharmaceutical (all multibillion-dollar, publicly traded companies), were gearing up for price hikes on <i>over 500</i> drugs, including over 140 different brands of drugs. For the second consecutive year, Pfizer declared the most price hikes in January as the New York-based drugmaker is responsible for more than a quarter of all the drugs with anticipated price hikes. Meanwhile, Takeda-owned Baxalta released the second-highest number of price increases, with 53 hikes planned thus far, and Sanofi plans to elevate prices on its typhoid fever, rabies and yellow fever vaccines each by 9% this month. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Why the markup for an exceptionally large number of medications this year? The expected culprits – lingering high inflation and supply chain backups, largely stemming from a drawn-out Middle East Conflict – account for some, but certainly not all, of the issues. At this moment in time, there are also notable political forces at play, namely Big Pharma bracing for the profound impact of healthcare cost reduction measures in President Biden’s <span style="background:white"><span style="color:black">Inflation Reduction Act (IRA) coming into effect. (This past August, the U.S. Department of Health and Human Services (HHS) publicly released the first ten drugs covered under Medicare Part D for negotiation; the negotiated prices will become effective beginning in 2026.) Not to oversimplify the matter, but Big Pharma is essentially anticipating lost revenue in the not-so-distant future and it feels it needs to compensate for the shortfall somehow, hence the hefty volume of upticks this month. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In other words, in the coming weeks, millions of Americans, many of whom are of advanced age and living below the federal poverty level, will be walking up to their local pharmacy counter to pay for their respective medications and learn that their co-pays and/or out-of-pocket expenses have gone up at least moderately, and in some cases, dramatically. And they will be faced with the gut-wrenching decision: do they fork over the extra cash for life-altering or even life-prolonging medications at the expense of cutting back on groceries and turning off the heat in single-digit temperatures? </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Of course, this conundrum does not only apply to January as throughout the calendar year, Americans grapple with such dilemmas. But it’s certainly a problem that becomes particularly acute this time of year – one that already presents considerable challenges to many people’s physical and mental health. </span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">While geopolitical events and policy decisions may be uncontrollable and unpredictable, there are cost containment techniques that employer-sponsored health plans can employ to alleviate said burden on their respective participants. There are, in fact, viable methods for lowering prescription drug costs even when the titans of the pharma industry inflate their prices. Certainly, prescription (and overall healthcare) cost containment programs are not necessarily easy to execute. They require ingenuity, extensive data benchmarking, and widespread participant engagement. But they do represent one effective means for countering what continues to be a dreaded January tradition: a surge in prescription drug prices across the board.</span></span></span></p> 1306Considerations Regarding the Exclusion of Gender-Affirming Carehttps://www.phiagroup.com/Media/Posts/PostId/1305/considerations-regarding-the-exclusion-of-gender-affirming-careBlog,Health Insurance,Healthcare Costs,PlanTue, 16 Jan 2024 20:33:52 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Kendall Jackson, Esq. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Gender-affirming care was a particularly popular topic throughout 2023. As we enter the new year, the prevalent discussion concerning plan coverage of such care will certainly continue. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">For self-funded health plans, the decision of whether to cover or exclude gender-affirming care is quite multilayered. Specifically for plans that exclude gender-affirming care within their plan documents, there are several potential discrimination concerns. An important element when evaluating these concerns is what law applies to the plan. For instance, certain state laws may not apply to a self-funded plan governed by the Employee Retirement Income Security Act (ERISA) due to ERISA preemption. ERISA preemption operates to preempt state insurance laws as they relate to employee benefit plans. Accordingly, any state laws that may require coverage or ban coverage for gender-affirming care would not apply to an ERISA plan. This is noteworthy as ERISA affords an employer the broad discretion to construct and design the coverage and benefits for its employees. As there is no federal requirement for plans to cover gender-affirming care, an ERISA plan may choose to cover or exclude benefits for gender-affirming care. Alternatively, non-ERISA plans, such as self-funded church plans or non-federal governmental plans, have slightly less flexibility and must adhere to both state and federal law. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Federal protections against discrimination have been, and will continue to be, integral to filling the gaps in health coverage for marginalized groups. Consequently, the potential compliance concerns outlined below apply particularly to plans that elect to exclude gender-affirming care. The first consideration is whether the plan is subject to Section 1557 of the Affordable Care Act (ACA), which hinges on whether the plan sponsor receives any federal financial assistance through the Department of Health and Human Services (HHS). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability. HHS provided guidance in a notice in March 2022 that clarified the extent of Section 1557’s protections.<a href="#_ftn1" name="_ftnref1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS opined that Section 1557’s protection against sex discrimination encompassed an individual’s right to access health programs that are free from discrimination based on gender identity. HHS stated that a plan categorically excluding benefits due to an individual’s gender identity was discrimination and prohibited by Section 1557. At the time, this guidance had a significant impact because if a plan was subject to Section 1557, generally, any exclusion of benefits or services related to, for example, transgender care, would be deemed a categorical exclusion and would be prohibited. Although HHS’s viewpoint was contested, nevertheless, it demonstrates the movement to protect against the exclusion of benefits based on gender identity. Accordingly, to avoid allegations of discrimination, self-funded plans subject to Section 1557 should consider removing gender-affirming care exclusions.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:105%"><span style="font-family:"Calibri",sans-serif">Even if a plan is not subject to ACA Section 1557, there are still significant discrimination concerns for plans with gender-affirming care exclusions if they create a disparity in coverage for certain individuals. These concerns stem from scrutiny from the Equal Employment Opportunity Commission and the protection against discrimination based on gender identity under Title VII of the Civil Rights Act of 1964. There have been several lawsuits brought forth by transgender individuals under these laws and Section 1557 about gender-affirming care exclusions, and courts have ruled in their favor on some occasions. An example of an exclusion that could create a disparity in coverage is a sex reassignment exclusion. In this case, while it does not exclude care for transgender individuals specifically, it is possible it could be viewed as discriminatory because it functions to categorically exclude services which will overwhelmingly be needed only by transgender individuals. As a result, while self-funded health plans are not mandated to cover gender-affirming care, the compliant approach with regard to all applicable laws would be to remove exclusions for gender-affirming care from the plan. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Pivoting to a different perspective, for self-funded non-ERISA plans subject to state law, there have been many changes surrounding gender-affirming care over the past year. For example, in Texas, on September 1, 2023, a<a name="_Hlk155366211"> law</a> banning gender-affirming care, such as treatments for gender dysphoria, transitioning, and reassignment for minors took effect. The law prohibits health plans from covering services “that are intended to transition a child’s biological sex as determined by the child’s sex organs, chromosomes, and endogenous profiles.”<a href="#_ftn2" name="_ftnref2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> In Ohio, governor Mike DeWine signed an executive order on January 5, 2024, that banned hospitals and ambulatory surgical facilities from performing gender-affirming surgeries on minors.<a href="#_ftn3" name="_ftnref3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> In New Hampshire, the New Hampshire House recently passed a bill that will now be sent to the New Hampshire Senate. This bill proposes to ban gender-affirming procedures for minors.<a href="#_ftn4" name="_ftnref4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> The bill also proposes to prohibit health care workers from referring minors to out-of-state facilities that may perform gender-affirming procedures. These are only a few examples of the recent developments in state legislation that concern gender-affirming care. As of November 2023, 22 states had a law or policy banning gender-affirming care.<a href="#_ftn5" name="_ftnref5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> There will likely be more development in state legislation in the new year and plans subject to state law should be mindful of how these laws and policies may influence their plan structure.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The decision of whether to cover or exclude gender-affirming care is a multilayered matter and will likely depend on the intent of the employer. There are varying considerations depending on the type of plan and applicable law. As the landscape is constantly changing in regard to gender-affirming care laws, it is essential that plans consider plan document compliance, the potential for discrimination allegations, and, if applicable, what is mandated or banned by relevant states. </span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <div>  <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref1" name="_ftn1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and</span></span></p> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif">Patient Privacy, https://www.hhs.gov/sites/default/files/hhs-ocr-notice-and-guidance-gender-affirming-care.pdf</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref2" name="_ftn2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> Senate Bill 14, https://capitol.texas.gov/tlodocs/88R/billtext/html/SB00014I.htm</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref3" name="_ftn3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> Ohio Gov. DeWine signs executive order banning hospitals from gender transition surgeries on minors, https://ohiocapitaljournal.com/2024/01/05/ohio-gov-dewine-signs-executive-order-banning-hospitals-from-gender-transition-surgeries-on-minors/</span></span></p> </div> <div id="ftn4"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref4" name="_ftn4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> House Bill 619, https://gencourt.state.nh.us/bill_status/legacy/bs2016/billText.aspx?sy=2024&id=71&txtFormat=pdf&v=current</span></span></p> </div> <div id="ftn5"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref5" name="_ftn5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> HRC Foundation, https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map</span></span></p> </div> </div> 1305Navigating 2024: The Latest, Most Innovative Plan Design Features & Stop-Loss Policy Updateshttps://www.phiagroup.com/Media/Posts/PostId/1304/navigating-2024-the-latest-most-innovative-plan-design-features-stop-loss-policy-updatesWebinarsTue, 16 Jan 2024 19:31:14 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">In this first webinar of 2024, our crew will provide a rundown of 2024’s biggest plan document and stop-loss updates, including matters about which our team has been asked the most.  Stay ahead of the crowd, and join The Phia Group as we jump into the year with a head start. Together we will resolve lingering problems of the past and equip you with a list of changes to expect and topics you need to monitor in 2024 and beyond.</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><a href="https://attendee.gotowebinar.com/recording/1761038732775148290"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Click Here to View Our Full Webinar</span></span></span></span></span></span></a></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to mpainten@phiagroup.com.</span></span></span></span></span></span></p> 1304The 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> 1303Empowering Plans: P179 – Higher Healthcare Prices (Made From Concentrate)https://www.phiagroup.com/Media/Posts/PostId/1301/empowering-plans-p179-higher-healthcare-prices-made-from-concentratePodcastsThu, 04 Jan 2024 21:07:23 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yxvGmRYSfIs?si=3SRQ2yJrW_cdGSAy" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="color:#000000;">The trend of provider consolidation is primed to pick up pace in 2024, distilling some areas into even more highly concentrated healthcare markets. Ron Peck and Nick Bonds break down how this concentration impacts the costs of healthcare and can drive costs upward for employers and employees alike. With fewer provider options, higher prices, and patients caught in the middle, Ron and Nick outline just a few of their concerns and discuss some of the tools health plans have at their disposal.  </span></span></span></span><br />  </p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><a href="https://youtu.be/yxvGmRYSfIs"><span style="color:#0071ce;"><u><span style="font-size:12.0pt">Click here to check out the podcast!</span></u></span></a><span style="font-size:12.0pt"><span style="color:#000000;"> (Make sure you subscribe to our <a href="https://youtu.be/yxvGmRYSfIs"><u>YouTube</u></a> and</span><span style="color:black"> </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:#000000;">Channels!)</span></span><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></p> 1301Is the Department of Labor Offsetting a Major Problem?https://www.phiagroup.com/Media/Posts/PostId/1300/is-the-department-of-labor-offsetting-a-major-problemBlog,Affordable Care Act,Cost Containment,Health Insurance,Healthcare Costs,Healthcare Exchanges,Hospital BillsWed, 03 Jan 2024 18:05:56 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As if Americans on employer-based health plans didn’t face enough obstacles in trying to obtain reasonably priced healthcare. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The inconvenient truth is that many participants on ERISA self-funded health plans, ones who are often already paying high premiums and deductibles, have unknowingly fallen victim to the ethically questionable – although not technically outlawed -- practice of cross-plan offsetting over the years. In fact, only very recently, as in the past several months, has there been heightened awareness of the adverse effects of cross-plan offsetting on unsuspecting American plan participants. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">First, a quick primer on cross-plan offsetting: </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">There are times when a given health plan erroneously overpays a provider for a service rendered. Perhaps because of a human or AI-induced oversight or timing snafu or minor typo, the plan will pay the full charge when it should have paid the claim based on the (lower) usual and customary or maximum allowable charge, per the plan document. Whatever the source of the erroneous payment might have been, the provider now has the extra funds (this could be thousands of dollars) and, by law, does not have to refund the plan. And they almost never do. It sounds like an inequitable practice, but, as long as the provider did not receive more than the billed charges, it’s entirely legal. Plans have<span style="background:white"><span style="color:#212121"> no legal recourse and are often left with no choice but to close the file. </span></span> </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Naturally, the plan’s respective TPA that administered the claim feels that the provider owes it money. In some cases, said TPA tries to recoup the excess funds by not<i> </i>paying that same provider the full amount due for a plan participant’s claim on <i>another</i> one of its plans. Yes, this is a blatant breach of their fiduciary duties. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">But most importantly, the end result is that the participant on this second plan, through no fault of their own, will see their claim denied by reading a cryptically written note on their explanation of benefits; the TPA is trying to exact revenge on the provider, but it is the hard-working, often cash-strapped participant – one with zero knowledge of the overpayment backstory -- who gets shortchanged by either getting balance billed for the erroneously offset claims or having to pay a hefty out-of-pocket amount for services rendered. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Many TPAs have been engaging in cross-plan offsetting for years, but this past fall, one in particular, EmblemHealth Inc., <span style="background:white"><span style="color:black">a New York-based insurer and TPA of ERISA group health plans,</span></span> was caught red-handed and made an example of for all the world to see. On September 29, the Department of Labor (DOL) <span style="background:white"><span style="color:black">entered into a settlement agreement with EmblemHealth Inc., resolving claims that the company violated its fiduciary duties under federal law by engaging in cross-plan offsetting to recover alleged overpayments. The DOL’s </span></span><span style="background:white"><span style="color:#212121">Employee Benefits Security Administration</span></span><span style="background:white"><span style="color:black"> (EBSA) submitted that Emblem benefitted by wrongfully keeping money from one health plan for a debt owed by another health plan.</span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">So, what were the repercussions for Emblem? Per the terms of the settlement, Emblem pledged to no longer practice cross-plan offsetting and modify its policies, procedures, and practices accordingly no later than January 1, 2024, or as soon as reasonably possible for insured plans prospectively. That the DOL essentially gave Emblem a three-month deadline is noteworthy. Traditionally, the DOL is known for working at a glacial pace in adjudicating matters. But not this time, not when a stern dictum is in order to TPAs across the country: no longer can they get away with committing </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#212121">blatant violations of ERISA by using one plan’s money to take care of another’s debt under the guise of (arbitrarily) denying claims. Meanwhile, regarding </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">retrospective corrective actions dating back to July 16, 2015, Emblem has been mandated to reimburse present and past participants and dependents whose reimbursements were reduced via cross-plan offsetting. Should Emblem not abide by the terms of this agreement, the DOL could very well take the TPA back to court.</span></span></span></span></span> </span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">To be clear, an untold number of other TPAs have long engaged in this practice, some possibly unaware of the legal issues caused by it. Clearly, the DOL has stepped up enforcement here and it will be interesting to see whether cross-plan offsetting continues to be a fairly commonplace practice now that Emblem has been put on notice.</span></span></span></span></span></p> 1300Time’s Up! It’s Gag Clause Attestation Seasonhttps://www.phiagroup.com/Media/Posts/PostId/1299/times-up-its-gag-clause-attestation-seasonBlog,Health Insurance,Healthcare Costs,Third Party AdministratorsTue, 26 Dec 2023 21:54:36 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Andrew Silverio, Esq.<br /> <br /> As the year wraps up and plans and TPAs around the country are scrambling to handle renewals, another challenge looms large in 2023 – the first annual gag clause attestation.  As a reminder, the Consolidated Appropriations Act, 2021 (CAA) prohibits plans from entering into any contracts with providers and certain other entities that contain “gag clauses” – and requires them to attest annually that their contracts are free of them. The first attestation is due at the end of 2023, and it will cover the period of December 27, 2021 through December 31, 2023. The goal of the legislation is transparency, but it has glaring holes – contracts can’t prohibit plans from sharing certain information with other entities, but nothing requires them to be granted access to this information in the first place.<br /> <br /> While payers have technically been on notice of this requirement since the CAA passed, we all know how things get put off, and we saw a furious uptick of questions and activity surrounding this requirement in the second half of 2023. Unfortunately, it’s because of the nature of how the industry and its contracts have developed over the years that it’s more likely to find gag clauses than not to – especially in network and pharmacy benefit agreements.  Unfortunately, many plans have been put in an unfortunate position by many big players – we won’t name names – who have simply issued broad statements that their contracts do not contain gag clauses (statements that are often proven false with a simple review of the actual agreements) and refused to entertain changes or even sometimes let plans review the contracts directly.  Plans in this situation face a difficult choice: submit an attestation knowing that these representations are questionable at best and that the compliance obligation ultimately falls on them, or fail to submit the attestation, risking whatever enforcement action might follow.  It’s not entirely clear how enforcement will play out, but penalties for failure to attest <i>could</i> come in the form of the $100 per day excise tax under ERISA or excise tax via the IRS.<br /> <br /> Given the widespread confusion, disagreement, and outright disregard of this requirement, it’s also not clear how much effort will go into enforcement and auditing plans for compliance.  We’ve been approached by countless clients inquiring about whispers and rumors of an enforcement delay.  Everyone has heard from someone who heard from someone that enforcement will be delayed - however we’ve seen no indication from any official source that any relief is coming.  At this point it’s safe to say relief in the form of delays or waivers, if it happens at all, won’t be coming in 2023.  So at this point, all plans can do is the best they can to get their existing agreements in order, submit the required attestation, and be on the lookout for gag clauses in any new contracts moving forward.</span></span></span></p> 1299For Sickle Cell Disease Patients, Hope Has Arrived – but at What Cost?https://www.phiagroup.com/Media/Posts/PostId/1298/for-sickle-cell-disease-patients-hope-has-arrived-but-at-what-costBlog,Cost Containment,Health Insurance,Healthcare Costs,Hospital BillsThu, 21 Dec 2023 16:32:52 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:#000000;">By: Kelly E. Dempsey, Esq.</span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> For generations of sickle cell disease (SCD) patients, the suffering has been unbearable – with no end in sight. SCD, an </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif">inherited genetic red blood cell disorder that affects hemoglobin, the protein that carries oxygen throughout the body, torments nearly 100,000 Americans (20 million people worldwide), a disproportionate number of whom are African-American. Among other symptoms, SCD often triggers chronic bouts of excruciating pain that require regular hospitalization, organ failure, strokes, and shortened life expectancy. Meanwhile, the only known cure for the insidious disease has been a bone marrow transplant</span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">. </span><br /> <br /> Until last month, that is. Developments in this area are exciting for patients, but may make some waves for employers and their self-funded health plans. </span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><br /> In the middle of the invariably hectic holiday season, some above-the-fold medical news dropped when the FDA announced approval of two gene-based treatments for SCD: </span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">Casgevy, the first-ever therapy to incorporate the gene-editing technique CRISPR which enables scientists to make cuts in DNA, and Lyfgenia, grounded in an older gene therapy approach in which a virus is used to deliver a healthy copy of the gene that produces adult hemoglobin to compensate for the one producing the sickled form. Both Casgevy (produced by Vertex Pharmaceuticals and CRISPR Therapeutics) and Lyfgenia (generated by Bluebird Bio) have been cleared for patients 12 and older and are designed to serve as a one-time panacea. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> Certainly, for those with sickle cell who have long felt they have been suffering in silence, the disease now being the focus of this dramatic new approach to therapy development is cause for celebration. In reality, the majority of sickle cell patients can’t find a matching bone marrow donor, so this scientific breakthrough could truly be life-changing for the masses dealing with the agonizing blood disorder. And the early signs are, in fact, promising: through rounds of clinical trials, Casgevy and Lyfgenia have proved to be so effective as one-time treatments that they have been widely considered to be “cures” by the scientific community. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> But, like any cutting-edge therapy, these won’t be cheap. Consider that Casgevy will cost <i>$2.2 million</i> for the one-time treatment while Lyfgenia will cost <i>$3.1 million</i>. It also bears mentioning that these multimillion-dollar treatments will need to be administered in a monthslong process within large-scale medical systems that can perform stem cell transplants – systems that are inaccessible to millions of impoverished Americans living in states that have not broadened their Medicaid programs. The global picture is even bleaker. A recent <i>New York Times</i> story indicated that Vertex has been focusing on gaining approval in six wealthy nations – U.S., Italy, Britain, France, Germany, and Saudi Arabia – that represent merely 2 percent of the worldwide sickle cell population. Meanwhile, approximately 75 percent of the planet’s sickle cell patients reside in sub-Saharan Africa, where basic medical resources can often be scarce, to put it mildly. It should be noted that not all sickle cell patients have cases severe enough to warrant the new therapies; for reference, roughly only 20,000 in the US are believed to be sick enough to qualify for treatment. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> But back to the daunting financial numbers. Why are the price tags so ridiculously expensive? Those pursuing Casgevy and Lyfgenia will need to have their cells harvested and transported to a lab for manufacturing; undergo multiple rounds of rigorous chemotherapy, which very well can pose its own risks; and be hospitalized for months on end. As Vertex’s chief scientific officer, Dr. David Altshuler, was quoted as saying in the previously mentioned <i>New York Times</i> article, “</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="color:#000000;">A medicine that is so resource-intensive as this is may not be appropriate in many places where the amount of resources for health care is more limited.” </span><span style="color:#363636"></span><br /> <span style="color:#000000;"><br /> For employer-sponsored health plans, the multi-million-dollar question is whether they will have the resources to foot the bill. Will most plans simply be inclined to outright exclude this therapy? Will these new treatments be the most cost-effective method for providing services to those with sickle cell disease?  For those plans that do provide coverage, how will their respective stop-loss policies be impacted? What sort of coverage, if any, will be provided by Medicaid and/or Medicare?  </span><span style="color:#363636"></span><br /> <span style="color:black"><span style="letter-spacing:.3pt"></span></span><br /> <span style="color:#000000;"><span style="letter-spacing:.3pt">Gene therapy and cellular therapy have been hot topics in the last year, as well as the ever-increasing price tag on medical care and new treatments. It reminds me of the meme floating around social media about Kevin McCallister’s grocery list from <i>Home Alone</i>. In 1990 he purchased a half-gallon of milk, a half-gallon of orange juice, a TV dinner, bread, frozen mac and cheese, laundry detergent, cling wrap, toilet paper, a pack of army men, and dryer sheets all for $19.83. In 2022, that same grocery list cost $44.40 and in 2023 it’s now up to $72.28 … My intent was to make readers laugh, but if you need tissues, I understand as well (I’ll see if Matt has any Phia logo tissues on hand). <br /> <br /> Stay tuned. </span></span><span style="color:black"><span style="letter-spacing:.3pt"></span></span></span></span></span></span></span></span></p> 1298Empowering Plans: P178 – Back to December (Phia’s Version)https://www.phiagroup.com/Media/Posts/PostId/1297/empowering-plans-p178-back-to-december-phias-versionPodcastsThu, 21 Dec 2023 13:12:30 GMT<p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;">It is the last podcast of the year, and you know All Too Well that it is Phia’s 2023 year-in-review! Sparks Fly as Kendall Jackson and Corey Crigger talk about how Everything in PGC and Provider Relations Has Changed in 2023. If you need to catch up on anything from the No Surprises Act to Gag Clause Attestations, You Need To Calm Down and Stay Stay Stay tuned into this podcast episode. In addition to the big changes in 2023, we look forward to 2024 and ask, are you … Ready For It?  </span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"> <u><br /> <a href="https://www.youtube.com/watch?v=rvIionN46NM">Click here to check out the podcast!</a></u> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=rvIionN46NM"><u>YouTube</u></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span> </span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> 1297The 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> 1295Is Artificial Intelligence the New Frontier for Healthcare?https://www.phiagroup.com/Media/Posts/PostId/1294/is-artificial-intelligence-the-new-frontier-for-healthcareBlog,Health Insurance,Healthcare CostsTue, 12 Dec 2023 19:13:59 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky<br /> <br /> The ills of the American healthcare system, namely an undue administrative burden on healthcare providers and a <span style="background:#fcfcfc">labor supply not keeping pace with the demand for services</span>, have been well documented. But now, as we grind through the 2020s, relief may be on the way with the booming popularity (or in some cases, acceptance) of artificial intelligence (AI). Many healthcare experts believe that AI – a mechanism grounded in the simulation of human intelligence by computerized systems and one that has already changed how many humans learn and work – could revolutionize the field. But as enticing as the prospect of AI driving forward greater industrywide systemic efficiency may be, should this gargantuan development be universally celebrated? <br /> <br /> Certainly, from a patient's perspective, AI has intriguing potential. Imagine not having to wait on hold for who knows how long to schedule your next medical appointment because instead you could simply connect with <span style="background:#fcfcfc">Generative AI that spews out language so natural and fluid that it seemingly emanates from a person’s voice box? The same holds true with medication refills and answers to straightforward medical inquiries. For tens of millions of Americans, including those for whom the day is not long enough to string together multiple low-paying jobs, the saved time could be, for lack of a better word, life-altering. Meanwhile, for an often burned-out, short-staffed medical workforce trying to allocate scarce resources, this could be a tremendous boon. And for their respective patients suffering from both acute and chronic conditions, the end result could be vastly higher quality, more customized care. </span></span></span><br /> <span style="background:#fcfcfc"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> The titans of the industry have certainly taken note over the past year plus. In a recent article published on the Johnson & Johnson website, </span></span></span></span><span style="font-size:12.0pt"><span style="background:#f4f3f1"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Jeff Headd, Vice President, Commercial Data Science, Janssen North America Business Technology, was quoted as saying, “The rapid growth in available healthcare-related data in recent years allows us to ask bigger questions. Using the latest innovations in AI and machine learning (ML), we are able to quickly analyze these vast datasets (including electronic medical records, lab results or even medical imaging like X-rays, MRIs and CT scans), uncover new insights and then drive actions with real potential to improve patient outcomes.”<br /> <br /> Bear in mind this could very well mean improving the welfare of some of America’s most historically underserved populations in healthcare – African Americans, Latinos, and American Indians and Alaska Natives. Perhaps another segment of the population that stands to be a chief beneficiary are communities residing in the country’s most rural outposts. Simply put, if medical practitioners are able to leverage AI toward streamlining time-consuming functions (i.e., administrative work), there will be more opportunities to interact with broader swaths of the population. </span></span></span></span></span></span></span></span><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:#fcfcfc"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> And yet, despite all of society’s collective wonderment, the potential drawbacks of AI taking over healthcare warrant consideration, too. Speaking of healthcare-related data, as Headd referenced, would the expected airtight protection of patients’ personal data ever be compromised with AI assuming a more prominent role? With </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">more healthcare software systems adopting AI-based features, there is greater need for gathering more data, naturally increasing the likelihood of security threats and violations of compliance with regulatory frameworks such as  </span></span></span></span></span><a href="https://logrhythm.com/solutions/compliance/hipaa/" style="color:blue; text-decoration:underline" target="_blank"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="text-decoration:none">Health Insurance Portability and Accountability Act of 1996 (HIPAA)</span></span></span></span></span></span></a><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">.<span style="background:white"> (As of this hour HIPAA does not have a specific provision that relates to AI.) What does this mean for the common folk? While the hypothetical answer could be a blog in and of itself, the safeguarding of protected health information (“PHI”), which can involve anything from one’s cholesterol levels to mental health history, could be in jeopardy. Lest we forget, AI is both <i>really</i> new and extremely powerful, meaning the unanticipated side effects are boundless. Just like personal financial information, PHI is not something that should be floating aimlessly around the virtual universe.</span></span></span></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> Nevertheless, there’s a reason that industries across all seven continents have incorporated artificial intelligence into their systems over the past couple years. Specifically concerning the medical field, what provider wouldn’t welcome enhanced efficiency and productivity and more expedited decision-making? What patient wouldn’t like to know that their physicians are making better use of their precious time? By all accounts, AI is not going anywhere – in the healthcare industry and beyond. But still, it doesn’t hurt to consume the latest (i.e., daily) news of artificial intelligence with a (no pun intended) healthy dose of skepticism.</span></span></span></span></p> 1294July 2012 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/327/july-2012-newsletterNewslettersMon, 11 Dec 2023 22:11:33 GMT<div class="entry"> <p><span id="more-528"></span><br /> What a month it has been. Typical, not much happens in our industry in July but not this year! Less than two weeks after the historic decision, we here at The Phia Group did a webinar on the Supreme Court case with the largest audience we have ever had. Its great to know we are trusted for our efforts on behalf of all of you. </p> <p><a href="http://archive.constantcontact.com/fs076/1103630262203/archive/1110492401579.html" target="_blank">Read more</a></p> </div>327Empowering Plans: P177 – Entering the Danger Zone: Cross-Plan Offsettinghttps://www.phiagroup.com/Media/Posts/PostId/1293/empowering-plans-p177-entering-the-danger-zone-cross-plan-offsettingPodcastsFri, 08 Dec 2023 14:53:17 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Cf9aLsrjCZY?si=FW9YlcmTuPQfKcHt" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="color:#000000;">Attorneys Jon Jablon and Cindy Merrell discuss the practice of cross-plan offsetting and the recent settlement between the Department of Labor and EmblemHealth Inc. Who wins and who loses when a TPA decides to use cross-plan offset? </span><br /> <br /> <u><a href="https://www.youtube.com/watch?v=Cf9aLsrjCZY">Click here to check out the podcast!</a></u> <span style="color:black">(Make sure you subscribe to our </span><u><a href="https://www.youtube.com/watch?v=Cf9aLsrjCZY">YouTube</a></u> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1293MAHP 2023 Annual Health Care Conference: Health Care Affordability, Quality and Equity in a Post Pandemic Worldhttps://www.phiagroup.com/Media/Posts/PostId/1292/mahp-2023-annual-health-care-conference-health-care-affordability-quality-and-equity-in-a-post-pandemic-worldBlogTue, 28 Nov 2023 14:32:25 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="color:black"><span style="letter-spacing:-.15pt">By: David Ostrowsky </span></span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:-.15pt"></span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:-.15pt"></span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="color:black"><span style="letter-spacing:-.15pt">A year later … and how (relatively) little has changed in the state of Massachusetts healthcare. </span></span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:-.15pt"></span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:-.15pt"></span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="color:black"><span style="letter-spacing:-.15pt">Last November, the Massachusetts Association of Health Plans (MAHP) Annual Conference focused on healthcare challenges and opportunities – both from a regional and national perspective -- amidst a receding pandemic. The 2022 conference, headlined by then-Governor Charlie Baker, homed in on two topics: a.) healthcare equity and b.) regulation of provider prices. Twelve months later, on November 17, 2023, the MAHP 2023 Annual Conference, held once again at the Seaport Hotel in downtown Boston, had an eerily familiar theme: “Health Care Affordability, Quality and Equity in a Post Pandemic World.” </span></span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:-.15pt"></span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:-.15pt"></span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="color:black"><span style="letter-spacing:-.15pt">Compared to last fall, COVID may be further and further in our rearview mirror but the underlying systemic issues of a largely broken American healthcare system remain just as prominent. This year’s keynote speaker, </span></span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">Marty Makary, MD, MPH, Chief, Islet Transplant Surgery & Professor of Surgery, Johns Hopkins Medicine, (also <i>New York Times </i>bestselling author of <i>The Price We Pay</i>), expressed particular concern about overtreatment and excessive health care spending. The two driving forces behind the runaway costs, from Makary’s viewpoint, are pricing failures in the marketplace, (a primary culprit is negligible transparency on costs of care and services) and pervasiveness of low-value care. There is no one overarching solution for remedying the country’s (and Masschusetts’) health care system, but addressing these two matters, while safeguarding the welfare of society’s most vulnerable, is essential at this hour. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">Preceding Dr. Makary’s talk were remarks by Lieutenant Governor Kim Driscoll, who presented at the conference for the second consecutive year. In reflecting on her first year in office in Governor Maura Healey’s administration while previewing Massachusetts healthcare developments in the new year, Driscoll also articulated the message that there still needs to be greater healthcare equity and accessibility for all of the state’s nearly seven million residents. To this end, Lieutenant Governor Driscoll stressed the significance of diversifying the health care workforce and generating a pipeline in underserved communities for providing robust, culturally competent health care. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">Reining in healthcare costs also was the dominant theme of the presentation delivered by Mark Miller, Executive VP of Health Care at Arnold Ventures. Miller, who has decades of experience </span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="color:black">implementing health policy as the Executive Director of Medicare Payment Advisory Commission and Assistant Director of Health and Human Resources at the Congressional Budget Office among other positions, </span></span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">emphasized the importance of transparency in rising pharmaceutical costs, including transparency among patient advocacy groups, as part of the campaign to bolster Rx affordability and accessibility for patients, employers, and taxpayers in general. In the same vein, </span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">Kate Walsh, Secretary of Health and Human Services, Commonwealth of Massachusetts -- in conversation with Mallika Marshall, MD, Medical Reporter, WBZ 4, CBS News Boston – made note of </span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">MassHealth’s success in direct negotiations with drug manufacturers, which have resulted in some $400 million in prescription drug savings.</span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"><span style="color:black"></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif">The conference concluded with a high-powered panel (Massachusetts Health Policy Commission Chair Deborah Devaux; Paul Hattis, MD, Senior Fellow at the Lown Institute; Jon Hurst, President, Retailers Association of Massachusetts; and Greg Wilmot, President and CEO, East Boston Neighborhood Health Center) discussing the topic du jour -- health care equity and affordability in a post-COVID society. The consensus among the esteemed panelists was that to effectively champion affordability and equity it is paramount to retain a strong cost growth benchmark, require site-neutral payments, bolster the performance improvement process, and include pharmaceutical manufacturers in the Health Policy Commission’s oversight.</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:115%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Next year’s MAHP Annual Conference will be held on Friday, November 15. Undoubtedly there will be a fresh panel of nationally recognized speakers discussing real-world solutions to pressing challenges in the health care sector. It will be interesting to see, however, if those challenges differ, if at all, from those of the past couple years. </span></span></span></p> 1292Minor Members and Third Party Settlementshttps://www.phiagroup.com/Media/Posts/PostId/1291/minor-members-and-third-party-settlementsBlog,ERISAMon, 27 Nov 2023 15:05:00 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">By: Cindy Merrell, Esq. </span></span><br /> <b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:#0070c0"><br /> Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? </span></span></span></b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The answer is yes. However, there are various factors that can influence the Plan’s recovery in these circumstances. Federal courts across the country have recently considered a few challenges to a health plan’s right of recovery and clarified an ERISA plan’s right of recovery through reimbursement. What is abundantly clear is good plan language is vital to a health plan’s recovery. </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:#4472c4">Who? What? When? Where?</span></span></span></b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Any subrogation professional is aware that good plan language is important to a plan’s successful recovery from the proceeds of a third-party settlement. <i>See </i><i>U.S. Airways, Inc. v. McCutchen</i>, 569 U.S. 88, 133 S. Ct. 1537 (2013). The Plan document must be crystal clear on the who, what, when, and where. The who can be answered in the plan document by defining the word “dependent” or “covered persons.” Next, the plan document must have strong subrogation and reimbursement language that addresses the remaining questions of what, where, and when. </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">What rights does the plan have? Subrogation and reimbursement waters were muddied in certain jurisdictions by a decision that the plaintiff’s bar argument prohibited a plan from pursuing subrogation in third-party liability recoveries. <i>See Janssen v. Minneapolis Auto Dealers Benefit Fund</i>, 447 F.3d 1109 (8th Cir. 2006) (8th Cir. 2006). However, in a recent unpublished decision the 8<sup>th</sup> Circuit clarified that a plan with the appropriate reimbursement language can pursue a recovery through reimbursement from the proceeds of a third-party settlement. <i>See</i> <i>Vercellino v. Optum Insight, Inc.</i>, No. 20-3524 (8th Cir. Feb. 14, 2022). The court clarified that subrogation is not reimbursement and that they are two different rights. Reimbursement is a much broader right of recovery. <i>See id. </i>The difference is when does each right become effective? Subrogation allows the plan to step into the shoes of the member and assert a claim against the responsible party while reimbursement is a right of recovery from the settlement funds. </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Where can a self-funded ERISA plan enforce its right of recovery? In nearly all state jurisdictions a state court must approve a minor’s settlement through the state’s probate court. This process is designed to protect the minor’s interest. Typically, once the court approves the distribution of the settlement including the portion of the funds owed back to a health plan, the funds are placed in a blocked account to be released once the minor turns 18. On its face, it appears that the state court through the probate process is where the plan’s portion of the settlement is determined. However, a federal court in Florida confirmed it has the exclusive jurisdiction of a self-funded ERISA plan’s claims for a reimbursement or equitable lien by agreement. <i>Publix Super Markets, Inc. v. Figareau</i>, Case No: 8:19-cv-545-T-27AEP (M.D. Fla. Mar. 17, 2020). </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:#4472c4">How to enforce the Plan’s right of recovery?</span></span></span></b></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Even with the strongest language a probate court may not be aware of the strong right of recovery of a self-funded ERISA plan. If an agreement cannot be made with the minor member’s attorney regarding the reimbursement amount to the Plan, it may become necessary for the health plan to retain local counsel to represent the health plan’s interest at a probate court. Another possibility is if the employee is still on the health plan, the plan could consider offsetting the member’s future benefits so long as the plan language supports this option. </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">In conclusion, a self-funded ERISA plan can seek recovery from settlement funds with the appropriate plan language. The Phia Group has set the gold standard for strong recovery language. Please contact The Phia Group if your health plan needs any assistance with a minor’s subrogation or reimbursement matters. </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Please note this article is not intended to be a comprehensive review of all health plans’ rights of recovery as various factors could impact the applicability of the above statements.  For a more detailed analysis of a specific matter please contact The Phia Group.  </span></span></span></span></span></p> 1291Empowering Plans: P176 – Copay Accumulator Programs Take a Hit: What’s Next?https://www.phiagroup.com/Media/Posts/PostId/1290/empowering-plans-p176-copay-accumulator-programs-take-a-hit-whats-nextPodcastsTue, 21 Nov 2023 20:54:03 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/FbGyR6zI5Wg?si=YEUk9MSJBdL70WoM" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="color:#000000;">Attorneys Brady Bizarro and Andrew Silverio discuss a recent federal court decision that saw drug manufacturers and patients alike score a win 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.  With the latest rule being struck down, where does the law stand now and what will happen next?</span><br /> <br /> <a href="https://www.youtube.com/watch?v=FbGyR6zI5Wg">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=FbGyR6zI5Wg">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></p> <p><span style="font-size:16px;"></span></p> <p style="margin:0in"> </p> <p style="margin:0in"> </p> 1290Strategizing for 2024: New AI Regulations and Transparency Rules Impacting Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/1289/strategizing-for-2024-new-ai-regulations-and-transparency-rules-impacting-healthcareWebinarsWed, 15 Nov 2023 20:13:29 GMT<p style="text-align:justify; margin:0in 0in 10pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:115%">Goodbye 2023, hello 2024.  The future has arrived, and we thank you for your efforts to date; the robots will take it from here.  Just kidding… maybe?  For those who are tracking developments in Artificial Intelligence, this technology is both intimidating and exciting.  Regardless of your position on the matter, you won’t be able to escape the meaningful impact A/I will have on our industry.  We believe that with the right measures, A/I will be a tool we can use for good in the advancement of our mission to provide the best benefits for the lowest cost.  Coupled with other regulatory developments – such as price transparency, a new emphasis on quality metrics, and general public engagement – and 2024 might be one of the best years ever, at least for those who prepare now.  Join The Phia Group’s team as they discuss these and other technological and legal improvements that are sure to dictate how you survive and thrive in the coming year.</span></span></span></span></span></span></p> <p style="margin:0in 0in 10pt"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="" style="font-family:"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:115%"><a href="https://attendee.gotowebinar.com/recording/4385211247601703257">Click Here to View Our Full Webinar</a><br /> <br /> To obtain a copy of our webinar slides, please reach out to</span></span></span><span style="font-size:12.0pt"><span style="line-height:115%"> <a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span><span style="font-size:12.0pt"><span style="line-height:115%"></span></span></span></span></span></p> 1289Being Mindful of Telemedicine Accesshttps://www.phiagroup.com/Media/Posts/PostId/1288/being-mindful-of-telemedicine-accessBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 09 Nov 2023 15:01:53 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By Jen McCormick, Esq. and David Ostrowsky<br /> <br /> From a healthcare standpoint, two of the most significant byproducts of the COVID-19 pandemic have been the exploding popularity of Telemedicine, </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">the practice of providing medical <i>and</i> mental health services remotely, and a heightened awareness of many Americans’ longstanding mental health issues. Due to a confluence of prolonged extenuating circumstances, it became readily apparent to healthcare providers, politicians, social workers, employers, teachers, and parents on both sides of the Mississippi that a.) the inimitable convenience of virtual healthcare does not compromise quality (at least for some patients and practitioners) and b.) many Americans experiencing emotional distress have long been suffering in silence.<br /> <br /> Why should these two developments that came to light during the dark days of the pandemic be mutually exclusive?<br /> <br /> Certainly, many health plans realize that the inherent advantages of Telemedicine (namely, ease of access and time efficiency) have motivated otherwise hesitant patients to seek mental healthcare support. Telemedicine, being such a convenient and effective alternative to traditional in-person care, has helped meet the unprecedented demand for mental health services. For many coping with severe mental health issues, an appropriate facility is not easily accessible via public transportation or even a car – a conundrum that is only exacerbated when one is juggling multiple low-paying jobs and scrounging for childcare. And yet, some health plans – ones that purportedly provide robust mental health coverage -- are inclined to provide Telemedicine services solely for patients suffering from physical ailments. Others were providing Telemedicine for both physical health and mental health/substance use disorder services when social distancing was in vogue during the pandemic, but have since precluded the latter amidst the return to relative normalcy. Ethics aside, this ultimately may be a potential violation of the </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Mental Health Parity and Addiction Equity Act (MHPAEA), which requires health plans that offer mental health and substance use disorder benefits to do so in parity with medical and surgical benefits. For the health plan, the monetary penalties could be steep, the long-term ramifications dire.<br /> <br /> Back to ethics. If someone who develops a severe skin rash on their abdomen has the ability to consult with a physician over their smartphone, why shouldn’t a participant on the very same health plan be able to consult with a mental healthcare provider about their uncontrollable OCD symptoms or worsening depression in the same (virtual) manner? Why should more stringent restrictions apply to those suffering from brain-related issues than to those dealing with tendinitis? Why should a plan participant enduring intense panic attacks – who’s paying the same premiums as everyone else on the plan – have to battle traffic and miss work to receive potentially life-changing treatment when those dealing with physical issues don’t have to be so inconvenienced? As if the stigma of requiring mental healthcare hasn’t been ingrained fully enough in the fabric of American society. By any measure, it's a grossly inequitable disparity and one that employer-sponsored health plans, particularly those subject to Nonquantitative Treatment Limitations (NQTL) requirements, would do well to strongly consider the draconian nature of.<br /> <br /> Thankfully, a new calendar year is right around the corner, meaning plan administrators and sponsors and employers still have time to review their respective plan documents and summary plan descriptions and make corresponding adjustments for lingering Telemedicine coverage discrepancies. Meanwhile, as Telemedicine regulations continue to evolve (lest we forget, this is still a fairly novel mechanism), there is even greater need for weighing potential changes to plan design as a means of ensuring MHPAEA compliance.</span></span></span></span></span></span><br /> <span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> Most importantly, America’s mental health crisis is not dissipating anytime soon, a reality of which the Department of Labor, in its compliance enforcement efforts, is well aware. </span></span></span></p> 1288Empowering Plans: P175 – No Surprises Act Brings More Surprises & Other Surprises for 2024https://www.phiagroup.com/Media/Posts/PostId/1287/no-surprises-act-brings-more-surprises-other-surprises-for-2024PodcastsThu, 09 Nov 2023 13:29:11 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/NIspcQL0hos?si=HIVTzGYbZuEQNCS3" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="color:#000000;">Join Provider Relations Senior Attorney, Brian O’Hara, and Vice President of Consulting, Kelly Dempsey, for a quick rundown of changes to be prepared for as we near 2024. While there are the regular recurring changes to ACA and IRS out-of-pocket limits, this podcast will uncover a couple lesser-known items hidden in some NSA proposed rules and a couple other items for 2024 that might have fallen off the radar, including COVID-19 tolling requirements. (COVID may be over but the impact on certain items could extend well into 2024…). </span><br /> <br /> <a href="https://www.youtube.com/watch?v=NIspcQL0hos">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=NIspcQL0hos">YouTube </a><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></p> 1287Update on the Federal IDR Processhttps://www.phiagroup.com/Media/Posts/PostId/1286/update-on-the-federal-idr-processBlog,Health Insurance,Healthcare CostsFri, 27 Oct 2023 14:58:32 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Kendall Jackson, Esq.</span></span></span></span></span><br /> <span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><br /> Recently there has been significant discussion about the federal IDR process. The IDR process is an important tool of the No Surprises Act (“NSA”) as it resolves claims for payment for out-of-network items and services. It not only provides a procedure for settling disputed claims but is also an integral mechanism for supporting the NSA’s protection for plan members against potentially crippling expenses from balance billing for high-cost out-of-network claims.<br /> <br /> In<i> Texas Medical Association v. United States Department of Health and Human Services, </i>Case No. 6:23-cv-59-JDK<i> </i>(<i>TMA IV</i>)<i>, </i>the U.S. District Court for the Eastern District of Texas<i> </i>vacated several provisions of the NSA—specifically, the batching provisions and the $350 administrative fee. In response to this decision, on August 3, 2023, the U.S. Department of Health & Human Services, the Department of Labor, and the Department of Treasury (collectively, the “Departments”) temporarily paused all federal IDR processes, including dispute initiation. On August 8, 2023, IDR entities were permitted to process batched disputes if, prior to August 3, 2023, they were already deemed eligible and administrative fees were paid. Other batched disputes that did not meet this criteria were paused.<br /> <br /> Only a few weeks later, the same court issued another opinion in <i>Texas Medical Association, et al. v. United States Department of Health and Human Services, </i>Case No. 6:22-cv-450-JDK (<i>TMA III</i>) and vacated several other provisions of the NSA, including portions of the QPA calculation methodology and the condition that a single medical air transport requires two separate IDR processes. Effective August 25, 2023, the Departments paused all federal IDR processes, including the batched disputes that were still being processed under the prior pause. Disputing parties in the open negotiations phase were permitted to continue with negotiations while all other processes were paused to allow the Departments to modify existing guidelines to comply with the court’s orders.<br /> <br /> On October 5, 2023, access to the Notice of Initiation, Selection Response, and Reselection Response webforms was restored. Access is available only for single disputes, which includes disputes submitted as a bundled item or service. Disputing parties are able to resume operations related to IDR entity selection and reselection and may also initiate new single disputes. Batched disputes, whether new or in-progress, as well as new air ambulance disputes remain paused. Parties whose IDR initiation deadline is between August 3 and November 3, 2023, will have until November 3, 2023, to initiate new single disputes. For disputes initiated between October 6 and November 3, 2023, parties will have ten business days from initiation to select a certified IDR entity. The deadline to submit fees and offers will be ten business days after the selection of the certified IDR entity. The administrative fee for new disputes is currently $50, as it reverted back to the fee that was established prior to the introduction of the $350 administrative fee in December 2022.</span></span></span></span></span></span><br /> <span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> We are likely to see more established rules in response to TMA IV and TMA III in the near future. In late September, the Departments, along with the Employee Benefits Security Administration and the Centers for Medicare & Medicaid Services, collectively issued a proposed rule to address the administrative fee and the fee ranges for certified IDR entities. The proposed rule is intended to apply to disputes initiated on or after the later of the effective date of the rule or January 1, 2024. The Departments proposed an administrative fee of $150 per party per dispute, which was determined based on the costs of operating the federal IDR process. In regard to the fees for certified IDR entities, the fees are currently set by the IDR entities within a range issued annually by the Departments. The rule proposes to alter the frequency in which guidance on ranges will be provided, suggesting a shift to issuing notices more or less frequently than annually. The Departments proposed the updated ranges for disputes initiated on or after the later of the effective date of the rule or January 1, 2024, would be $200 to $840 for single determinations and $268 to $1,173 for batched disputes. Comments on the proposed rule were due by October 26, 2023. With the period recently closing, there will surely be new developments in the federal IDR process in the coming months.</span></span></span></p> 1286Empowering Plans: P174 – PCORI and Parity and Lawsuits, Oh My!https://www.phiagroup.com/Media/Posts/PostId/1285/empowering-plans-p174-pcori-and-parity-and-lawsuits-oh-myPodcastsThu, 26 Oct 2023 20:14:26 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/bJZChZk9J-I?si=aGhVpmF8KOumiZlq" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:14.0pt"><span style="line-height:107%">It’s the spookiest time of the year, and I’m not just talking about renewal season. In this Halloween episode of the Empowering Plans podcast, Jennifer McCormick and Nick Bonds talk through 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. But don’t be scared, Phia is here to help!  </span></span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:14.0pt"><span calibri="" style="font-family:"><a href="https://youtu.be/bJZChZk9J-I">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://youtu.be/bJZChZk9J-I">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></span></p> 1285Empowering the 2023 SIIA National Conferencehttps://www.phiagroup.com/Media/Posts/PostId/1284/empowering-the-2023-siia-national-conferenceBlog,Health Insurance,Healthcare CostsThu, 26 Oct 2023 18:28:38 GMT<p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p class="MsoNoSpacing" style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Earlier this month, the self-insurance industry’s most prominent thought-leaders, innovative service providers, and esteemed subject matter experts convened at the 2023 Self-Insurance Institute of America (<span style="background:white"><span style="color:black">SIIA) National Conference at the JW Marriott Phoenix Desert Ridge Resort & Spa. The SIIA National Conference,</span></span> which this year covered such pressing topics as artificial intelligence, surprise billing, emerging trends impacting the employer stop-loss market, and recent legislative and regulatory updates, <span style="background:white"><span style="color:black">is widely considered to be the self-insurance industry’s annual marquee event, bringing together hundreds of industry professionals including TPAs, vendors (</span></span>there were over 950 booths representing industry vendors stationed in the exhibitor hall)<span style="background:white"><span style="color:black">, brokers, captive managers, stop-loss carriers, and solution providers. Naturally, The Phia Group was well represented with a six-person contingent consisting of </span></span>Adam Russo, Garrick Hunt, Tim Callender, Jason Davis, Jen McCormick, and Brady Bizarro present. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In addition to meeting with clients to strategize about how to improve our partnerships going into 2024, Phia had two representatives – CEO Adam V. Russo, Esq. and Brady Bizarro, Esq., Senior Director of Legal Compliance & Regulatory Affairs – deliver one of the conference’s final presentations (“Empowering Plan Participants to Leverage Cost Containment Strategies”). The premise of Russo and Bizarro’s presentation was fairly straightforward: </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The recent trends in healthcare are cause for concern. Consider that with premiums for family health plans having increased by 54 percent in recent years, employee contributions have shot up 71 percent. Sadly, the increase in wage growth (26 percent) has not been commensurate with such drastic spikes. Put another way, tens of millions of industrious Americans, already grappling with inflation and a declining stock market, have been deprived of what they deserve – access to affordable, first-rate healthcare. Although there is no single panacea to this systemic problem bedeviling the American workforce, employers, as Russo and Bizarro reasoned, can take steps to empower their employees toward becoming engaged and knowledgeable consumers of healthcare. </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Russo and Bizarro’s presentation had a particularly acute focus on espousing the merits of employee workshops and incentive programs to accomplish this goal. Regardless of the industry, it is often challenging to make a given employee population <i>care </i>about their healthcare spending. For many, simply being aware of paycheck deductions and out-of-pocket costs is sufficient. But what if employees learn how to access data that indicates whether they’re seeing the most capable providers? What if employees learn that a given facility they are considering for surgery is three times more expensive than an alternative one, which would translate to higher healthcare premiums? What makes these presentations even more compelling is when management, in conjunction with their respective HR department, can provide proper contextual background and empirical information – that is easily accessible in an online repository -- to elucidate the message. Rather than speaking in broad terms, offering specific examples of cost containment measures germane to the company’s make-up, health plan, and geographic location(s) can further pique participants’ interests. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Ultimately, though, for some employees, educational workshops still are not enough. They need personalized monetary incentives to be more engaged. Hence, the incentive programs that Attorneys Russo and Bizarro discussed in their presentation. In short, this is where employers may need to get creative. While there are more traditional methods for offering participants financial rewards (i.e., initiating a claim audit review program, encouraging preemptive consultation regarding medical procedures and specialty drugs), plans can customize incentive programs geared toward their employee population’s needs. For example, The Phia Group has long championed a program whereby employees (or their spouses) expecting babies will receive a $300 monthly stipend for diapers and wipes for 12 months if they choose to deliver at a facility identified as high quality, low-cost. In fact, in 2016 the <i>Boston Globe</i> ran a story on employee benefit programs (“Employers reward workers who shop around for health care”) that highlighted this unique program. This is just one example of how selecting the best provider at the best price can be a win-win for the company (as in potentially saving tens of thousands of dollars) and employee. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As seasoned experts in the healthcare cost containment industry, Attorneys Russo and Bizarro, on behalf of The Phia Group, were honored to deliver such a well-received presentation at SIIA’s biggest annual convention and look forward to enlightening the audience at next year’s conference. </span></span></span></span></span></span></p> 1284The 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> 1282Cell and Gene Therapy: Industry and Claim Cost Impacthttps://www.phiagroup.com/Media/Posts/PostId/1281/cell-and-gene-therapy-industry-and-claim-cost-impactWebinarsWed, 18 Oct 2023 13:58:28 GMT<p style="margin: 0in 0in 10pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:16px;"><span style="line-height:115%"><span calibri="">Drugs are on our mind!  In our industry, they are what can make or break the bank.  Is this an episode of Breaking Bad?  No – It’s American healthcare.  From specialty drugs and gene therapy to pharmacogenomics and international drug importation, prices aren’t the only thing getting high.  Join The Phia Group’s innovators as they discuss frightening trends in drug costs, define the risks and present solutions you can implement today.    </span></span></span></span></p> <p style="margin: 0in 0in 10pt; text-align: justify;"><span style="font-size:16px;"><span style="line-height:115%"><span calibri="" style="font-family:"><span style="color:#000000;"><a href="https://attendee.gotowebinar.com/recording/4208561509839729501">Click Here to View Our Full Webinar</a><br /> <br /> To obtain a copy of our webinar slides, please reach out to</span> <a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span></p> 1281Empowering Plans: P173 – Gene-y in a Bottle: A Magical Overview of Cell and Gene Therapyhttps://www.phiagroup.com/Media/Posts/PostId/1280/empowering-plans-p173-gene-y-in-a-bottle-a-magical-overview-of-cell-and-gene-therapyPodcastsThu, 12 Oct 2023 20:27:05 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/4qZA5-pAiog?si=A-hw5eC9x5pAe7cN" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span calibri=""><u><span style="color:#0071ce"></span></u></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;">Your wish is our command!  Join Ron Peck and Corey Crigger as they discuss how this emerging treatment can impact self-funded health plans. With prices as high as $3.5 million, you can’t just wish for a strategy for dealing with these therapies, you must plan for it. Ron and Corey discuss the motivations to cover, the future benefits, and the concerns they are hearing from clients. You don’t know what we can see, so join us on a magic carpet ride around this life saving, but costly treatment. </span></span></span><br />  </p> <p style="margin: 0in; text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><u><span style="color:#0071ce"></span></u></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><u><span style="color:#0071ce"></span></u></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=4qZA5-pAiog"><u><span style="color:#0071ce">Click here to check out the podcast!</span></u></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=4qZA5-pAiog"><u><span style="color:#0071ce">YouTube</span></u></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1280District Court Strikes a Blow to Copay Accumulator Programshttps://www.phiagroup.com/Media/Posts/PostId/1279/district-court-strikes-a-blow-to-copay-accumulator-programsBlog,Health Insurance,Healthcare Costs,Hospital BillsWed, 11 Oct 2023 15:36:22 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">By: Andrew Silverio, Esq.<br /> <br /> Many of our clients are aware of, or even utilize, “copay accumulator” programs – these programs create plan savings by not counting amounts received by patients from manufacturer assistance programs toward annual deductibles and out-of-pocket maximums.  Some programs go a step further by actually increasing the applicable copayment for certain drugs to maximize the amount a patient may be eligible to receive from manufacturers. <br /> <br /> The Trump Administration’s Notice of Benefit and Payment Parameters for 2021 (“NBPP”) facilitated these programs by explicitly permitting plans to <i>not </i>count manufacturer assistance amounts toward annual deductibles or out of pocket maximums.  That allowed these programs to drastically increase the amounts they can redirect to plan savings – the alternative would be a program which only works until an out-of-pocket maximum is reached, which, with expensive specialty drugs, can happen in an instant.<br /> <br /> However, several patient groups brought a legal challenge against HHS and CMS, challenging the NBPP as unlawful.  On September 29 of this year, the United States District Court of the District of Columbia ruled on that challenge and sided with the Plaintiffs (see https://hivhep.org/wp-content/uploads/2023/09/HIV-Hepatitis-Policy-Institute-v.-HHS-DDC-opinion.pdf).  The Court found to be arbitrary and capricious the Trump administration’s “interpretation of the same statutory and regulatory provisions as having two different meanings, to be chosen at the discretion of regulated parties.”  Per the Court, payers cannot choose what is and is not cost-sharing paid by or on behalf of a participant – the law clearly defines that.<br /> <br /> So, for now, plans should be counting amounts received by patients from manufacturer assistance programs toward deductibles and out of pocket maximums, at least in situations where the drug is a name brand drug and there is no generic equivalent available.  The industry will need further regulations or guidance from the current administration to clarify the current state of the law and state definitively whether this practice is allowed in situations where there is a generic equivalent available. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: center;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><img alt="" src="/Portals/phiagroup/images/Blog Images/Co-Pay.jpg?ver=sKiKchHKEDlhoqB2bjNX9A%3d%3d" style="width: 400px; height: 267px;" /></span></span></span></span></p> 1279Choking on the Gag Clausehttps://www.phiagroup.com/Media/Posts/PostId/1278/choking-on-the-gag-clauseWebinarsWed, 04 Oct 2023 13:12:15 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="line-height:107%">The Consolidated Appropriations Act of 2021 (CAA) introduced many significant industry changes, including a prohibition on “gag clauses” – that is, contractual provisions that restrict health plans from disclosing certain important provider cost and quality information. This prohibition has the self-funded industry scrambling for answers amidst vague guidance – not only as TPAs and health plans seek to avoid being bound by gag clauses, but also as these entities work to submit mandatory compliance attestations to the federal government. Needless to say, there are many compliance nuances and business decisions for both health plans and TPAs.<br /> <br /> Whether you’re a health plan, TPA, broker, or anyone else, join The Phia Group’s consulting team leaders as they gather to discuss the prohibition on gag clauses, best practices, and next steps to ensure a gag-free tomorrow!<br /> <br /> <a href="https://attendee.gotowebinar.com/recording/224830770959230977">Click Here to View Our Full Webinar</a><br /> <br /> To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span></p> 1278Empowering Plans: P172 – Navigating the Gag Clause Prohibitionhttps://www.phiagroup.com/Media/Posts/PostId/1277/empowering-plans-p171-navigating-the-gag-clause-prohibitionPodcastsThu, 28 Sep 2023 17:33:30 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/byPFLbtE1n4?si=yjJQz64WGWICwydE" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri=""><span style="font-size:12.0pt">In this installment of The Phia Group’s Empowering Plans podcast, attorneys Jon Jablon and Kendall Jackson delve into the issue of the gag clause prohibition, a mysterious law that continues to confound the self-funded industry. With the first attestation requirement approaching at the end of 2023, now is the time to make sure you know what needs to be done, how to do it, and how to keep yourself safe and compliant.</span></span></span></span></p> <p style="margin: 0in; text-align: justify;"> </p> <p style="margin:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span calibri=""><a href="https://www.youtube.com/watch?v=byPFLbtE1n4"><u><span style="color:#0071ce">Click here to check out the podcast!</span></u></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=byPFLbtE1n4"><u><span style="color:#0071ce">YouTube</span></u></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> 1277Fall Is Here & So Are the Cold-Weather Germs – New CDC Recommendationshttps://www.phiagroup.com/Media/Posts/PostId/1276/fall-is-here-so-are-the-cold-weather-germs-new-cdc-recommendationsBlog,Affordable Care ActTue, 26 Sep 2023 19:02:25 GMT<p style="text-align:justify; margin:0in"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;">By: Kelly Dempsey, Esq.<br /> <br /> Fall is officially here as the fall equinox has passed and with fall comes the impending “flu season” which also brings a bunch of other germs – new strains of COVID-19 and a rise in RSV cases. If you have children who have headed back to school (even college kids), you’ve probably noticed an uptick in stuffy noses and tummy aches already.<br /> <br /> In anticipation of the upcoming turn in weather that brings an increase in viral illnesses, the Centers for Disease Control and Prevention (CDC) has been busy issuing new recommendations related to RSV – formally known as Respiratory Syncytial Virus. RSV is a common respiratory virus that, like other viruses, generally brings mild, cold-like symptoms; however, RSV can be a serious illness for infants and older adults.<br /> <br /> Recommendations from the CDC Advisory Committee on Immunization Practices are recommendations that are added to the list of ACA Preventive Care Services that non-grandfathered plans must cover at 100% with no cost sharing.<br /> <br /> The following is a quick summary of the three different recommendations related to RSV and when self-funded health plans would need to ensure compliance: </span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;"> </span></span></span></p> <ol> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;"><span style="font-size:12.0pt"></span>June 21, 2023: adults aged ≥60 years may receive a single dose of RSV vaccine, using shared clinical decision-making. Effective for plan years beginning on or after July 1, 2024.</span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;"><span style="font-size:12.0pt"></span>August 3, 2023: new RSV immunization starting this fall to help protect all infants under 8 months and some older babies at increased risk of severe illness caused by RSV. Effective for plan years beginning on or after September 1, 2024.</span></span></span></li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;"><span style="font-size:12.0pt"></span>September 22, 2023: RSV vaccine during weeks 32–36 of pregnancy to protect babies from severe RSV. Effective for plan years beginning on or after October 1, 2024.</span></span></span></li> </ol> <p style="text-align:justify; margin:0in"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;"> </span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;">While many of these effective dates are far off in the future, self-funded plans have the option to begin covering the above items as preventive care prior to the effective date. Plans that wish to address these requirements sooner rather than later should work with their claims administrators and communicate updates to participants accordingly.<br /> <br /> As the most recent CDC RSV recommendation was just issued on September 22, the CDC is still in the process of updating their website. Additional websites with preventive care information will also likely be updated in the near future. In the meantime, if you have questions, you know The Phia Group is here to help.</span></span></span></p> 1276Three Shots for Autumnhttps://www.phiagroup.com/Media/Posts/PostId/1275/three-shots-for-autumnBlog,COVID-19Mon, 18 Sep 2023 13:46:42 GMT<p style="margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky<br /> <br /> It’s a daunting Venn diagram – the interplay of three potentially fatal diseases: <span style="background:white">Respiratory Syncytial Virus</span> (“RSV”), COVID-19, and influenza. And with summer slipping into fall, this triple-headed monster is (once again) threatening to rear its ugly head. But, thanks to modern medicine, could this cold-weather season have a less devastating toll on humanity than what transpired a year ago?<br /> <br /> As has been well publicized this past week, there is in fact reason for optimism as <span style="background:white">updated COVID-19 vaccines from Pfizer and Moderna</span> targeting<span style="background:white"> the devilish Omicron variant XBB.1.5 will soon hit the market. It’s a promising development that, combined with the emergence of the first-ever shots to shield older adults and infants from RSV,</span> behold potential to blunt the impact of another “tripledemic” of respiratory viruses. But naturally, the new breakthroughs have sparked a flurry of questions, some of which lack definitive answers.<br /> <br /> Is the RSV vaccine safe? Are the vaccines for RSV, COVID-19, and influenza recommended for everyone? When should one receive the vaccines? Is it effective or even safe to have multiple shots during the same visit or is separation more prudent?</span></span><br /> <span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> While federal health officials are banking on the widespread adoption of such immunizations to avoid a repeat of last winter, there is, in many cases, simply a dearth of knowledge regarding this multifaceted topic.<br /> <br /> What we do know: </span></span></span></span></span></span></span></span><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 8pt;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></span></p> <ul> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 0in;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">RSV looms as a severe respiratory threat to older adults (particularly those over 75 who have preexisting conditions such as cardiovascular disease, chronic lung disease, or diabetes) as well as newborns and infants. Last month, the Centers for Disease Control and Prevention (“CDC”) did advocate for a new shot against RSV – Beyfortus, a monoclonal antibody – for both infants less than eight months old and infants eight months to nineteen months at risk for serious illness. Also in August, the Federal Drug Administration (“FDA”) did greenlight the use of Pfizer’s vaccine, Abrysvo, for pregnant women as a means of protecting infants from contracting RSV. </span></span></span></span></span></span></span></span><br />  </li> <li style="text-align: justify; margin-top: 0in; margin-right: 0in; margin-bottom: 8pt;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Perhaps the most pressing matter is that of the timing for inoculation. While COVID-19, RSV, and influenza are all expected to significantly resurge this fall, a more precise timetable is very challenging to gauge. This is due in large part to the seasonal patterns of influenza and RSV being out of whack amidst the yearslong pandemic. For example, last winter, the flu crested in December instead of in February, when it traditionally does; meanwhile, RSV peaked several weeks earlier than usual last year and it circulated longer than it would in the pre-pandemic era. While scientists predict that the flu and RSV will eventually return to their pre-pandemic patterns, it may be a couple years before that materializes.</span></span></span></span></span></span></span><br /> <span style="font-size:12pt"><span style="background:white"><span style="vertical-align:baseline"><span style="font-family:"Times New Roman",serif"><span style="background:white"><br /> Along the same lines, many are wondering just how safe it will be to receive multiple vaccines concurrently. Unfortunately, there’s much ambiguity surrounding this question. Though many received the influenza and Covid vaccines together last fall without reporting issues, (</span>“The available data pertaining to the administration of influenza and COVID-19 vaccines at the same time do not indicate safety concerns,” the Department of Health and Human Services said in a statement to The New York Times), <span style="background:white">the RSV vaccine is still a great unknown. While some research suggests that the RSV and flu vaccines produce lower levels of antibodies when administered together than when delivered separately, </span>there simply isn’t sufficient information about how it might interact with the other two vaccines. <span style="background:white">The CDC is expected to make recommendations later this fall – a matter of great importance to many Americans who are not inclined or even able to make multiple stops to a clinic or pharmacy to space the shots apart.</span><span style="background:white"></span></span></span></span></span></span></li> </ul> <p class="css-at9mc1" style="margin-top:0in; margin-right:0in; margin-bottom:0in; margin-left:.5in; text-align:justify"> </p> <p><span style="color:#000000;"></span></p> <p class="css-at9mc1" style="margin-top:0in; margin-right:0in; margin-bottom:0in; margin-left:.5in; text-align:justify"><span style="color:#000000;"><span style="font-size:12pt"><span style="background:white"><span style="vertical-align:baseline"><span style="font-family:"Times New Roman",serif"><span style="background:white"></span></span></span></span></span></span></p> <p><span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Hopefully, in the coming weeks, there will be more clarity for such issues, which in turn would ease the burden on healthcare clinics, urgent care centers, and hospitals bracing for (or in some cases already dealing with) an onslaught of patients suffering from respiratory illnesses.</span></span></span></span></span></p> <p> </p> 1275Empowering Plans: P171 – Mass Torts 101https://www.phiagroup.com/Media/Posts/PostId/1274/empowering-plans-p171-mass-torts-101PodcastsFri, 15 Sep 2023 12:31:32 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/LVFD7cWwQpc?si=3_APJ4tD3O0_HKC7" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><u></u></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="color:#000000;">From time to time, do you hear about mass torts in the news but feel like you could use a little more background knowledge? Look no further than the latest edition of the Empowering Plans podcast series, (“Mass Torts 101”) in which attorneys Cindy Merrell and Lisa Hill explain 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. </span> </span></span><br />  </p> <p style="margin:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"></span></span></p> <p style="margin:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span calibri=""><u></u></span></span></span></p> <p style="margin:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span calibri=""><a href="https://youtu.be/LVFD7cWwQpc"><u><span style="color:#0071ce">Click here to check out the podcast!</span></u></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://youtu.be/LVFD7cWwQpc"><u><span style="color:#0071ce">YouTube</span></u></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1274Empowering Plans: P170 – PSA on the NSAhttps://www.phiagroup.com/Media/Posts/PostId/1273/empowering-plans-p170-psa-on-the-nsaPodcastsThu, 31 Aug 2023 19:21:31 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/S3WrfaDC724?si=KkBU3Tf5QVW6tGq6" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;"></span></p> <p><span style="color:#000000;"></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt">It’s 10’o clock, do you know where your IDR determinations are? Join Attorneys Brian O’Hara and Corey Crigger as they issue a public service announcement on the state of the No Surprises Act, and specifically the challenges with the IDR process. Friends don’t let friends miss this podcast! In addition to the PSA on NSA, Corey discusses a case study highlighting the benefits of the Safeguard Program. Just Say No to skipping this episode of Empowering Plans.</span></span></span></span><br />  </p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><u><a href="https://youtu.be/S3WrfaDC724"><span style="color:#0071ce">Click here to check out the podcast!</span></a></u> <span style="color:black">(Make sure you subscribe to our </span><u><a href="https://youtu.be/S3WrfaDC724"><span style="color:#0071ce">YouTube</span></a></u> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> <p><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="color:black"></span></span></span></span></p> 1273The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiationshttps://www.phiagroup.com/Media/Posts/PostId/1272/the-first-ten-the-initial-round-of-drugs-subject-to-medicare-price-negotiationsBlog,Health Insurance,Healthcare Costs,MedicaidWed, 30 Aug 2023 14:36:00 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky<br /> <br /> Traditionally, August is a slow news month. Congress is on recess; dignitaries have ensconced themselves in their summer homes; many reporters are on vacation. Invariably, the waning days of summer don’t appear conducive to delivering breaking news.<br /> <br /> Not this year, however. Indeed, August 2023 will go down as a momentous period of time in American history. A month that was dominated by headlines involving criminal charges brought against former President Donald Trump ended with a healthcare development that will surely impact an untold number of Americans for the foreseeable future.<br /> <br /> On August 29, President Biden unveiled the first ten prescription drugs that will be subject to price negotiation with Medicare (<span style="background:white"><span style="color:black">Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp and NovoLog), representing a watershed moment for Democrats </span></span>who have spent years clamoring for lower prescription costs. <span style="background:white"><span style="color:black">The Medicare Drug Price Negotiation Program was a key component of the </span></span></span></span></span><a href="https://abcnews.go.com/Politics/biden-takes-victory-lap-inflation-reduction-act-amid/story?id=102319410" style="color:blue; text-decoration:underline" target="_blank"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black"><span style="text-decoration:none"><span style="text-underline:none">Inflation Reduction Act</span></span></span></span></span></span></span></a><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">, which also caps the monthly out-of-pocket cost of insulin at $35 for Medicare enrollees, enabling the U.S. government to directly negotiate with drug manufacturers for the first time in the program’s 58-year history. When the new prices for the aforementioned drugs that <span style="letter-spacing:.3pt">treat heart disease, certain cancers, diabetes, and autoimmune diseases </span>go into effect in 2026, over nine million Medicare recipients will enjoy significant cost savings. It’s worth noting that Medicare beneficiaries taking the ten drugs chosen for negotiation paid an aggregate total of $3.4 billion in out-of-pocket costs for such medications in 2022, per the Department of Health and Human Services.<br /> <br /> “For far too long, Americans have paid more for prescription drugs than any major economy,” Biden remarked in an official statement released from The White House. “And while the pharmaceutical industry makes record profits, millions of Americans are forced to choose between paying for medications they need to live or paying for food, rent, and other basic necessities. Those days are ending.”<br /> <br /> Big Pharma, as Biden alluded to, is naturally not so giddy about this news. In fact, the pharmaceutical industry has been hellbent on hindering such efforts, recently filing eight lawsuits in federal courts across the U.S. declaring the program unconstitutional. However, as has been the consensus among legal experts, the Biden administration has opined that there is no provision in the U.S. Constitution that prevents it from negotiating medication prices.<br /> <span style="letter-spacing:.3pt"><br /> “The Biden-Harris Administration isn’t letting anything get in our way of delivering lower drug costs for Americans,” Secretary of Health and Human Services Xavier Becerra said in a statement back in June. “Pharmaceutical companies have made record profits for decades. Now they’re lining up to block this administration’s work to negotiate for better drug prices for our families. We won’t be deterred.”</span><br /> <br /> If pharma companies opt not to comply with the process, they will have to pay an excise tax of up to 95% of <span style="letter-spacing:.3pt">the medications’ U.S. sales or remove all their products from the Medicare and Medicaid markets. Some in the pharmaceutical industry contend that many of the medications on the list already have large rebates and discounts due to negotiations that currently occur in Part D insurance plans while others predict that the actual penalty will run as high as 1,900% of sales. And, of course, this program will not subside in 2026: per the </span>Inflation Reduction Act, the federal government can choose up to fifteen more drugs for negotiation in 2027, another fifteen drugs for 2028, and as many as 20 more drugs each year thereafter.<br /> <br /> But Biden has made it abundantly clear that he is not backing down against Big Pharma. After all, taking on Big Pharma is central to his larger “Bidenomics” vision of rebuilding the American economy from the middle out and the bottom up.<br /> <br /> “Let me be clear: I am not backing down,” Biden said on the morning of the major unveiling. “There is no reason why Americans should be forced to pay more than any developed nation for life-saving prescriptions just to pad Big Pharma’s pockets.”<br /> <br /> But Big Pharma, and its supporters such as </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#333333">lobby group Pharmaceutical Research and Manufacturers of America (PhRMA), don’t see it that way. They see the drug repricing program as the U.S. government having unfettered power, which they say would, in effect, stymie innovation in medical research and development.<br /> <br /> As Ameet Sarpatwari, an assistant professor at Harvard Medical School, told NPR following the August 29 announcement, “This is going to be a heavyweight battle.”</span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> 1272Protecting the Most Vulnerablehttps://www.phiagroup.com/Media/Posts/PostId/1271/protecting-the-most-vulnerableBlog,Balance BillingThu, 24 Aug 2023 17:21:46 GMT<p style="margin-bottom: 15pt; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="color:#374151">By: Corey Crigger, Esq. </span></span></span></span></p> <p style="margin-bottom: 15pt; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="color:#374151">In February 2022, we received a balance bill referral that was truly exceptional, but for all the wrong reasons. Our client received a staggering bill of over $675,000.00 after a premature delivery with major complications resulted in a two-month stay in the NICU. It was an unjust financial burden exacerbating an already challenging situation.</span></span></span></span></p> <p style="margin-bottom: 15pt; margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt">Our Efforts to Help:</span></b> <span style="font-size:12.0pt"><span style="color:#374151">We immediately sprang into action, aiming to halt collection efforts while devising a strategy to achieve desired results. While the provider was unwavering in their stance, our #PatientDefenseProgram Partner Firm came to our aid. After over a year of negotiations, the provider eventually agreed to a settlement of an additional $50,000. </span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="color:#374151">This isn't just a victory for The Phia Group and the Balance Bill SafeGuard program; it's a triumph for a family that should never have been subjected to this ordeal. If you're seeking to protect your clients from similar situations, get in touch with The Phia Group today.</span></span></span></span></p> 1271Wegovy: The Heart of the Matterhttps://www.phiagroup.com/Media/Posts/PostId/1270/wegovy-the-heart-of-the-matterBlog,Health Insurance,Healthcare Costs,Hospital BillsFri, 18 Aug 2023 13:15:29 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">By: David Ostrowsky </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment?</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">On August 8, Novo Nordisk, the Danish pharmaceutical juggernaut, unveiled the intriguing results of a large-scale clinical study documenting the efficacy of its obesity drug called Wegovy: of the nearly 18,000 participants aged 45 years or older suffering from both obesity and cardiovascular disease, 20 percent were found less likely to suffer from further heart disease and stroke symptoms after taking Wegovy. Perhaps, as the results indicated, obesity drugs such as Wegovy do not merely help patients shed weight but also deliver other long-term health benefits. The five-year trial was the first to demonstrate that an obesity drug could trigger lasting benefits to cardiovascular health for patients who are overweight but do not necessarily have diabetes. </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">So, now the question becomes will such promising results make more insurers feel inclined to provide coverage for a drug that costs $1,349 a month and whose documented benefits have yet to be chronicled in a peer-reviewed or medical journal? </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">(Novo has said it plans to present the results at a conference later this year.) <span style="background:white"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">“It’s going to make it much harder to deny coverage and not pay for these products for a non-diabetic population,” noted Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management, in the August 8 edition of the <i>New York Times</i>. “It’s going to make it very difficult to make the argument that this isn’t part of an essential health benefit when there are cardiovascular benefits.” </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">It's undeniable that Wegovy has potential for delivering profound benefits for those afflicted with heart disease, which remains the deadliest – not to mention costliest – malady in America. Consider that the study’s reported 20 percent lower incidence of heart attack was considerably higher than the 15-17 percent range anticipated by investors and industry analysts. Also, it’s not as though Novo Nordisk is an unproven entity in the world of pharma. </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Another version of a weight loss drug manufactured by Novo Nordisk, Ozempic, has been approved for reducing blood sugar levels in adults with type 2 diabetes and has been found to lower the risk of heart complications in diabetic patients. <span style="background:white"></span></span></span></span></span></span></span></p> <p class="css-at9mc1" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span style="vertical-align:baseline"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">But there’s still murkiness surrounding the findings and legitimate questions as to whether insurance companies will see direct cost savings by covering the medication. </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Novo Nordisk posited that Wegovy reduced the overall risk of heart attacks, strokes and cardiovascular deaths by 20 percent, but the company failed to categorize the effects of the drug on each of those outcomes individually.<span style="background:white"><span style="color:black"> Meanwhile, Novo Nordisk also did not detail how much weight patients lost or provide details on side effects of the drug (reportedly, patients have reported experiencing nausea, diarrhea, vomiting, constipation and stomach pain) that may have deterred a sizable number of patients from completing the trials. </span></span><span style="background:white"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">On another level, though, perhaps due to the well-publicized favorable results stemming from the Wegovy clinical trials, there will be a shift in how mainstream society – and not just the medical field – perceives obesity. Perhaps, this recent development – the emergence of widely accepted empirical evidence proving obesity is a biological condition that can be treated with a medical remedy – will move the needle in making the epidemic less stigmatized.</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p class="css-at9mc1" style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span style="vertical-align:baseline"><span style="font-family:"Times New Roman",serif"><span style="background:white"><span style="color:black">As </span></span><span style="color:black">Dr. Ania Jastreboff, an endocrinologist and obesity-medicine specialist at Yale University, was quoted as saying<span style="background:white"> in the aforementioned August 8 <i>New York Times</i> article, </span>“Obesity’s not a personal choice <span style="background:white">–</span> it’s not behavioral, it’s not something that people choose. Medications like this, we believe, are potentially treating that underlying biology.”</span></span></span></span></span></p> 1270Empowering Plans: P169 – Let’s Keep Learning - Back to (Law) Schoolhttps://www.phiagroup.com/Media/Posts/PostId/1269/empowering-plans-p169-lets-keep-learning-back-to-law-schoolPodcastsThu, 17 Aug 2023 20:18:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/GfqZpnOdWYU" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;"><span style="font-size:12.0pt">In the latest edition of the Empowering Plans podcast series, “</span></span><span style="font-size:12.0pt"><span style="color:#000000;">Let’s Keep Learning - Back to (Law) School,” Attorneys Kelly Dempsey and Corey Crigger are here to take us all back to school! Listen as they discuss renewal season preparation items and a variety of late breaking lawsuits that pertain to multiple aspects of the self-funded industry. From civil courts hearing cases about NSA administrative issues all the way to ACA compliance (or lack thereof) there is something in this podcast for everyone. Once you listen to the podcast - class dismissed! </span><br /> <a href="https://www.youtube.com/watch?v=6PATqw1WDDY" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce"></span></a><br /> <a href="https://youtu.be/GfqZpnOdWYU"><span style="color:#0071ce">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://youtu.be/GfqZpnOdWYU"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1269A Duty to Serve and Protect … the Planhttps://www.phiagroup.com/Media/Posts/PostId/1268/a-duty-to-serve-and-protect-the-planWebinarsThu, 17 Aug 2023 11:50:09 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Think you can’t be sued for breaching a fiduciary duty?  Think again!  Lawsuits filed by plan sponsors against their claims administrators are gaining increased media attention.  Between talk of a possible recession and passage of new laws such as the No Surprises Act, employers are tightening their belts and examining their partners with renewed vigor.  Accusations suggest that anyone managing plan assets has a fiduciary duty to do so prudently.  Regardless of fiduciary status, only those who carefully examine claims, manage appeals, navigate disputes, curb plan spending, and leverage all possible sources of reimbursement will likely avoid such scrutiny.  Join The Phia Group for another complimentary webinar.  Their team will contemplate strategies applicable to every stage in a claim’s lifecycle, and divulge best practices that will keep you out of the court house.</span></span></span></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://attendee.gotowebinar.com/recording/6869555569524625582">Click Here to View Our Full Webinar</a><br /> <br /> To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span></p> 1268The Power Dynamics of Gag Clauseshttps://www.phiagroup.com/Media/Posts/PostId/1267/the-power-dynamics-of-gag-clausesBlog,Health Insurance,Healthcare Costs,Self FundingMon, 14 Aug 2023 14:23:09 GMT<p style="text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">By: Jon Jablon, Esq. </span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights are immense, and it’s worth looking into the power dynamics at play since it’s not quite as simple as saying that plans can no longer have these gag clauses.</span><br /> <b><span style="font-size:12.0pt"><br /> A Brief History: The Emergence of Gag Clauses</span></b></span></span><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> <br /> Per the Consolidated Appropriations Act 2021, the now-impermissible “gag clauses” are contractual terms that tend to prohibit health plans from receiving or disclosing specific information about providers, particularly relating to the cost or quality of care. Historically, health plans and their vendors could, and often did, freely enter into agreements that included gag clauses. This secrecy has been an unfortunate staple of the self-funded industry, and has played a part in preventing many health plans and plan participants from truly understanding (and, sometimes, presented a barrier to compliance with) their contractual obligations.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> While the intention of the gag clause prohibition is to foster transparency and consumer protection, the introduction and enforcement of the prohibition has raised some eyebrows, particularly concerning the balance of power in the self-funded health insurance industry. In particular, many are less than thrilled that the onus is placed on the health plan to avoid agreeing to gag clauses rather than, for instance, the onus being placed on a vendor with far greater bargaining power to avoid attempting to impose gag clauses to begin with.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> Bargaining Power and The Shadows of Big Players</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> Larger entities, most predominantly vast national PPO networks that so many health plans and TPAs ally with, possess inequitably-high bargaining power, given their relative ubiquity. Leaving aside the talking point that these national networks provide relatively little cost-containment value for health plans, instead offering prohibition on balance billing (which is certainly valuable, but not in the cost-containment context) alongside discounts so small as to be virtually meaningless in many cases, their geographic and market dominance allows them to set terms that are favorable to them and their contracted providers, often sidelining transparency, and often intentionally. What we’ve seen is that the larger the entity, the more likely it is to use gag clauses as strategic tools to maintain their market stronghold.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> Inequity in the Requirement: <i>Why Health Plan</i>s?</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> The statutory prohibition on gag clauses is placed squarely on health plans, which presents an inherent and undeniable bias. Surely Congress knows that it’s <i>not</i> health plans, but their vendors, that impose these clauses; these vendors push for such clauses to safeguard their interests, keeping cost structures and quality metrics under wraps specifically to quash transparency. Health plans are the unfortunate victims of this power imbalance and therefore gag clauses, not the perpetrators.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> In light of that, putting the onus solely on health plans seems a bit unjust, effectively holding a health plan accountable for a provision that a given health plan very likely didn't <i>want,</i> but had no choice but to accept due to the power dynamics at play. Lest we forget, too, that even given this gag clause prohibition, <i>vendors</i> are certainly not prohibited from attempting to demand the continued existence of gag clauses; vendors remain free to make demands, and the prohibition on gag clauses does not extend to a vendor – but health plans prohibited from <i>accepting</i> those gag clauses. Placing this limitation on health plans sidesteps the real culprits that do actually promote gag clauses, and we continue to see vendors trying to put a wolf in sheep’s clothing by trying to promote not-quite-so-obvious gag clauses, but gag clauses nonetheless.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> Crossroads for TPAs</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> As they so often are, TPAs are caught in the whirlwind of all this. As with so many other aspects of their business, TPAs must walk a tightrope between providing comprehensive assistance to health plans and increasing their workload and responsibility. To pile on more confusion, many employer groups simply expect their TPAs to handle the discovery of gag clauses, attestation of whether there are gag clauses, and future avoidance of gag clauses as part of their normal business, which can lead to some awkward conversations.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> A Call for a More Balanced Approach & Support</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> Though the gag clause prohibition (and the resultant requirement to attest to whether or not there are currently any gag clauses in place) is a tangible issue that TPAs, health plans, and other players in the industry need to proactively deal with, the prohibition itself offers a window into the larger power imbalances in the self-funded marketplace, and the perhaps somewhat misguided . As regulations evolve, we sincerely hope that the powers that be recognize the urgent need to more evenly balance this power, ensuring that health plans are not unduly burdened, nor vendors given a free pass.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> The American healthcare system is as much about patient well-being as it is about business dynamics (though some might say that business dynamics are more prominent in many ways). As the various stakeholders navigate these murky waters, a holistic approach that considers the roles and influences of all entities, big or small, is crucial, and we hope that Congress eventually agrees. For now, though, health plans have a tough road ahead. </span></span></span><br /> <b><i><span style="font-size:12.0pt"><span calibri="" style="font-family:"><br /> Please don’t forget that The Phia Group is here to help! ICE clients, don’t hesitate to use your dedicated ICE inbox for gag clause-related support at no additional cost. Others needing support can reach out to <a href="mailto:PGCReferral@phiagroup.com" style="color:#0563c1; text-decoration:underline">PGCReferral@phiagroup.com</a> for assistance.</span></span></i></b></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin-left:.5in; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> 1267Empowering Plans: P168 – “Drafting” Plan Exclusionshttps://www.phiagroup.com/Media/Posts/PostId/1266/empowering-plans-p168-drafting-plan-exclusionsPodcastsFri, 04 Aug 2023 13:10:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/6PATqw1WDDY" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="color:#000000;">In this episode of Empowering Plans, Andrew Silverio and Kevin Brady discuss the unanticipated costs of playing pickleball and then “draft” their favorite (and least favorite) plan limitations and exclusions. Let us know who you think had the better picks!</span><br /> <span calibri=""><a href="https://www.youtube.com/watch?v=6PATqw1WDDY" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce"><br /> Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=6PATqw1WDDY" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> 1266Empowering Plans: P167 – Who is a Fiduciary and Does it Even Matter? Lawsuits Abound!https://www.phiagroup.com/Media/Posts/PostId/1262/empowering-plans-p167-who-is-a-fiduciary-and-does-it-even-matter-lawsuits-aboundPodcastsFri, 21 Jul 2023 12:55:59 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/jSpSOLpolqE" title="YouTube video player" width="560"></iframe></p> <p><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="color:#000000;">In this episode of Empowering Plans, The Phia Group’s Chief Legal Officer – Ron Peck – and Sr. VP of Consulting – Jennifer McCormick, analyze recent lawsuits involving self-funded plan sponsors and their third party administrators, and accusations of fiduciary breach on the part of TPAs.  We delve into whether TPAs can be fiduciaries, what this means, and whether it even matters when it comes down to how administrators manage plans.  Finally, are plan sponsors signing contracts enabling TPAs to do things contrary to ERISA, and who is to blame when this is the case?  Anyone and everyone handling self-funded plan assets needs to tune into this one! </span><span calibri=""><a href="https://youtu.be/0GRiq4kgrSQ" style="color:#0563c1; text-decoration:underline"><span style="color:#000000;"> </span></a></span></span></span></p> <p><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span calibri=""><a href="https://www.youtube.com/watch?v=jSpSOLpolqE" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=jSpSOLpolqE" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1262The Phia Group's 3rd Quarter 2023 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1261/the-phia-groups-3rd-quarter-2023-newsletterNewslettersMon, 17 Jul 2023 19:42:27 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/Q3 2023/newheader3.jpg?ver=Xf-DeK8bMpWJu1_N4km31g%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/Q3 2023/block071723.png?ver=v3YsgLyVQrqpmhzTUV7J8A%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pace3"><img src="/Portals/phiagroup/Newsletters/Q3 2023/block071723_2.png?ver=v3YsgLyVQrqpmhzTUV7J8A%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="290" src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" width="299" /></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;">I love July! Here in New England the weather is perfect – not too hot, not too cold … just right. The same can be said for the services and advice that we at The Phia Group bring to the industry … just right. Speaking of what we bring to the industry, I am so proud of the amazing “Phia Forum” event we hosted last month in gorgeous Newport, Rhode Island for select clients and partners. We showcased both our talented staff and future endeavors. My hope going into the affair was that those in attendance would not only see that The Phia Group is comprised of hundreds of passionate individuals who have come together to deliver the best in cost containment and regulatory guidance for our clients, but also, that we are combining legal knowhow with a focus on future technologies to build some of the most impressive products and services. My lofty hopes were exceeded in every way.</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;">As usual, everyone raved about the numerous subject matter experts who displayed their knowledge and experience while doing so with energy and gusto. Our guests also readily shared, however, that while they have always known that we are the preeminent experts when it comes to health care laws and regulations, they now see The Phia Group in another light – as an organization that is on the cutting edge when it comes to our software and technical prowess. We lead in process efficiency, price and quality transparency, compliance and regulatory demands, cost containment delivery, plan design and fiduciary prowess. I am so proud of what we have built here at The Phia Group and I am excited to see what the next few years will bring.</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="#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 2023 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#EEOQ">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="pace3" name="pace3"></a></p> <p class="bodytext"><strong>Service Focuses of the Quarter: Phia Unwrapped</strong> </p> <p class="bodytext" style="text-align: justify;">Ever feel like the tiny discounts and auditing restrictions of wrap, extender, and other leased networks aren't doing enough for you or your groups? Phia Unwrapped is the solution. We replace typical wrap network access and traditional non-network payment methods to secure the lowest possible payment, while still abiding by defensible fair market standards. </p> <p class="bodytext" style="text-align: justify;">With Phia Unwrapped, an EDI feed ensures that claims are automatically flagged, transferred, and repriced; fees are based on a percentage of your actual savings, so you'll get great savings without unexpected or undeserved costs. </p> <p class="bodytext" style="text-align: justify;">Claims processed through our Unwrapped program have averaged a 74% savings off billed charges. That's three times the average wrap discount. We don't set any minimum on claims for repricing or negotiation, and we strive to get providers to accept the plan's payment as full ― and if there are issues or balance-billing, our experienced Provider Relations team is prepared to handle it. </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="russo4"></a> <p class="bodytext" style="text-align: justify;"><strong>Enhancement of the Quarter: Ignite Pricing Engine</strong></p> <p class="bodytext" style="text-align: justify;">Get ready for The Phia Group’s Ignite Repricing Engine, our supercharged cost-containment powerhouse, built specifically to supplement our Unwrapped, No Surprises Act Support, and Balance Bill Support services. </p> <p class="bodytext" style="text-align: justify;">We've designed Ignite to be a precise and efficient pricing model to help you better navigate the sea of healthcare claims confusion. Especially in light of the No Surprises Act and its various complex demands, taking into account everything from quality and cost to market effects on claims has never been more important. That's why the Ignite Repricing Engine doesn't just meet these challenges, but it runs circles around them, providing you with a smooth, reliable, and budget-friendly solution. </p> <p class="bodytext" style="text-align: justify;">Aside from the next-generation software we’ve designed, the magic of Ignite is the team that powers it. With a combination of certified clinical and medical coding professionals, legal eagles, process and reporting experts, and administrative staff (22 individuals in total!), our team has strong expertise in all parts of the process. Ignite stands out for its unparalleled defensibility, integration of quality metrics, and compatibility with future technology. </p> <p class="bodytext" style="text-align: justify;">Integration isn’t just a buzzword for the Ignite Repricing Engine. We’ve designed it to thrive on standard SFTP and 837 files – and even for our partners with platforms using more advanced tech, Ignite is versatile enough to be bound to any platform for pricing and support on claims and disputes through Phia’s Provider Relations Operating System (PROS) software. </p> <p class="bodytext" style="text-align: justify;">Using vast amounts of data, strategic benchmarking, reliable quality metrics, and artificial intelligence – and a crack team of humans as well – the Ignite Pricing Engine will soon be revolutionizing claims handling.</p> <p class="bodytext"><strong>Phia Case Study:</strong></p> <p class="bodytext" style="text-align: justify;">A client of Phia’s Independent Consultation and Evaluation (ICE) service received stop-loss reimbursement denial in the amount of $140,000; the denial involved claims incurred by an employee who was out of work on a lengthy and unpaid, but approved, personal leave of absence. </p> <p class="bodytext" style="text-align: justify;">The employee handbook provided for one unpaid, personal leave of absence per year, but the employee had allegedly taken two, per the stop-loss carrier. There were no other explicit references made to other leaves of absence in the employee handbook. The Plan Document did not clearly reference leaves of absence under the continuation of coverage section. Phia’s legal team analyzed the applicable documents and found the best language in each to make the case that the carrier should reimburse the claims at issue. This is a stop-loss policy we had seen before, and we found terms in it that undercut the carrier’s argument, as well as language in the Plan Document that provided significant discretion to the employer. We also found additional details surrounding the actions taken by the Human Resources department that benefitted the employer’s position. </p> <p class="bodytext" style="text-align: justify;">Ultimately, after formulating the best positions for the Plan to take, Phia drafted content for a letter that the TPA sent to the stop-loss carrier, which ultimately led to the carrier reversing its denial, and reimbursing the Plan $140,000. </p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Doing What The SPD Says!</strong></p> <p class="bodytext" style="text-align: justify;">We still find ourselves revisiting this important fiduciary duty every so often, since it is perpetually relevant and it never stops being problematic for many – especially in light of drastic industry changes. As one example, many SPDs have not been updated to account for the many requirements of the No Surprises Act! </p> <p class="bodytext" style="text-align: justify;">Here are some general suggestions about SPD language in light of the NSA, and how to best ensure compliance with this important fiduciary duty of complying with the SPD: </p> <p class="bodytext" style="text-align: justify;">• Try to update SPDs as soon as possible when new laws become applicable </p> <p class="bodytext" style="text-align: justify;">• Avoid “lesser of” payment language since network contracts, an Independent Dispute Resolution decision, or a court might contradict it </p> <p class="bodytext" style="text-align: justify;">• Make sure the plan has authority to pay a negotiated rate or IDR directive if there is one </p> <p class="bodytext" style="text-align: justify;">• Clearly explain the plan’s patient responsibility calculations with an eye on compliance </p> <p class="bodytext" style="text-align: justify;">• Allow payments based on IDR or court decisions when appropriate </p> <p class="bodytext" style="text-align: justify;">• Ensure that there is a clear distinction between a denial eligible for a normal plan appeal (such as under ERISA) and a denial eligible for open negotiations and potentially IDR</p> <p class="bodytext"> </p> <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 May 18, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/the-business-of-benefits">“The Business of Benefits,”</a> in which we discussed current issues and case studies that impact the success of organizations in the health benefit plan industry. </p> <p class="bodytext" style="text-align: justify;">• On April 20, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/before-and-after-examples-of-mistakes-that-were-addressed-and-how-to-avoid-them">“Before and After – Examples of Mistakes that Were Addressed and How to Avoid Them,”</a> in which we discussed case studies and examples where The Phia Group was called upon to address some avoidable losses, as well as compare them to scenarios where the proper preemptive steps were taken. </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 June 26, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p165-artificial-intelligence-meets-subrogation">“Artificial Intelligence Meets Subrogation,”</a> in which our hosts, Jon Jablon and Cindy Merrell, discussed how AI could have a monumental impact on the field of subrogation within the larger context of healthcare law. </p> <p class="bodytext" style="text-align: justify;">• On June 9, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p164-the-key-to-a-successful-self-funding-experience-knowledge">“The Key to a Successful Self-Funding Experience: Knowledge!”</a> in which our hosts, Andrew Silverio and Christopher Aguiar, discussed the challenges that arise when self-funded plans aren’t educated about their benefit offerings, risk mitigation mechanisms, and cost containment tools ensuring the plan’s viability. </p> <p class="bodytext" style="text-align: justify;">• On May 19, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p163-chatgpt-disrupting-the-healthcare-industry">“ChatGPT: Disrupting the Healthcare Industry,</a>” in which our hosts, Brady Bizarro and Brian O’Hara, discussed ChatGPT and how it affects the healthcare industry, and in particular, the advantages and potential disadvantages of using AI to act as a virtual assistant for patient care. </p> <p class="bodytext" style="text-align: justify;">• On May 12, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p162-mind-the-gap-20-dont-be-afraid-to-ask-for-a-handbook">Mind the Gap 2.0: Don’t be Afraid to Ask for a Handbook</a>,” in which our hosts, Kelly Dempsey and Kevin Brady, described our Handbook Gap Free Reviews service and discussed the case studies which gave rise to this service. </p> <p class="bodytext" style="text-align: justify;">• On April 28, 2023, The Phia Group presented “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p161-new-challenges-to-old-favorites-nsa-aca-and-more-acronyms">New Challenges to Old Favorites – NSA, ACA, and more (Acronyms)!</a>” in which our hosts, Nick Bonds and Corey Crigger, discussed the No Surprises Act (NSA) and the Affordable Care Act (ACA), as well as the recent legal challenges out of Nick’s home state of Texas. </p> <p class="bodytext" style="text-align: justify;">• On April 18, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p160-how-the-ending-of-covid-era-national-emergency-impacts-your-health-plan">“How the Ending of COVID-era National Emergency Impacts Your Health Plan,”</a> in which our hosts, Jen McCormick and Joanie Verinder, discussed the sudden end to the National Emergency, the ways in which health benefit plans are affected, and the information their respective participants need to be aware of.</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/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/2023/06/20/factors-for-compliance-caa-gag-clause-attestations/">Factors for compliance: CAA gag clause attestations</a> – June, 2023 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/Gene_and_Cell_Therapy-Where_Compassion_and_Cost_Collide_by_Jen_McCormick%2C_Esq.pdf">Gene and Cell Therapy: Where Compassion and Cost Collide</a> – May, 2023 </p> <p class="bodytext" style="text-align: justify;">• America’s Benefit Specialist – <a href="https://user-35215390377.cld.bz/America-s-Benefit-Specialist-April-2023/4/">Price transparency Issues</a> – April, 2023 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/Eli_Lilly_Caps_Insulin_Cost_by_David_Ostrowsky.pdf">Eli Lilly Caps Insulin Cost</a> – April, 2023 </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></p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/merck-vs-biden">Merck vs. Biden</a>. A first attempt by a drugmaker to challenge the Medicare drug price negotiation program contained in the Inflation Reduction Act. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/what-happens-when-auto-and-health-insurance-collide">What Happens When Auto and Health Insurance Collide?</a> An overview of the intersection of auto insurance and health benefits in the event of an auto collision. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/a-weight-off-my-chest">A Weight Off My Chest</a>. A discussion of health plans and how they are affected by the increasing number of prescriptions of drugs with weight loss properties. </p> <p class="bodytext" style="text-align: justify;">•<a href="https://www.phiagroup.com/Media/Posts/autism-benefits-dol-enforcement-for-sufficient-coverage"> Autism Benefits: DOL Enforcement for Sufficient Coverage.</a> The Department of Labor (DOL) strongly advocates for more comprehensive autism coverage under group health plans. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/digitizing-subrogation">Digitizing Subrogation</a>. Read about The Phia Group’s own digitization of The Phia System and Case Management System. </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>.</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>The Stacks:</span></p> <p class="bodytext" style="text-align: justify;"><strong>Gene and Cell Therapy: Where Compassion and Cost Collide</strong></p> <p class="bodytext" style="text-align: justify;">By: Jen McCormick, Esq. – June 2023 – <a href="https://www.sipconline.net/files/Gene_and_Cell_Therapy-Where_Compassion_and_Cost_Collide_by_Jen_McCormick%2C_Esq.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">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.</p> <p class="bodytext" style="text-align: justify;"><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>Eli Lilly Caps Insulin Cost</strong></p> <p class="bodytext">By: David Ostrowsky – April 2023 – <a href="https://www.sipconline.net/files/Eli_Lilly_Caps_Insulin_Cost_by_David_Ostrowsky.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">On March 1, Eli Lilly, a pharmaceutical company with vast global reach, announced that it was indeed capping the out-of-pocket cost of its insulin at $35 a month—in addition to slashing the price of its two highest-selling insulin products, Humalog and Humulin, by 70%—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. </p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2023-newsletter">Click here to read the rest of this article.</a>  </p> <br /> <a href="#top">Back to top ^</a> <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 Boys & Girls Clubs’ mission 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 Clubs of Metro South (BGCMS) was founded in 1990 to create a positive place for Brockton, Massachusetts, youths. It immediately met a need in the community: in the first year alone, 500 youngsters, ages 8-18, became members. In the 30-plus years since then, BGCMS has expanded its scope exponentially by offering a unique mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since BGCMS’ founding, over 20,000 youths have been welcomed. Currently, they serve over 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>Boys & Girls Club of Metro South 2023 Bids for Kids Gala Auction</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group was the Cocktail Reception Sponsor at the Boys & Girls Club of Metro South 2023 Bids for Kids Gala Auction on April 14, 2023, at Gillette Stadium. Thanks to the bids, donations, and dedication from the Boys & Girls Club’s partners, including Phia and special surprise guest New England Patriots quarterback Mac Jones, this event raised half a million dollars towards youth development programming!</p> <p><img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/auction77.png?ver=wm3UfTvLsMespqjJL9UgZw%3d%3d" style="width: 547px; height: 399px;" /></p> <p class="bodytext"><strong>Boys & Girls Club Youth of the Year Scholarship</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Each year, the Boys & Girls Club 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’s signature effort to foster a new generation of leaders, fully prepared to live and lead in a diverse and integrated world economy. The Phia Group is a proud sponsor of the local competition and awards the winner with a $5,000 scholarship and a laptop. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">On March 27, 2023, we hosted the competition for this scholarship in our Canton office. There were four candidates, and the winner, 2023 Youth of the Year, is Sarah Chavez, pictured below with Phia’s Co-Founder and CEO, Adam!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/charity77.png?ver=w7a2O8HOgjI2xcjg6TIeRg%3d%3d" style="width: 310px; height: 414px;" /> <p class="bodytext" style="font-weight: normal; text-align: justify;"><br /> The 2022 Youth of the Year, Kiley Georges, and the President/CEO of The Boys & Girls Club of Metro South, Derek Heim, both spoke at our conference in Newport on Monday, June 12.</p> <p class="bodytext"><strong>The Phia Group Great Futures Scholarship</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">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 has first-hand experience understanding the struggles and challenges of overcoming obstacles, facing adverse circumstances, and the determination necessary for self-perseverance. The Great Futures Scholarship recognizes one graduating senior annually for their commitment to education and dedication to a better future. With Adam’s vision, our club annually awards a $10,000 scholarship to assist one student in their pursuit of their educational dreams as they develop a strong work ethic and self-appreciation. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The 2023 Youth of the Year, Sarah Chavez, also won the 2023 Phia Group Great Futures Scholarship… bringing her total to $15,000 from The Phia Group!</p> <p class="bodytext"><strong>The Leukemia and Lymphoma Society</strong></p> <p class="bodytext" 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 proudly supported the noble organization by participating in the “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="" src="/Portals/phiagroup/Newsletters/Q3 2023/society1.png?ver=6Yoe2RobmhoeSkDuuT7pFg%3d%3d" style="width: 391px; height: 472px;" /> <p><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">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/Q3 2023/topplaces2023.png?ver=h7f0DVUWuNKhSgamTaA6eQ%3d%3d" style="width: 377px; height: 397px;" /></p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>May is Mental Health Awareness Month</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">In May, Phia held different activities each week such as Meditation Mondays, encouraging employees to take a break from their busy days for a brief guided meditation to help reduce negative emotions and build concentration. Employees were able to follow along anywhere — at their desks, outside, or at home! Phia also held Wellness Wednesdays to provide employees with a fun and stress-free activity during/after lunch, including Chit Chat & Color, Paint & Plant, and Food Truck & Trivia. Our remote employees in Idaho got together for a nature walk, and our employees in Louisville painted birdhouses together.</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/mh1.jpg?ver=w7a2O8HOgjI2xcjg6TIeRg%3d%3d" style="width: 515px; height: 314px;" /> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/mh2.jpg?ver=cv75MXB2IuN8fKuPo_OP0Q%3d%3d" style="width: 515px; height: 313px;" /></strong> <p class="bodytext"><strong><br /> May Mixer</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">On May 25, 2023, Phia employees gathered at Trillium Brewery for our May Mixer! There was no better way to usher in the Memorial Day weekend than getting together for craft beers and homemade pizzas in postcard weather.</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/maymixer.png?ver=WImmPEPvXEtNU0uXKWLbFw%3d%3d" style="width: 521px; height: 370px;" /> <p class="bodytext"><strong><br /> Trivia Champions</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">A small group of Phians went out for some 2000-2010 Pop Culture Trivia and won 1st Place! Congratulations to everyone who was able to attend!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/triviachamps.png?ver=9pHQXbnh4BwS_KJk3FnuTQ%3d%3d" style="width: 612px; height: 458px;" /> <p class="bodytext"><strong><br /> Leader Appreciation Event</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Phia held this event for Team Leads & above in honor of all their hard work! There were handwritten, personalized notes from Adam and gift cards for everyone. Everyone who attended was also entered into a raffle to win amazing prizes, such as Ed Sheeran concert tickets, Red Sox tickets in the first row behind home plate, Red Sox tickets in the grandstand behind home plate with field access, batting practice, and a tour before the game, tickets to TreeTop Adventures, and a brewery gift certificate.</p> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/appreiciation2.png?ver=cAc63QMcReaE8x_QMtCysw%3d%3d" style="width: 510px; height: 358px;" /></strong> <p class="bodytext"><strong><br /> Wednesday Lunches: Food Trucks & BBQs</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Each Wednesday, Phia caters lunch for everybody, giving employees the opportunity to chat and eat together!</p> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/foodtruck.png?ver=jbf0bwhkSoEEDPM3nL3_CQ%3d%3d" style="width: 581px; height: 412px;" /></strong> <p class="bodytext"><strong><br /> 1st Ping Pong Tournament</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Phia held its first-ever ping pong tournament, and the winner was Boris Senic! The top two players were he and his brother, Igor.</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/pinfpong.jpg?ver=fHFZ1M3yMHtxlQNP0W1JBQ%3d%3d" style="width: 398px; height: 206px;" /> <p class="bodytext"><strong><br /> Cleveland Opening Day</strong></p> <p class="bodytext" style="font-weight: normal">On April 6, 2023, Phia held a bbq to celebrate Cleveland Opening Day, as well as Adam’s birthday!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/clevelandopen.png?ver=h7f0DVUWuNKhSgamTaA6eQ%3d%3d" style="width: 422px; height: 207px;" /><a id="EEOQ" name="EEOQ"></a> <p class="bodytext"><strong><br /> Get to Know Our Employee of the Quarter: Brittney Willoughby</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 Brittney Willoughby as The Phia Group’s 2023 Q2 Employee of the Quarter!</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"> Here is one person’s comments about Brittney: “Brittney not only goes above and beyond daily to ensure the success of her team, she also takes care of business in the Louisville office that is not in her job description, such as ensuring that all desks are set up with proper IT equipment and that the equipment is up and running in time for new hires to start work. This takes extra hours away from her team but she does whatever is asked with zero complaint.”</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q3 2023/brittney.png?ver=S8_D1ev5WpDlzHQhEryUvw%3d%3d" style="width: 312px; height: 312px;" /><br />   <p class="bodytext" style="font-weight: normal">Congratulations Brittney, 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 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.">https://siiaconferences.org/nationalconference/2023/index.cfm. </a><br />  </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Job Opportunities:</span></p> <p class="bodytext" style="font-weight: normal">• Claims Negotiator </p> <p class="bodytext" style="font-weight: normal">• Customer Care Representative </p> <p class="bodytext" style="font-weight: normal">• Claim and Case Support Analyst </p> <p class="bodytext" style="font-weight: normal">• Project Manager (PMO) </p> <p class="bodytext" style="font-weight: normal">• Project Coordinator (PGC)</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"><strong>New Hires</strong></p> <p class="bodytext">• Bridget Binda was hired as Case Investigator. </p> <p class="bodytext">• Brittany Farr was hired as Sr. Customer Care Auditor and Trainer. </p> <p class="bodytext">• Vrushali Nar was hired as Instructional Designer. </p> <p class="bodytext">• Susan Bodner was hired as Claim Recovery Specialist – WC. </p> <p class="bodytext">• Jack Lauro was hired as Canton High Extern. </p> <p class="bodytext">• Andrew Sheehan was hired as Customer Service Rep. </p> <p class="bodytext">• James Ruel was hired as EDI Data Engineer. </p> <p class="bodytext">• Sabina Gill was hired as Customer Service Rep. </p> <p class="bodytext">• Kaya Dua was hired as DSG Intern. </p> <p class="bodytext">• Gabby Peck was hired as Data Quality Analyst. </p> <p class="bodytext">• Allison Jo was hired as Marketing Intern. </p> <p class="bodytext">• Robert Lewis was hired as Director, Data Services. </p> <p class="bodytext">• Emily Kewer was hired as Lead Case Investigator. </p> <p class="bodytext">• Max Tremblay was hired as Claim and Case Support Analyst. </p> <p class="bodytext">• Jessie Boyle was hired as Content Specialist Intern. </p> <p class="bodytext">• Jamie Izlar was hired as Sr. Subrogation Attorney. </p> <p class="bodytext">• Owen Langan was hired as Claim and Case Support Analyst.</p> <p class="bodytext">• Tracey Wilson was hired as Sr. Claim Recovery Specialist.</p> <p class="bodytext">• Kiron Allen was hired as Customer Service Rep. </p> <p class="bodytext">• Laura Good was hired as HR Generalist.</p> <p class="boldtext">Phia Attending the SIIA National Conference</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">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">https://siiaconferences.org/nationalconference/2023/index.cfm</a>. </p> <a name="story"> </a> <p class="boldtext"><a name="story">  </a></p> <a name="story"> </a> <p class="bodytext"><a name="story"> </a></p> <hr class="horiz" /> <a name="story"> </a> <a name="story"> </a> <p class="bodytext"><a name="story"><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. </a></p> <a name="story"> </a> <p class="bodytext"><a name="story">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. </a></p> <a name="story"> </a> <p class="bodytext"><a name="story">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. </a></p> <a name="story"> </a> <p class="bodytext"><a name="story">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. </a></p> <a name="story"> </a> <p class="bodytext"><a name="story"><strong></strong></a><br />  </p> <a name="story"> </a> <p class="bodytext"><a name="story"></a><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> 1261Illuminated by Phia Ignite! Leveraging A/I and Multifaceted Price and Quality Datahttps://www.phiagroup.com/Media/Posts/PostId/1259/illuminated-by-phia-ignite-leveraging-ai-and-multifaceted-price-and-quality-dataWebinarsTue, 11 Jul 2023 12:55:55 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Benefit plans are struggling with the No Surprises Act, are overburdened by disproportionate expenses, and are butting heads with stop-loss over inadequate risk disclosures and network terms.  Meanwhile, too many are ignoring modern technology, and are overdependent on cost data while ignoring quality metrics.  Join The Phia Group’s leadership team as they present and dissect case studies addressing regulatory compliance, claim appeals, and dispute resolution. From the NSA and IDR, to transparency rules and provider pricing, The Phia Group’s best and brightest will show you a defensible payment strategy with Phia Ignite, as well as determine what role artificial intelligence will play. Drive costs down and address today’s most pressing industry issues by registering for this complimentary webinar.  There are sure to be some fireworks!<br /> <br /> <a href="https://attendee.gotowebinar.com/recording/8425746052543974495">Click Here to View Our Full Webinar</a><br /> <br /> To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></p> 1259The 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> 1258Empowering Plans: P166 – Delving Into Dobbs, One Year Inhttps://www.phiagroup.com/Media/Posts/PostId/1257/empowering-plans-p166-delving-into-dobbs-one-year-inPodcastsFri, 07 Jul 2023 16:27:30 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/0GRiq4kgrSQ" title="YouTube video player" width="560"></iframe></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:16px;"><span style="color:#000000;"><span calibri="" style="font-family:">In the latest episode of Empowering Plans, attorneys Nick Bonds and Kendall Jackson discuss the changes that have occurred in the past year following the Supreme Court’s decision in <i>Dobbs</i>. How will new abortion laws affect self-funded plans and what are the implications for their participants? Tune in to learn how plans can navigate these changes.</span></span><br /> <span calibri="" style="font-family:"><a href="https://youtu.be/0GRiq4kgrSQ" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce"><br /> Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://youtu.be/0GRiq4kgrSQ" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></p> 1257The Phia Group and Healthcare Recovery Solutions (HRS) Join Forces to Empower Healthcare Payers in Recovering Lost Dollars from PFAS, PFOA and PFOS Payoutshttps://www.phiagroup.com/Media/Posts/PostId/1255/the-phia-group-and-healthcare-recovery-solutions-hrs-join-forces-to-empower-healthcare-payers-in-recovering-lost-dollars-from-pfas-pfoa-and-pfos-payoutsPress ReleasesThu, 29 Jun 2023 20:39:29 GMT<p>FOR IMMEDIATE RELEASE</p> <p>6/29/2023</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 new="" roman="" style="font-family:" times=""><span style="color:#140028">CANTON, MA – </span></span></span></span>The Phia Group, a distinguished leader in healthcare cost containment, and Healthcare Recovery Solutions (HRS), a prominent healthcare mass tort subrogation expert, announce their most recent and pressing initiative. In response to an environmental crisis in the US, our team is launching a robust initiative to provide unparalleled recovery solutions for healthcare payer clients. Through the integration of our unique and exclusive capabilities, including patented, state-of-the-art mass tort data analytics and subrogation recovery specialists, we will offer an extraordinary opportunity for clients to identify and recover medical costs associated with toxic chemicals known as PFAS, PFOA and PFOS.<span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#140028"></span></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:">The urgency of this initiative is highlighted by the recent high-profile settlement reached on June 22, 2023, by Minnesota-based chemical and manufacturing company, 3M. The $10.3 billion settlement with U.S. municipalities addresses claims of water contamination caused by polyfluoroalkyl and perfluoroalkyl substances (PFAS), commonly referred to as "forever chemicals." Additionally, DuPont, Corteva, Solvay and other manufacturers announced settlements totaling several billion dollars for similar claims.<span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#140028"></span></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:">In response to this critical matter, The Phia Group and HRS' Subrogation and Recovery Services department are leveraging their decades of experience in mass tort subrogation, along with proprietary analytics and patented algorithms, to enforce their clients' recovery rights. Together, we will identify health benefit plans and plan members who may have suffered harm from not only 3M and DuPont products, but also a broader range of industrial and household products emitting hazardous chemicals.</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:">"With our subrogation expertise and formidable analytical data integration, we can identify these specific mass tort cases, place the appropriate parties on notice, and recover millions for our clients' health plans, which can be utilized for future medical claims," said Adam Russo, CEO of The Phia Group. "This isn’t your basic car accident subrogation case and that is why Phia is the premier recovery partner for your plans. These cases are tougher to find but the recoveries are worth the efforts.” </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:">Harnessing their combined subrogation and technical expertise, The Phia Group is now mobilizing to assist benefit plans, stop-loss carriers, plan members, and participants who have suffered damages, ensuring they receive the support they deserve.</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:">"Our clients rely on us in mass tort litigations like this to help them identify and maximize recoveries, to help make them whole," concluded Mr. Russo. Ron Peck, Chief Legal Officer of The Phia Group, emphasized the importance of subrogation in situations where massive organizations with substantial resources are accused of causing significant damage to a large population. "We are working hard to ensure that victims and their health benefit plans are not left paying for damages caused by someone else."</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:">For more information, please visit <a href="http://www.phiagroup.com"><span style="color:#0000ff;">www.phiagroup.com</span></a> or contact Garrick Hunt at <a href="mailto:GHunt@phiagroup.com" style="color:blue; text-decoration:underline">GHunt@phiagroup.com</a>. </span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">About The Phia Group: The Phia Group, LLC, is a seasoned provider of healthcare cost containment techniques, offering comprehensive claim repricing, No Surprises Act support, claims recovery, plan document, and consulting services designed to control healthcare costs and safeguard plan assets. Through industry-leading consultation, plan drafting, subrogation, and other cost containment solutions, The Phia Group truly empowers plans. Learn more at phiagroup.com.</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:">About Healthcare Recovery Solutions: HRS is a leading innovator in mass tort in healthcare subrogation, specializing in delivering patented comprehensive recovery services to healthcare payers. With a strong track record in mass tort litigation recoveries, HRS brings extensive experience and expertise to the table. By partnering with The Phia Group, HRS further strengthens its capabilities and extends its reach, providing a formidable solution for healthcare payers seeking to recover lost dollars from PFAS-related payouts. </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:">To learn more about Healthcare Recovery Solutions, please visit <a href="http://www.hrs-recovery.com" style="color:blue; text-decoration:underline">www.hrs-recovery.com</a> or contact Sarah Klein at <a href="mailto:sklein@hrs-recovery.com" style="color:blue; text-decoration:underline">sklein@hrs-recovery.com</a>. </span></span></span></p> 1255Empowering Plans: P165 – Artificial Intelligence Meets Subrogationhttps://www.phiagroup.com/Media/Posts/PostId/1254/empowering-plans-p165-artificial-intelligence-meets-subrogationPodcastsMon, 26 Jun 2023 16:39:56 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/67YPwfrEJmo" title="YouTube video player" width="560"></iframe></p> <p><span style="color:#000000;"><span style="font-size:14px;">We are halfway through 2023, and Artificial Intelligence (AI) remains one of the year’s hottest topics, particularly in the worlds of business and healthcare. In the latest edition of The Phia Group’s Empowering Plans podcast, Attorneys Jon Jablon and Cindy Merrell zero in on how AI could have a monumental impact on the field of subrogation within the larger context of healthcare law. </span></span> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:10.5pt"><a href="https://youtu.be/wE-5GLCqyio" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce"> </span></a></span></span></span></p> <p><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:10.5pt"><a href="https://youtu.be/67YPwfrEJmo"><span style="color:#0071ce">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://youtu.be/67YPwfrEJmo"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1254The Phia Group Introduces its Phia Ignite Repricing Engine: A Game-Changer in Cost Containmenthttps://www.phiagroup.com/Media/Posts/PostId/1250/the-phia-group-introduces-its-phia-ignite-repricing-engine-a-game-changer-in-cost-containmentPress ReleasesWed, 14 Jun 2023 19:32:07 GMT<p style="margin:0in"><span style="display: none;"> </span> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">FOR IMMEDIATE RELEASE</span></span></span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The Phia Group Introduces the Phia Ignite Repricing Engine – Seamlessly Encompassing Focused Artificial Intelligence, Detailed Quality Metrics, Multiple and Defensible Repricing Datapoints with Best in Class Balance Bill Support and Resolution.</span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">CANTON, MA – The Phia Group proudly unveiled its Phia Ignite Repricing Engine, a cutting-edge tool that will now empower their already renowned Phia Unwrapped service, which for <span style="color:#212121">many years has been the industry’s best out-of-network solution, with its expert assistance for appeals, No Surprises Act (NSA) compliance, and IDR navigation to ultimately yield unbeatably low payments. </span>Now, Phia Unwrapped is even better, thanks to the Phia Ignite repricing engine. Developed to consistently calculate equitable and defensible claims payments – by leveraging price transparency, provider quality metrics, and other proprietary methodologies – Phia Unwrapped, empowered by Ignite, further reduces unnecessary risks while maximizing savings.</span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="color:#212121"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">“Phia Ignite promises to be a groundbreaking means for not only optimizing savings but also <span style="background:white"><span style="color:black">ensuring support for the complexities inherent in the No Surprises Act (NSA),” remarked The Phia Group’s own Scott Bennett, Senior Vice President of Provider Relations.</span></span></span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="background:white"><span style="color:black"></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Phia Ignite, which is compatible with both standard and advanced integration, benefits from fluid synchronization of SFTP and 837 files across multiple platforms, and employs a distinct gap-filling strategy to price claims for which benchmarks and rates would be otherwise unavailable. <span style="color:#212121">The Phia Group’s experts also leverage Phia Ignite toward identifying the highest quality providers offering optimal care for the most equitable prices -- a critical step for navigating patients to centers of excellence. </span>Further, Ignite represents next-generation technology through its ability to leverage APIs and harness Artificial Intelligence-driven data.</span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="display: none;"> </span></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="color:#212121"></span></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">“Ultimately, healthcare consumers will reap the benefits of Phia Ignite,” The Phia Group’s CEO, Adam Russo, explained, “and that is why we do what we do.  Maximizing savings, minimizing costs, reducing risk, increasing compliance, and helping our partners thrive – these are all steps we take in our mission to help hard working Americans secure better care, and better benefits, for less.”</span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">“Phia Ignite adds to The Phia Group’s toolbox an optimal, forward-thinking cost containment device for providing balance bill and NSA support, the complexities of which have accelerated the need to consider factors like quality, cost, and market impact on claims,” Scott Bennett remarked.  “After all, when it comes to healthcare savings, we believe it’s time to go beyond kindling a flame. With Phia Ignite, you have the opportunity to spark a revolution.” </span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">For more information, please visit <a href="https://www.phiagroup.com/" style="color:#0563c1; text-decoration:underline">https://www.phiagroup.com/</a> or contact Garrick Hunt at <a href="mailto:GHunt@phiagroup.com" style="color:#0563c1; text-decoration:underline">GHunt@phiagroup.com</a></span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""> </span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""> </span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">About The Phia Group</span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The Phia Group, LLC, is an experienced provider of health care cost containment techniques offering comprehensive claim repricing, No Surprises Act support, claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly empowering plans. Learn more at phiagroup.com.</span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"></span></span></p> <p><span style="font-size:14px;"></span><span style="display: none;"> </span></p> 1250Empowering Plans: P164 – The Key to a Successful Self-funding Experience: Knowledge!https://www.phiagroup.com/Media/Posts/PostId/1249/empowering-plans-p164-the-key-to-a-successful-self-funding-experience-knowledgePodcastsFri, 09 Jun 2023 13:01:59 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/wE-5GLCqyio" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">With many self-funded employers entering the field from a world where their benefits are “set it and forget it,”  educating plan sponsors about their obligations, relationships, opportunities, and risks is often the difference between retaining and losing a client. Attorneys Andrew Silverio and Christopher Aguiar muse about the challenges arising when self-funded plans aren’t educated about their benefit offerings, the risk mitigation mechanisms, and the cost containment tools being utilized to ensure the plan’s viability.<br /> <span style="font-size:10.5pt"><a href="https://youtu.be/wE-5GLCqyio" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce"><br /> Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://youtu.be/wE-5GLCqyio" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1249Empowering Plans: P163 – ChatGPT: Disrupting the Healthcare Industryhttps://www.phiagroup.com/Media/Posts/PostId/1246/empowering-plans-p163-chatgpt-disrupting-the-healthcare-industryPodcastsFri, 19 May 2023 12:44:42 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Euw6oX2CHKg" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">In this episode of the Empowering Plans podcast, attorneys Brady Bizarro and Brian O'Hara provide an overview of ChatGPT, the artificial intelligence chatbot developed by OpenAI, and describe how it is disrupting the healthcare industry. In particular, they focus on one emerging use for the technology - acting as a virtual assistant for patient care. What are the advantages of using AI in this manner? What are the concerns? Tune in for what will be a topic that we revisit in the coming weeks and months!<br /> <span style="font-size:10.5pt"><a href="https://www.youtube.com/watch?v=Euw6oX2CHKg" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce"><br /> Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=Euw6oX2CHKg" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">YouTube</span></a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1246The Business of Benefitshttps://www.phiagroup.com/Media/Posts/PostId/1245/the-business-of-benefitsWebinarsThu, 18 May 2023 18:30:28 GMT<p style="margin-bottom:0in; text-align:justify; margin:0in 0in 10pt; margin-right:0in; margin-left:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt">Those who service health benefit plans are usually focused on delivering the most robust coverage for the least cost.  Yet, all too often we forget that our industry, like any other, only thrives when our own businesses prosper.  From adjustments to a post-pandemic environment (and employee populations working remotely from numerous locations), to conflict resolution between entities (such as disputes between plans, stop-loss, and TPAs over reimbursement of fees for savings and management of the NSA), join The Phia Group as we discuss the current events and case studies that will impact whether your own organization sinks or swims.</span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 10pt; 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></span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><a href="https://attendee.gotowebinar.com/recording/2273797074524433760" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Click Here to View Our Full Webinar</span></a></span></span></span></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><span style="color:black">To obtain a copy of our webinar slides, please reach out to <span calibri="" style="font-family:"><a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0071ce">mpainten@phiagroup.com</span></a><span style="color:#0071ce">.</span></span></span></span></span></span></p> 1245Empowering Plans: P162 – Mind the Gap 2.0: Don’t be Afraid to Ask for a Handbookhttps://www.phiagroup.com/Media/Posts/PostId/1244/empowering-plans-p162-mind-the-gap-20-dont-be-afraid-to-ask-for-a-handbookPodcastsFri, 12 May 2023 14:20:58 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/KJa-8i-R5sQ" title="YouTube video player" width="560"></iframe></p> <p><span style="font-size:14px;"><span style="color:#000000;"><span calibri="">In this episode of Empowering Plans, Kelly Dempsey and Kevin Brady outline the relevant details provided within our Handbook Gap Free Reviews. They provide a description of the service, the case studies which gave rise to this service and describe why a review of the Handbook is more important now than ever before!</span></span><br /> <a href="https://youtu.be/KJa-8i-R5sQ"><span style="color:#0071ce;"><u><br /> Click here to check out the podcast!</u></span></a><span calibri=""><span calibri=""> <span style="color:#000000;">(Make sure you subscribe to our </span></span></span><a href="https://youtu.be/KJa-8i-R5sQ"><span style="color:#0071ce;"><u>YouTube</u></span></a><span calibri=""><span calibri=""> <span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce;">Apple Podcasts</span><u> </u></a><span style="color:#000000;">Channels!)</span></span> </span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></p> 1244Empowering Plans: P161 – New Challenges to Old Favorites - NSA, ACA, and more (Acronyms)!https://www.phiagroup.com/Media/Posts/PostId/1241/empowering-plans-p161-new-challenges-to-old-favorites-nsa-aca-and-more-acronymsPodcastsFri, 28 Apr 2023 11:53:37 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/SS7qr8cV1ow" title="YouTube video player" width="560"></iframe></p> <p><span style="font-size:16px;"><span style="color:#000000;"><span calibri="">In their latest podcast, Attorneys Nick Bonds and Corey Crigger are back to discuss the No Surprises Act (NSA) and the Affordable Care Act (ACA). Join them as they provide an overview of each of these laws and the recent legal challenges out of Nick’s home state of Texas. Will payment determinations resume? Has the ACA finally been struck down? Tune in to find out! </span></span><span calibri=""><span calibri="" style="font-family:"></span></span></span></p> <p><span style="font-size:16px;"><u><a href="https://www.youtube.com/watch?v=SS7qr8cV1ow">Click here to check out the podcast!</a></u><span calibri=""><span calibri=""> <span style="color:#000000;">(Make sure you subscribe to our </span></span></span><u><a href="https://www.youtube.com/watch?v=SS7qr8cV1ow">YouTube</a></u></span><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:16px;"><span calibri=""> <span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts<u> </u></a><span style="color:#000000;">Channels!)</span></span></span> </span></span></p> 1241Before and After – Examples of Mistakes that Were Addressed and How to Avoid Themhttps://www.phiagroup.com/Media/Posts/PostId/1240/before-and-after-examples-of-mistakes-that-were-addressed-and-how-to-avoid-themWebinarsThu, 20 Apr 2023 14:41:36 GMT<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 calibri="" style="font-family:">Accidents happen, but they aren’t all inevitable.  Often, errors that lead to conflicts and costly outcomes could be avoided.  Join The Phia Group’s team as they dig into real case studies, and share examples where The Phia Group was called upon to address some avoidable losses, as well as compare them to scenarios where the proper preemptive steps were taken.  This April, remember what Benjamin Disraeli said: "The fool wonders; the wise man asks."  Register today for this free and informative webinar!</span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><a href="https://attendee.gotowebinar.com/recording/7334552228418538079"><span style="font-size:16px;"><span style="color:#0071ce;"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></span></a></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><span style="color:black">To obtain a copy of our webinar slides, please reach out to </span><a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0071ce;">mpainten@phiagroup.com</span></a><span style="color:#0071ce;">.</span><span style="color:black"></span></span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> 1240Empowering Plans: P160 – How the Ending of COVID-era National Emergency Impacts Your Health Planhttps://www.phiagroup.com/Media/Posts/PostId/1239/empowering-plans-p160-how-the-ending-of-covid-era-national-emergency-impacts-your-health-planPodcastsTue, 18 Apr 2023 19:30:49 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/78HyRY8VrqU" title="YouTube video player" width="560"></iframe></p> <p><span style="color:#000000;"><span style="font-size:11pt"><span calibri=""><span style="font-size:11pt"><span calibri=""> On April 10, President Joe Biden signed a bipartisan congressional resolution to terminate the U.S. national emergency in response to the COVID-19 pandemic—weeks before the development was supposed to occur in conjunction with a separate public health emergency expiring on May 11. Unsurprisingly, in the wake of such a stunning announcement, group health plans from coast to coast are scrambling to decide whether they must adjust their processes.<br /> <br /> In the latest Empowering Plan Podcast, Attorney Jennifer McCormick, Senior Vice President, Consulting, and Joanie Verinder, Director, Service Strategist, discuss the sudden end to the National Emergency, the many ways in which health benefit plans are affected, particularly in regards to timelines, and the information their respective participants need to be aware of. </span></span></span></span></span></p> <p><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:11pt"><span calibri="" style="font-family:"><a href="https://youtu.be/78HyRY8VrqU">Click here to check out the podcast!</a> <span style="color:#000000;">(Make sure you subscribe to our </span><a href="https://youtu.be/78HyRY8VrqU">YouTube</a> <span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a><span style="color:#000000;">Channels!)</span></span></span> </span></span></p> 1239The 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> 1235Empowering Plans: P159 – Putting the Patient First: Challenges to Common TPA Operationshttps://www.phiagroup.com/Media/Posts/PostId/1234/empowering-plans-p159-putting-the-patient-first-challenges-to-common-tpa-operationsPodcastsFri, 31 Mar 2023 12:58:28 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/ptxbTOaei3o" title="YouTube video player" width="560"></iframe></p> <p style="margin-left:.5in; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">In this episode of The Phia Group's Empowering Plans podcast, attorneys Katie Malkin and Jon Jablon take a dive into three aspects of TPA operations designed to try to make the TPA's job more manageable: simplifying EOB denial codes, sending family EOBs, and recouping overpayments by offsetting. These are three common strategies used by TPAs, but applicable law places certain limits on all of them that are not always so intuitive. Tune in as Jon and Katie discuss some best (and worst) practices, and examine critical issues facing TPAs and health plans in today's self-funded industry.<br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><br /> <a href="https://www.youtube.com/watch?v=ptxbTOaei3o">Click here to check out the podcast!</a> (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=ptxbTOaei3o">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a>Channels!)</span></span> </span></span></p> 1234Empowering Plans: P158 – Seek and Ye Shall Findhttps://www.phiagroup.com/Media/Posts/PostId/1232/empowering-plans-p158-seek-and-ye-shall-findPodcastsFri, 17 Mar 2023 12:19:40 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/TJ8-MkcsDzM" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">In the world of subrogation, there’s (almost) always more funds to recover, you just have to go searching for them—even if that means in unconventional places. In their latest podcast, attorneys Chris Aguiar and Cindy Merrell discuss how, particularly in regards to auto accidents involving participants who have substandard coverage, there is a heightened need to capitalize on opportunities for plans to recover funds. Don’t miss Phia’s veteran subrogation attorneys weighing in on how healthcare plans can be reimbursed so that their participants reap long-term benefits.<br /> <br /> <a href="https://www.youtube.com/watch?v=TJ8-MkcsDzM">Click here to check out the podcast!</a> (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=TJ8-MkcsDzM">YouTube </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a>Channels!)</span></span></p> 1232Empowering Plans: P157 – New TPA Liabilities – Section 1557https://www.phiagroup.com/Media/Posts/PostId/1228/empowering-plans-p157-new-tpa-liabilities-section-1557PodcastsFri, 03 Mar 2023 12:52:59 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/5Tgrg1AL_Yo" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span calibri="" style="font-family:">One of the healthcare trends we have been following so far in 2023 is expanded TPA liabilities. In this edition of the Empowering Plans podcast, attorneys Brady Bizarro and Andrew Silverio discuss a recent federal court case in which a TPA was found liable for violations of the ACA’s Section 1557. Despite numerous defenses raised by the TPA, many of which we see regularly used by TPAs, the court rejected them all, potentially expanding the scope of Section 1557. Tune in to hear more about this significant case and what it means for our industry.</span><br /> <a href="https://www.youtube.com/watch?v=5Tgrg1AL_Yo"><span style="line-height:107%"><span calibri="" style="font-family:"><u><br /> Click here to check out the podcast!</u></span></span></a><span style="line-height:107%"><span calibri="" style="font-family:"> (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=5Tgrg1AL_Yo"><u>YouTube</u></a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a>Channels!)</span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></p> 1228Empowering Plans: P156 – Accommodating Reasonably: Navigating the ADA and PWFA in 2023https://www.phiagroup.com/Media/Posts/PostId/1226/empowering-plans-p156-accommodating-reasonably-navigating-the-ada-and-pwfa-in-2023PodcastsThu, 16 Feb 2023 16:13:48 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/6HOrkZC7zrw" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">On this episode of Empowering Plans, Kelly Dempsey and Kevin Brady provide some valuable insights into the reasonable accommodation process under the ADA and PWFA. The PWFA, which will be effective this June, expands the scope of existing federal law with respect to accommodating employees with known limitations related to pregnancy, childbirth, or related medical conditions. Tune in to learn why this is important for employers in 2023 and beyond!</span></span></p> <p style="margin: 0in; text-align: justify;"> </p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/6HOrkZC7zrw"><u>Click here to check out the podcast!</u></a> (Make sure you subscribe to our <a href="https://youtu.be/6HOrkZC7zrw"><u>YouTube</u></a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a>Channels!)</span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></p> 1226Love is in the (Health)Care!https://www.phiagroup.com/Media/Posts/PostId/1224/love-is-in-the-healthcareWebinarsWed, 15 Feb 2023 14:46:59 GMT<p style="margin-bottom:0in; text-align:justify; margin:0in 0in 10pt; 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">Roses are red, violets are blue, and The Phia Group has some hot tips for you.  Whether you sponsor, administer, or service self-funded health plans, The Phia Group’s free webinar will thrill and amaze you. The Phia Group’s team presented a variety of important issues, best practices, and case studies. From disputes with providers, to subrogation, to regulatory updates, and beyond… this webinar is better than a box of chocolates.  Don’t wait to unwrap your gift!</span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 10pt; 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></span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><a href="https://attendee.gotowebinar.com/recording/629272924010795779"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><span style="color:#0071ce;">Click Here to View Our Full Webinar</span></span></span></span></a></p> <p><span style="font-size:12.0pt"><span style="line-height:115%"><span calibri="" style="font-family:"><span style="color:black">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%20Slides" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></span></p> 1224Empowering Plans: P155 – The State of the Union 2023: Phia’s Takehttps://www.phiagroup.com/Media/Posts/PostId/1223/empowering-plans-p155-the-state-of-the-union-2023-phias-takePodcastsFri, 10 Feb 2023 14:43:12 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/FOPexp9-o7o" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The State of the Union has always served as an important bellwether for our country, but also, for our industry, revealing what the current administration’s healthcare policies will be going forward, and in some cases, which ones enjoy bipartisan support. In this special edition podcast, join attorneys Ron Peck and Brady Bizarro as they break down the president’s speech, providing you with their reaction and analysis, and explain what you should be watching this year.</span></span></span></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><a href="https://www.youtube.com/watch?v=FOPexp9-o7o">Click here to check out the podcast!</a> (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=FOPexp9-o7o">YouTube </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a>Channels!)</span></span></span></p> 1223Empowering Plans: P154 – No Ordinary Time in Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/1221/empowering-plans-p154-no-ordinary-time-in-healthcarePodcastsFri, 03 Feb 2023 15:30:45 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/hpsEQTQCAOc" title="YouTube video player" width="560"></iframe></p> <p><span style="color:#000000;"> </span><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color:#000000;"><span calibri=""> Corey Crigger and Nicholas Bonds cover a lot of ground in the newest installment of The Phia Group’s Empowering Plans podcast: Whether it’s the National and Public Health Emergencies starting to wind down or what state legislatures have in store for non-profit hospitals that overcharge or Amazon creeping into the healthcare space, Phia’s attorneys are here to keep you up to date on the ever-changing world of healthcare. </span></span></span></span></p> <p><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=hpsEQTQCAOc">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=hpsEQTQCAOc">YouTube</a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1221The Phia Group Is Proud to Announce That Ujwal Shrestha and Caitlin Lankston Have Joined Their Teamhttps://www.phiagroup.com/Media/Posts/PostId/1219/the-phia-group-is-proud-to-announce-that-ujwal-shrestha-and-caitlin-lankston-have-joined-their-teamPress ReleasesTue, 31 Jan 2023 14:30:18 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">For Immediate Release</span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">01/31/2023<br /> <br /> CANTON, MA—The Phia Group continues to reinforce its commitment to offering elite technology and advanced analytics by recently hiring Ujwal Shrestha, VP, Business Analytics and Data Services, and Caitlin Lankston, Senior Data Scientist.<br /> <br /> With an impressive track record leading data analysis and data strategy work in the self-funded industry as well as in management consulting firms, Ujwal will expand Phia’s data-driven decision algorithms that optimize business process efficiencies, data identifications and client results. He will serve as a conduit to executive leaders by applying techniques such as Artificial Intelligence (AI), Machine Learning (ML) and predictive analytics to present data insights in a digestible and actionable format.  As Phia is poised for considerable growth, Ujwal will channel his data analysis skills toward pushing technical boundaries to spur innovation while spearheading analytics geared toward optimizing recovery opportunities.<br /> <br /> “The main reason I joined Phia is I wanted to be in a growing company in the healthcare industry,” states Ujwal. “I believe I can help the company make better business decisions that are data-driven, based on the expansive healthcare claims data we have.”<br /> <br /> Adds Chief Operating Officer Joe Montalto, “We are delighted to welcome Ujwal to The Phia Group. With his diverse background in the self-funded space and his experience at D2Hawkeye, Inc., Ujwal will be an invaluable resource to our company as we look to take our Data Services Group to the next level. I am very excited to see Ujwal grow into this role and continue to help Phia make a positive impact for our clients.”<br /> <br /> As Phia’s Senior Data Scientist, Caitlin, a graduate of the University of Montana, where she received her master’s degree in Statistics, will be engaging in hands-on data analysis work relying heavily on Python and Tableau reporting as a means of optimally aggregating data, streamlining internal processes, and leveraging Predictive Analytics and advanced algorithms. Prior to joining Phia, Caitlin handled case prioritization work for DataSmart Health Solutions.<br /> <br /> “Advanced and predictive analytics offer extremely exciting potential at Phia in our recovery efforts allowing us to look at our data in a new prescriptive and proactive way,” says Caitlin. “Until now, Phia relied on strong industry knowledge and robust logic to prioritize case workflow. Predictive analytics, however, leverages machine learning to discover hidden patterns and trends. Identifying these patterns will help Phia find new business opportunities and answer complex questions.”<br /> <br /> To learn more about The Phia Group, what it is doing to empower plans, and to learn more about its Provider Relations solutions, please contact Garrick Hunt by email at </span></span><a href="mailto:ghunt@phiagroup.com"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:blue">ghunt@phiagroup.com</span></span></span></a><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"> or by phone at 781-535-5644.</span></span><br /> <br /> About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></span></span></p> 1219Empowering Plans: P153 – Living Up To Expectationshttps://www.phiagroup.com/Media/Posts/PostId/1216/empowering-plans-p153-living-up-to-expectationsPodcastsFri, 20 Jan 2023 14:57:06 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/uhPjkkvqV14" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:16px;"><span style="color:#000000;"><span calibri="" style="font-family:">Over the last decade, The Phia Group’s leaders have made quite a few predictions.  There have been some hits and misses. Join attorneys Ron Peck and Jen McCormick as they discuss past predictions, their predictions for 2023, and what the best health plans need to do to stay ahead of the game this year!</span></span><span calibri="" style="font-family:"><br /> <br /> <a href="https://youtu.be/uhPjkkvqV14">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://youtu.be/uhPjkkvqV14">YouTube</a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></p> <p><span style="font-size:16px;"></span></p> <p style="margin:0in"> </p> 1216An Omnibus Edition to Kick Off 2023https://www.phiagroup.com/Media/Posts/PostId/1215/an-omnibus-edition-to-kick-off-2023WebinarsThu, 19 Jan 2023 14:59:02 GMT<p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:16px;"><span style="line-height:normal"><span calibri="">It’s only January, but 2023 already promises to be a momentous year in healthcare law. From the recent passage of The Consolidated Appropriations Act of 2023—and its inclusion of protections for pregnant and nursing mothers—to regulatory updates regarding the No Surprises Act and manufacturer assistance programs, there’s quite a bit to break down as the new year unfolds. Join The Phia Group’s panel of experts as they discuss how such sweeping changes will impact your group’s health plan.</span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 10pt; margin-right:0in; margin-left:0in"><span style="font-size:16px;"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><a href="https://attendee.gotowebinar.com/recording/5185319255406904664"><span style="font-size:16px;"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><span style="color:#0071ce">Click Here to View Our Full Webinar</span></span></span></span></a></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:16px;"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><span style="color:black">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span><span new="" roman="" style="font-family:" times=""><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"> </p> <p style="text-align:justify; margin-right:0in; margin-left:0in"> </p> 1215The 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 Phia Group is Proud to Announce that Joanie Verinder has Joined their Teamhttps://www.phiagroup.com/Media/Posts/PostId/1212/the-phia-group-is-proud-to-announce-that-joanie-verinder-has-joined-their-teamPress ReleasesTue, 17 Jan 2023 14:51:59 GMT<p><span style="color:#000000;">For Immediate Release</span></p> <p><span style="color:#000000;">01/17/2023</span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><em><span style="font-size:14px;"><span lang="PL"></span></span></em></span><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt"><span calibri=""></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;">CANTON, MA—The Phia Group continues to demonstrate its commitment to provide the industry’s best cost containment services, by proudly announcing the hiring of Joanie Verinder as its Service Strategist.<br />  <br /> As The Phia Group’s Service Strategist, Joanie will serve as a client liaison and achieve a new level of collaboration, regarding everything from service updates to current regulatory news.  Advocating for the company’s clients, Joanie will communicate the industry’s needs to The Phia Group’s leaders and monitor the company to ensure it is always excelling on behalf of its clientele.  When a new issue, rule, or development creates need, Joanie Verinder will ensure The Phia Group takes action on the industry’s behalf.<br />  <br /> Ms. Verinder is no stranger to The Phia Group, having previously served as the Compliance Officer for Group and Pension Administrators (GPA) TPA.  There, Joanie routinely interacted with The Phia Group as a client.  Additionally, Ms. Verinder served as a leader and President of Health Care Administrators Association  (“HCAA”), and in that and other industry roles often worked with The Phia Group to ensure association members were receiving important industry news, updates, and education from Phia.  “After working as a client with the Phia team for 20 years, and witnessing first hand their passion and commitment to helping our industry, I’m excited to become a member of that team.  I look forward to evolving from a ‘Phia Phriend’ to becoming a member of the ‘Phia Phamily’ … and assisting all of our loyal clients.”<br />  <br /> Senior Vice President of Consulting, Jennifer McCormick, said, “We are thrilled to welcome Joanie to the Phia team! In her new role Joanie will be working tirelessly to continue to build relationships while ensuring our teams deliver the highest levels of value and quality for our partners and clients. We look forward to this new year with Joanie on the team.”<br />  <br /> The company’s CEO, Adam Russo, added, “I have personally known Joanie for decades… longer than most of our own team members.  For most of my career, I’ve looked to her as a friend, advisor, innovator, and voice of the industry.  Adding her to our roster takes us to a new level.  I couldn’t be happier – not only for myself and The Phia Group, but for our clients… all of whom are going to benefit from her presence.”<br />  <br /> To learn more about The Phia Group and what it is doing to empower plans, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> or by phone at 781-535-5644.<br />  <br /> About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></p> 1212Empowering Plans: P152 – The Contemporary Fiduciary: Emerging Law on an Old Topichttps://www.phiagroup.com/Media/Posts/PostId/1211/empowering-plans-p152-the-contemporary-fiduciary-emerging-law-on-an-old-topicPodcastsThu, 05 Jan 2023 16:32:14 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/GtepPNzuz0I" title="YouTube video player" width="560"></iframe></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="color:#000000;"><span calibri="">In this installment of The Phia Group’s Empowering Plans podcast, join attorneys Katie MacLeod and Jon Jablon as they discuss fiduciary status, both traditionally and in the new age of self-funding. This industry is faced with changes all the time, even to some of its oldest rules; in the spirit of consumer protection, the legal and regulatory winds are once again changing to challenge certain long-held understandings about fiduciary duties. TPAs in particular should tune into this one!</span></span><br /> <br /> <a href="https://www.youtube.com/watch?v=GtepPNzuz0I">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=GtepPNzuz0I">YouTube</a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></p> 1211Empowering Plans: P151 – The Who, What, and When of Offsetting Benefitshttps://www.phiagroup.com/Media/Posts/PostId/1207/empowering-plans-p151-the-who-what-and-when-of-offsetting-benefitsPodcastsTue, 20 Dec 2022 19:34:23 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/WI5JfdmWJho" title="YouTube video player" width="560"></iframe></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 calibri="" style="font-family:">In this installment of The Phia Group’s Empowering Plans podcast, attorneys Chris Aguiar and Cindy Merrell discuss offsetting benefits and when a Plan may consider it.</span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=WI5JfdmWJho" style="color:blue; text-decoration:underline"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=WI5JfdmWJho" style="color:blue; text-decoration:underline"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1207The 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> 1206A Flip of the Calendar: Looking Ahead to Healthcare in 2023https://www.phiagroup.com/Media/Posts/PostId/1204/a-flip-of-the-calendar-looking-ahead-to-healthcare-in-2023WebinarsTue, 13 Dec 2022 14:24:48 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:">With a new year comes new developments in healthcare — and 2023 will be no exception. While ever-increasing healthcare costs remain at the forefront of our attention, landmark healthcare legislation — in particular, the No Surprises Act (“NSA”) — continues to cause unforeseen issues for health plans and stop-loss carriers. Additionally, evolving business trends involving mergers, acquisitions, and investments from non-traditional entities promise to impact the industry. Join The Phia Group’s panel of cost containment experts as they look ahead to the challenges and opportunities that await us next year.  </span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><a href="https://attendee.gotowebinar.com/recording/2112118284256921173"><span style="color:#0071ce;"><span style="font-size:12pt"><span new="" roman="" times=""><span style="font-size:11.0pt"><span calibri="">Click Here to View Our Full Webinar</span></span></span></span></span></a></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><span style="color:#000000;">To obtain a copy of our webinar slides, please reach out to</span><span style="color:black"> <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> 1204Empowering Plans: P150 – Manufacturer Assistance Programshttps://www.phiagroup.com/Media/Posts/PostId/1203/empowering-plans-p150-manufacturer-assistance-programsPodcastsThu, 08 Dec 2022 21:38:15 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/BaJnBKT3KGc" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="">Attorneys Brady Bizarro and Andrew Silverio discuss manufacturer/copay assistance programs and outline some of the different approaches being utilized to manage specialty drug spending.  Also on the agenda is a current lawsuit against one such program administrator, and how the landscape might be shaped in the coming months.</span></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><a href="https://youtu.be/WvtsbAM0Jrc"><span style="color:#0563c1"></span></a><a href="https://www.youtube.com/watch?v=BaJnBKT3KGc"><span style="color:#0563c1">Click here to check out the podcast!</span></a><span style="color:#0563c1"></span> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=BaJnBKT3KGc"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span><span style="font-size:12.0pt"></span></span></span></span></p> 1203Empowering Plans: P149 – Another Ping-Ponging of IC/EE Rules?https://www.phiagroup.com/Media/Posts/PostId/1199/empowering-plans-p149-another-ping-ponging-of-icee-rulesPodcastsThu, 17 Nov 2022 16:51:09 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/WvtsbAM0Jrc" title="YouTube video player" width="560"></iframe></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%">In recent history there have been several rules that have been amended and re-amended (or just overturned and new rules published). Join Kelly Dempsey and Kevin Brady as they explore the ever-changing world of employee classification rules. The 2021 rule is viewed as leaving workers vulnerable to misclassification and was inconsistent with existing federal court decisions, thus the current administration is seeking to make a change. Tune in to learn more and why this rule matters to self-funded health plans.</span></span></span></span></span></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/WvtsbAM0Jrc"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://youtu.be/WvtsbAM0Jrc"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1199Down the Stretch: Wrapping up a Historical 2022https://www.phiagroup.com/Media/Posts/PostId/1198/down-the-stretch-wrapping-up-a-historical-2022WebinarsTue, 15 Nov 2022 14:12:13 GMT<p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt">We are entering the home stretch.  With a couple months to go, we can confidently say that 2022 has been one of the most momentous years in the history of American healthcare. The Phia Group’s panel of experts will revisit what they feel were the ten most impactful healthcare developments of 2022, covering a broad swath of topics that includes price transparency (the Consolidated Appropriations Act and No Surprises Act), governance (state laws that preempt ERISA), and equitable benefit coverage (Mental Health Parity and Addiction Equity Act). Who knew one year could have such a profound impact on our industry?  Join the fun and find out how impactful 2022 has been.</span></span></span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><a href="https://attendee.gotowebinar.com/recording/6928987465459170318"><span style="color:#0071ce;"><span style="font-size:12pt"><span new="" roman="" times=""><span calibri="">Click Here to View Our Full Webinar</span></span></span></span></a></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="color:#000000;">To obtain a copy of our webinar slides, please reach out to</span><span style="color:black"> <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span></span></p> 1198Empowering Plans: P148 – The Ever Changing Times of Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/1195/empowering-plans-p148-the-ever-changing-times-of-healthcarePodcastsThu, 03 Nov 2022 14:45:39 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/aKLjqLX1TqI" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="color:#000000;"><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%">“It’s an ever changing time…” in the healthcare landscape. Corey Crigger and Nick Bonds are back on the podcast mics to discuss some of the more interesting developments they’ve seen in 2022. Tune in to be sure these developments aren't burdensome and rest assured that the dreams you believe in will still come true.</span></span></span></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=aKLjqLX1TqI"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=aKLjqLX1TqI"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1195Empowering Plans: P147 – Transparency & More: Burning CAA/NSA FAQshttps://www.phiagroup.com/Media/Posts/PostId/1192/empowering-plans-p147-transparency-more-burning-caansa-faqsPodcastsThu, 27 Oct 2022 14:17:33 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/4pcu2YrsLdE" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="color:#000000;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:">In this installment of The Phia Group’s Empowering Plans podcast, attorneys Jen McCormick and Jon Jablon bring up some of the most common questions that The Phia Group’s consulting team has been asked to field over and over again. From the so-called broker compensation rules to a TPA’s obligations related to a group’s No Surprises Act compliance, Jen and Jon highlight some of the main points to keep in mind when making important decisions regarding your business.</span></span></span></span></span></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/4pcu2YrsLdE"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://youtu.be/4pcu2YrsLdE"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1192Book of Russo: Chapter 5https://www.phiagroup.com/Media/Posts/PostId/1191/book-of-russo-chapter-5PodcastsFri, 21 Oct 2022 13:21:03 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/iSXvwIajFVA" title="YouTube video player" width="560"></iframe></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 style="color:#000000;">In the latest episode of The Book of Russo, tune in to find out what The Phia Group’s CEO, Adam Russo, and guest host, Mike Ferguson, President & CEO of the Self-Insurance Institute of America (SIIA), have to say about SIIA’s 2022 National Conference, the history of SIIA, and what to expect from SIIA in years to come.  </span>  </span></span></span></span></span></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=iSXvwIajFVA"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=iSXvwIajFVA" style="color:blue; text-decoration:underline"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></span></p> 1191The Witching Hour for Healthcare Planshttps://www.phiagroup.com/Media/Posts/PostId/1190/the-witching-hour-for-healthcare-plansWebinarsThu, 20 Oct 2022 16:27:56 GMT<p style="text-align:justify; margin:0in 0in 8pt; margin-right:0in; margin-left:0in"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri=""><span style="font-size:12.0pt"><span style="line-height:107%">Quite a few treats are in store for those tuning into The Phia Group’s next webinar, one that will cover some tricky topics. From breaking down regulatory changes impacting the healthcare industry (i.e., mental health parity, discretionary authority) to developments concerning plan drafting language, Phia’s roundtable of experts will keep you in the know. Oh, and did we mention that there’s also going to be a discussion of what to expect from a health policy standpoint in next month’s midterm elections?</span></span></span></span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><a href="https://attendee.gotowebinar.com/recording/7437462114706360847"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></a></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:"><span style="color:black">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span><span style="font-family:"Calibri",sans-serif"></span></span></span></p> 1190The 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> 1188Empowering Plans: P146 - A Possible Threat to a Plan’s Discretionary Authorityhttps://www.phiagroup.com/Media/Posts/PostId/1187/empowering-plans-p146-a-possible-threat-to-a-plans-discretionary-authorityPodcastsFri, 14 Oct 2022 13:21:53 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/IXb7L3vpioY" title="YouTube video player" width="560"></iframe></p> <p><span style="color:#000000;">Currently before the Senate, a new bill 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. Regardless of whether this bill will be passed, what does this and similar rhetoric say about public and political attitudes towards self-funded health plans? Ron Peck, Chief Legal Officer, and attorney Kaitlyn MacLeod are here to talk about this and more. Enjoy! </span></p> <p><span style="font-size:14px;"><span calibri=""> <a href="https://www.youtube.com/watch?v=IXb7L3vpioY" style="color:#0563c1; text-decoration:underline">Click here to check out the podcast!</a> <span style="color:black">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=IXb7L3vpioY" style="color:#0563c1; text-decoration:underline">YouTube</a> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:black">Channels!)</span></span></span></p> 1187Book of Russo: Chapter 4https://www.phiagroup.com/Media/Posts/PostId/1182/book-of-russo-chapter-4PodcastsThu, 22 Sep 2022 14:50:14 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/RvNewAwuU4A" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:18px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=qmEBxpfs48I"><span style="color:#0563c1"></span></a></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;">In the latest episode of The Book of Russo, tune in to find out what The Phia Group’s CEO, Adam Russo, and guest host, Dr. Jeffery Gold, have to say about Direct Primary Care and why Dr. Gold decided to open his own practice in Massachusetts.  </span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""></span></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=RvNewAwuU4A"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:#000000;">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=RvNewAwuU4A"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:#000000;">Channels!)</span></span></span></span></p> 1182Empowering Plans: P144 - The Latest Developments Involving Patient Assistance Programshttps://www.phiagroup.com/Media/Posts/PostId/1181/empowering-plans-p144-the-latest-developments-involving-patient-assistance-programsPodcastsFri, 16 Sep 2022 14:20:18 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/y73BHLaBuME" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:16px;"><span style="color:#000000;"><span calibri="" style="font-family:">In this episode of the Empowering Plans podcast, attorneys Brady Bizarro and Andrew Silverio discuss patient assistance programs. They explain what these programs are, how they have been utilized in the industry, and the latest regulations and litigation surrounding them. Tune in to find out what plan sponsors need to know!</span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=N_95JpGN9aM"><span style="color:#0563c1"></span></a></span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=y73BHLaBuME"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:#000000;">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=y73BHLaBuME"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:#000000;">Channels!)</span></span></span></span></p> 1181A Prescription for Success? The Unknown Impact of Recent Legislation on Prescription Expenseshttps://www.phiagroup.com/Media/Posts/PostId/1180/a-prescription-for-success-the-unknown-impact-of-recent-legislation-on-prescription-expensesWebinarsThu, 15 Sep 2022 14:22:03 GMT<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 calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%">The Inflation Reduction Act, signed into law by President Biden last month, includes provisions to lower prescription drug prices for Medicare recipients. But what about most Americans who are on employer-sponsored plans? Could they be adversely affected by pharma companies potentially elevating prices in response? In its next webinar, The Phia Group takes a deeper dive into the residual effects of this landmark act on your plan—as well as how the recent Johnson & Johnson lawsuit involving patient assistance programs may heighten the risk for companies using such PAPs. For good measure, Phia’s panel of experts will also provide an update on final rules just released regarding the No Surprises Act.</span></span></span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><a href="https://attendee.gotowebinar.com/recording/6566977658710285067"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></a></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="color:black">To obtain a copy of our webinar slides, please reach out to<span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"> <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:blue; text-decoration:underline"><span style="color:#0563c1">mpainten@phiagroup.com</span></a>.</span></span></span></span></span></span></span></p> 1180Empowering Plans: P143 - Is Wrongful Death the Death of a Subrogation Claim?https://www.phiagroup.com/Media/Posts/PostId/1179/empowering-plans-p143-is-wrongful-death-the-death-of-a-subrogation-claimPodcastsFri, 02 Sep 2022 13:43:50 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/N_95JpGN9aM" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:18px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=qmEBxpfs48I"><span style="color:#0563c1"></span></a></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%">In this installment of the Empowering Plans podcast, attorneys Chris Aguiar and Cindy Merrell discuss the murky waters of wrongful death and healthcare subrogation claims.</span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span calibri=""></span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span calibri=""><a href="https://www.youtube.com/watch?v=N_95JpGN9aM"><span style="color:#0563c1"></span><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:#000000;">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=N_95JpGN9aM"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:#000000;">Channels!)</span></span></span></span></p> 1179Book of Russo: Chapter 3https://www.phiagroup.com/Media/Posts/PostId/1178/book-of-russo-chapter-3PodcastsFri, 26 Aug 2022 14:49:13 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/tNGwVsxTvOc" title="YouTube video player" width="560"></iframe></p> <p><span style="font-size:18px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="color: rgb(25, 25, 25);">In the latest episode of The Book of Russo, tune in to find out what The Phia Group’s CEO, Adam Russo, and guest host, Ernie Clevenger, have to say about Ernie’s famous Saturday night newsletter, CareHere, and much more.</span> </span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span calibri=""><a href="https://www.youtube.com/watch?v=qmEBxpfs48I"><span style="color:#0563c1"></span></a><a href="https://www.youtube.com/watch?v=tNGwVsxTvOc"><span style="color:#0563c1">Click here to check out the podcast!</span></a> <span style="color:#000000;">(Make sure you subscribe to our</span> <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=tNGwVsxTvOc"><span style="color:#0563c1">YouTube</span></a> </span><span style="color:#000000;">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a><span style="color:#000000;">Channels!)</span></span></span></span></p> 1178Empowering Plans: P142 - The (Healthcare) Times They Are A-Changin’https://www.phiagroup.com/Media/Posts/PostId/1176/empowering-plans-p142-the-healthcare-times-they-are-a-changinPodcastsFri, 19 Aug 2022 13:39:18 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/aqZyvp_7Arg" title="YouTube video player" width="560"></iframe></p> <p><span style="font-size:14px;"><span calibri=""></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:14px;"><span calibri="" style="font-family:">In this installment of The Empowering Plans podcast, attorneys Nick Bonds and Corey Crigger discuss two recent shifts in the healthcare landscape: The FDA’s stance on OTC hearing aids and recent developments showing that not all debt is created equal, especially medical debt. </span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span calibri=""></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span calibri=""><a href="https://www.youtube.com/watch?v=qmEBxpfs48I"><span style="color:#0563c1"></span></a><a href="https://www.youtube.com/watch?v=aqZyvp_7Arg"><span style="color:#0563c1">Click here to check out the podcast!</span></a> (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=aqZyvp_7Arg"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span></p> 1176Empowering Plans: P141 - Do You Mind (…The Gap)?!https://www.phiagroup.com/Media/Posts/PostId/1174/empowering-plans-p141-do-you-mind-the-gapPodcastsFri, 05 Aug 2022 13:21:48 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/qmEBxpfs48I" title="YouTube video player" width="560"></iframe></p> <p><span style="font-size:14px;"><span calibri=""> <span calibri="" style="font-family:">In this installment of The Phia Group’s Empowering Plans podcast, attorneys Jen McCormick and Jon Jablon discuss the age-old topic of stop-loss gaps, with a modern twist. Emerging law and industry trends color so many decisions that self-funded plans and those who service them must make on a daily basis, and one player that sometimes gets forgotten about is stop-loss. Since stop-loss coverage expectations don’t always align with reality, health plans, TPAs, and brokers need to be proactive to find potential gaps and try to rectify them before they evolve into real problems.</span></span></span></p> <p><span style="font-size:14px;"><span calibri=""><a href="https://www.youtube.com/watch?v=qmEBxpfs48I"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=qmEBxpfs48I"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span></p> 1174Louisville Business First Names The Phia Group, LLC a 2022 Best Place to Work in Greater Louisvillehttps://www.phiagroup.com/Media/Posts/PostId/1171/louisville-business-first-names-the-phia-group-llc-a-2022-best-place-to-work-in-greater-louisvillePress ReleasesFri, 29 Jul 2022 14:10:29 GMT<p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11.0pt"><span calibri=""><span style="color:#000000;">For Immediate Release<br /> <br /> 07/29/2022<br /> <br /> Louisville, KY – Louisville Business First Names The Phia Group, LLC a 2022 Best Place to Work in Greater Louisville.<br /> <br /> Today The Phia Group announced that it has earned a 2022 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 50 businesses and nonprofits, with at least 10 full-time employees and an office in the Louisville area, that scored high enough to be awarded.<br /> <br /> “What an honor,”  The Phia Group’s CEO, Adam Russo, remarked.  “Of course, we would be thrilled to be recognized as a best place to work anywhere, but this is especially meaningful in Louisville.  This area is known by those in our industry to be the capital of subrogation and cost containment.  The people here are true professionals; they are the best and expect the best.  Thus, to be so recognized by this group?  I couldn’t be more proud of our organization and our team.”<br /> <br /> Mr. Russo went on to say, “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.”<br /> <br /> To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at </span><a href="mailto:ghunt@phiagroup.com" style="color:blue; text-decoration:underline"><span style="color:#000000;">ghunt@phiagroup.com</span></a><span style="color:#000000;"> or by phone at 781-535-5644.<br /> <br /> About The Phia Group:<br /> <br /> The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and – of course – Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.<br /> <br /> About Louisville Business First:<br /> <br /> Louisville Business First is the leading source for business news, data and networking for the Greater Louisville area. Providing a Weekly Edition, Afternoon and Morning Editions, email newsletters, a multimedia website, social media channels, as well as events and awards programs, Louisville Business First is a one-stop-shop to gather information, insights and connections you need to succeed in business.</span></span></span></span></p> 1171The Phia Group's 3rd Quarter 2022 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1170/the-phia-groups-3rd-quarter-2022-newsletterNewslettersThu, 28 Jul 2022 12:27:32 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: #FF; } .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 Q3 2022/icons6622.png?ver=rEP_uJTtJ9WGJJlxVlzt5A%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/block0422l.png?ver=tuRE_0H4iv6GOfDHnvU83A%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#ICE NSA"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/block0422r.png?ver=ylSPZ1_5qK1hw1RL26IEoA%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="292" src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" width="292" /></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;">I’ll be straight with you - I’m at the beach. I’m literally typing this as I sit upon some warm, white sand, and gaze at the ocean. Yes indeed, I am celebrating my anniversary with my wife in Jamaica. More accurately, I am celebrating my anniversary with my wife and my family in Jamaica. Even more accurately, I am celebrating my anniversary with my wife and my entire family – including extended family – in Jamaica. Indeed; whether we are talking about a vacation or services meant to address any and all industry needs, I am a giver. Humor aside for a moment, I am so thankful for this much needed time; an opportunity to reflect upon what an amazing team we have built at The Phia Group, the incredible services and products we’ve developed hand-in-hand with you – our partners, and the incredible strides we’ve taken together over the years in our quest to maximize benefits, minimize costs, and empower plans.</p> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">It wasn’t “that” long ago when we were simply viewed as a subrogation company, or when Ron, Jen and I were the only Phia Group “speakers” that could reliably attend conferences and confidently talk about any and all health insurance related topics. Today, I’m proud to say that through our targeted efforts – including but not limited to our future leaders committee and “6th person” (building the roster of professional speakers) program, we have identified 16 staff members that can travel anywhere in the country, to talk about any of the issues impacting you and your clients today, the opportunities for tomorrow, and how Phia can guide you to success. </p> <p class="bodytext" style="text-align: justify;">There’s nothing I’m more proud of than creating a second generation of industry thought leaders that will work to advance our mission of ensuring you, your plans, their employees and families can access and afford high quality health care for a lower cost. I love this team.  </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="#russo4">Enhancements of the Quarter: Mass Tort Subrogation</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="#PHIA NEWS2">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: Mass Tort Subrogation </strong></p> <p class="bodytext" style="text-align: justify;">Some years ago, Phia partnered with HRS to use patented logic to help identify treatment that was related to class action lawsuits. They are typically divided into those related to toxic elements, device-related losses, and drugs. As an example, there are numerous cancer claims for which RoundUp has been considered responsible. </p> <p class="bodytext" style="text-align: justify;">Phia runs claims data through certain logic to identify cases that may not have obvious third-party liability, but which may ultimately be subject to mass tort subrogation. In addition to wanting us to identify cases where a plan participant has already filed a mass tort claim, many of our subrogation clients ask us to proactively reach out to participants to potentially include them in the mass tort lawsuit or settlement, thereby expanding reimbursement opportunities. </p> <p class="bodytext" style="text-align: justify;">Over the past year there has been a significant increase in cases identified, backlog of these cases, and expected recoveries – and in the last quarter, we have continued to refine our case identification and reporting capabilities. </p> <p class="bodytext" style="text-align: justify;">If you don’t already benefit from Phia’s subrogation services, contact <a href="mailto:sales@phiagroup.com">sales@phiagroup.com</a> for more information.<a id="ICE NSA" name="ICE NSA"></a></p> <p class="bodytext" style="text-align: justify;"><strong>Service Focuses of the Quarter: Independent Consultation and Evaluation (ICE) and No Surprises Act Support</strong> </p> <p class="bodytext" style="text-align: justify;"><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 know TPAs. Like the back of our hand. That’s why we developed our Independent Consultation and Evaluation service, otherwise 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 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 such as 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 playbook. ICE was created to ensure that health plans and the TPAs that work with them have a resource to tap into when things get hairy – and since it’s billed at a flat monthly fee rather than on an hourly basis, it’s affordable and accessible, and 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 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 to 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. 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> <p class="bodytext" style="text-align: justify;"><strong>Success Story of the Quarter: Unwrapping a Delayed Bill from the Provider</strong></p> <p class="bodytext" style="text-align: justify;">A TPA with which The Phia Group works closely has a benefit plan client that incurred a $245,000 air ambulance claim. Notably, this was incurred prior to the application of the No Surprises Act, so those protections do not apply here. </p> <p class="bodytext" style="text-align: justify;">This claim was subject to the Phia Unwrapped service, and so the claim was repriced at the client’s chosen rate of 160% of Medicare. The provider did not appeal, and the TPA periodically checked in with the patient to ensure that there was no balance billing; eventually the TPA considered the claim closed when there was no word whatsoever from the provider. </p> <p class="bodytext" style="text-align: justify;">A whopping 15 months later, the provider sent a demand letter to the plan, which was denied on procedural grounds as being filed later than the SPD’s terms allowed. The provider again appealed to the plan, and balance billed the member, which triggered the TPA to re-engage Phia. The TPA considered both the appeal and balance bill to be improper and prohibited by the terms of the SPD, but after reviewing the file, Phia determined that in fact both were valid! </p> <p class="bodytext" style="text-align: justify;">Generally, balance billing is subject to state contract law, which typically allows at least three years, meaning a provider may balance bill within a very long timeframe. In addition, since the United States is still in a state of national emergency, the COVID-related timeframe extensions remain in play – meaning that providers are granted an additional year to take steps such as submitting initial claims and appealing denials. Consequently, the appeal should have been considered timely, even if meritless. </p> <p class="bodytext" style="text-align: justify;">As a result, Phia advised that the plan simultaneously re-adjudicate the appeal and manage the balance billing, which the plan did. Ultimately, the appeal was denied as the plan did not owe more money, and Phia was engaged to negotiate the claim for potentially a higher payment to alleviate the balance billing. After a lengthy negotiation process (during which Phia pointed out to the provider that the billed charges constituted over 900% of Medicare), the plan approved settlement at 275% of Medicare, which protected the patient and closed the file for good.  </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></strong></p> <p class="bodytext" style="text-align: justify;"><strong>Phia Case Study: Continuity of Care Requirement</strong></p> <p class="bodytext" style="text-align: justify;">We have received numerous consulting requests regarding compliance with the No Surprises Act’s requirements, including the Continuity of Care requirements. In sum, federal law requires that a patient who is currently undergoing a course of treatment for a serious or complex condition, and whose provider’s contract with the plan terms during the course of treatment, is offered the opportunity to have claims that are part of that course of treatment paid as if the contract had not termed. </p> <p class="bodytext" style="text-align: justify;">TPAs have been struggling with how to proactively discover exactly when this applies and to whom, and many have asked whether these requirements can be met by including a general statement on all EOBs, to the effect of telling participants: “If you are undergoing a serious or complex course of treatment and your contracted provider becomes non-contracted, you may have continuity of care rights…” </p> <p class="bodytext" style="text-align: justify;">We have consistently opined that this is likely not a viable option for compliance; to quote from one response provided: </p> <p class="bodytext" style="text-align: justify;">“Notices of this kind are intended to be sufficiently specific as to inform a patient of the patient’s rights. If the notice is included on all EOBs – depending on the language ultimately used – either (1) all participants are effectively being told that their OON providers were previously INN, and that those patients have CoC rights (which is not accurate); or (2) all participants are being told that their OON providers may have previously been INN, and that those patients may have CoC rights (which we believe is not specific enough to actually inform patients of the bullets below). </p> <p class="bodytext" style="text-align: justify;">We have concerns that informing individuals that they have rights they don’t actually have (or don’t have a good way to find out), or informing everyone broadly that they may have certain rights – does not further the type of consumer protections envisioned by the NSA, nor does it provide the specific notifications required by the regulations. The EOB may ultimately include language that seems like it applies, but does not actually apply, to a given patient, which is not ideal from a consumer confusion standpoint or from an NSA compliance standpoint.”</p> <p class="bodytext"> </p> <hr class="horiz" />_ <p class="bodytext"><strong>Fiduciary Burden of the Quarter: “Good Faith, Reasonable Interpretations”</strong></p> <p class="bodytext" style="text-align: justify;">The self-funded industry heaved a collective sigh when the No Surprises Act was passed, and it seems like every day a new question arises that makes us sigh just a little bit more. Part of the frustration is the actual compliance burden, but part of it is the difficulty in figuring out how to comply. Although the regulatory bodies charged with interpreting the NSA have provided some guidance, it is not a whole lot – and with other federal laws, the regulators have directed health plans to use a “good faith, reasonable interpretation” of the law and regulations that have been promulgated. We view this as a blessing and a curse.<br /> <br /> Whether or not a particular interpretation meets that standard is anyone’s guess – but many view the opportunity to exercise judgment as a good thing, since it leaves some leeway to get creative or to interpret the regulations in a way that makes the most sense for a given plan sponsor. The “good faith, reasonable interpretation” standard also generally means that there are many ways to skin that particular cat, which can make compliance easier! </p> <p class="bodytext" style="text-align: justify;">On the flip side, however, the inherent lack of clarity regarding the limits of a “good faith, reasonable interpretation” can be viewed as a negative. Just as many plan sponsors or TPAs thrive when given the chance to get a bit creative and interpret the rules in their own ways, other plan sponsors and TPAs may do much better simply following clear directions; the fact that the regulators have essentially said, “we don’t know; you figure it out!” can cause as many problems as it solves. </p> <p class="bodytext" style="text-align: justify;">In general, though, as long as a given interpretation of a law can be backed up with evidence that the sponsor believes is a good faith, reasonable interpretation – even if it is later identified as an unwitting violation – the punishment is likely to be far less severe than if the regulators gave very specific guidance that went unheeded.</p> <br /> <a name="pdef"></a>  <hr class="horiz" /> <p><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a></p> <p class="heading1">Webinars:</p> <p class="bodytext" style="text-align: justify;">• On May 24, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/fiduciary-liability-the-no-surprises-act">Fiduciary Liability and The No Surprises Act</a>,” in which the team engaged in a candid roundtable discussion, providing both guidance and real case studies regarding the NSA requirements and best practices for dealing with balance bills … all while avoiding administrative errors that could result in serious penalties. </p> <p class="bodytext" style="text-align: justify;">• On April 19, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/spring-cleaning-a-candid-roundtable-discussion-of-industry-opportunities-and-concerns">A Candid Roundtable Discussion of Industry Opportunities & Concerns</a>,” in which we discussed real case studies and provided a candid analysis of recent industry developments and concerns.</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 June 24, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/us-supreme-court-rules-on-dialysis-carve-outs-the-phia-group">U.S. Supreme Court Rules on Dialysis Carve-outs</a>,” in which our hosts, Brady Bizarro and Andrew Silverio, broke down the Supreme Court’s ruling in the Marietta case on dialysis carveouts. </p> <p class="bodytext" style="text-align: justify;">• On June 10, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/breaking-down-breaks-in-service-the-phia-group">Breaking Down Breaks in Service</a>,” in which our hosts, Kelly Dempsey and Kevin Brady, discussed the important considerations surrounding rehired employees and breaks in service. </p> <p class="bodytext" style="text-align: justify;">• On May 27, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-benefits-of-direct-primary-care-the-phia-group">The Benefits of Direct Primary Care</a>,” in which our hosts, Nick Bonds and Corey Crigger, discussed Direct Primary Care (DPC). </p> <p class="bodytext" style="text-align: justify;"> • On May 13, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p134-changing-laws-changing-relationships">Changing Laws & Changing Relationships</a>,” in which our hosts, Jen McCormick and Jon Jablon, discussed some emerging laws and trends that impact the self-funded industry, with an emphasis on what it means for the TPA/employer dynamic. </p> <p class="bodytext" style="text-align: justify;">• On April 15, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p133-will-congress-proposals-to-limit-insulin-costs-make-a-difference">Congress’ Proposals to Limit Insulin Costs</a>,” in which our hosts, Cindy Merrell and Micah Iberosi-Parnell, discussed the insulin cost crisis, Congress’ band-aid on insulin prices, and what’s really needed to lower costs for employers and patients. </p> <p class="bodytext" style="text-align: justify;">• On April 1, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p132-planning-for-parity-exploring-the-enhanced-dol-enforcement-efforts">Planning for Parity: Exploring The Enhanced DOL Enforcement Efforts</a>,” in which our hosts, Jen Berman of MZQ and Jen McCormick, discussed the DOL’s evolving approach on MHPAEA, which is moving from a "compliance assistance" model to a "proactive enforcement" model. Book of Russo </p> <p class="bodytext" style="text-align: justify;">• On June 17, 2022, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-book-of-russo-chapter-1">The Book of Russo: Chapter 1</a>,” in which our host, Adam Russo, discussed the new podcast series, healthcare transparency, and so much more.</p> <p class="bodytext" style="text-align: justify;"><strong>Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></strong></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/2022/06/16/my-blood-sugar-is-boiling/">My Blood (Sugar) is Boiling</a> – June 16, 2022 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/No_Surprises_Act-_Open_Negotiation_Strategies_and_Compromises_by_Scott_Bennett%2C_Esq.pdf">No Surprises Act: Open Negotiation Strategies & Companies</a> – June 3, 2022 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/The_Newest_Fiduciary_Duty-Protecting_Participants_From_Themselves_by_Jon_Jablon%2C_Esq.pdf">The Newest Fiduciary Duty: Protecting Participants From benefitsThemselves</a> – May 6, 2022 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2022/04/22/fiduciaries-dont-forget-all-your-duties/">Fiduciaries …. Don’t forget ALL your duties!</a> – April 22, 2022 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Ongoing_Litigation_Of_Interest_To_Employer_Group_Health_Plans_by_Carrie_Cripps.pdf">Ongoing Litigation Of Interest To Employer Group Health Plans</a> – April 1, 2022</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/the-baby-formula-shortage-and-preventive-care">The Baby Formula Shortage and Preventive Care.</a> The baby formula shortage in the United States has been worsening for months. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/recent-sixth-circuit-decision-shows-limits-of-arbitration-provisions-on-participant-erisa-claims">Limits of Arbitration Provisions on Participant ERISA Claims.</a> A recent decision by the U.S. Circuit Court of Appeals for the Sixth Circuit will likely have a significant impact on the enforcement of arbitration agreements in ERISA claims and more direct consequences on employers across the country. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/the-mess-that-is-the-american-healthcare-system-why-was-i-surprised">The Mess in the American Healthcare System</a>. A system worth fixing. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/california-law-still-governs-most-surprise-bills">California Law Still Governs Most Surprise Bills</a>. In March, the California Department of Managed Health Care (“DMHC”) issued an “All Plan Letter.” </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/texas-new-pre-authorization-exemption-law">Texas’ New Pre-Authorization Exemption Law</a>. Pre-Authorizations just got a lot easier in Texas!</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"><br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pstacks" name="pstacks"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">The Stacks:</span></p> <p class="bodytext" style="text-align: justify;"><strong>No Surprises Act: Open Negotiation Strategies & Companies</strong></p> <p class="bodytext" style="text-align: justify;">By: Scott Bennett, Esq. – June 2022 – <a href="https://www.sipconline.net/files/No_Surprises_Act-_Open_Negotiation_Strategies_and_Compromises_by_Scott_Bennett%2C_Esq.pdf">Self-Insurers Publishing Corp</a>.  </p> <p class="bodytext" style="text-align: justify;">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. </p> <p class="bodytext" style="text-align: justify;">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.  </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2022-newsletter-the-phia-group">Click here</a> to read the rest of this article<br />  </p> <p class="bodytext" style="text-align: justify;"><strong>The Newest Fiduciary Duty: Protecting Participants From Themselves</strong></p> <p class="bodytext" style="text-align: justify;">By: Jon Jablon, Esq. – May 2022 – <a href="https://www.sipconline.net/files/The_Newest_Fiduciary_Duty-Protecting_Participants_From_Themselves_by_Jon_Jablon%2C_Esq.pdf">Self-Insurers Publishing Corp.</a>  </p> <p class="bodytext" style="text-align: justify;">In the recent case of Hughes v. Northwestern University, 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. </p> <p class="bodytext" style="text-align: justify;">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.  </p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2022-newsletter-the-phia-group">Click here</a> to read the rest of this article<br />  </p> <p class="bodytext" style="text-align: justify;"><strong>The Newest Fiduciary Duty: Protecting Participants From Themselves</strong></p> <p class="bodytext" style="text-align: justify;">By: Corrie Cripps – April 2022 – <a href="https://www.sipconline.net/files/Ongoing_Litigation_Of_Interest_To_Employer_Group_Health_Plans_by_Carrie_Cripps.pdf">Self-Insurers Publishing Corp</a>. </p> <p class="bodytext" style="text-align: justify;">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. </p> <p class="bodytext" style="text-align: justify;">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.</p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2022-newsletter-the-phia-group">Click here</a> to read the rest of this article  </p> <p class="bodytext" style="text-align: justify;"><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"><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 programs. </p> <p class="bodytext" style="font-weight: normal"><strong>Volunteer Day!</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group had the opportunity to visit The Boys & Girls Clubs of Metro South to participate in some fun activities for the kids! With over 100 kids to entertain all day, we had plenty for people to do. Archery, rock climbing, face painting, hiking, and so many more activities filled the day with so much joy and left us with so many memories. We are looking forward to next year’s Volunteer Day!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/tent.jpg?ver=20Rcmbq_9njAowge8OyzWA%3d%3d" style="width: 599px; height: 419px;" /> <p class="bodytext" style="font-weight: normal"><strong>Boys & Girls Club Youth of the Year</strong></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’s signature effort to foster a new generation of leaders, fully prepared to live and lead in a diverse, global and integrated world economy. One lucky teen was awarded a $4,000 scholarship and a new laptop, courtesy of The Phia Group. The Boys & Girls Clubs of Metro South has announced the Boys & Girls Clubs of Metro South’s 2021 Youth of the Year winner, Kiley George! Best of luck in your future endeavors.</p> <p class="bodytext" style="font-weight: normal"><strong>Boys & Girls Club Gala</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club Gala raised nearly $500,000 through its 2022 Bids for Kids Gala Auction held April 8 at the Putnam Club at Gillette Stadium. It was a true pleasure to be in attendance at this amazing event and we hope that the money raised will help kids in our area have an amazing summer!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/gala.jpg?ver=uVygpCtNcDUS1iDk4DyqjQ%3d%3d" style="width: 599px; height: 419px;" /> <p class="bodytext" style="font-weight: normal"><br /> <a href="#top">Back to top ^</a></p> <p class="heading1"><span class="heading1"><a id="pemployee" name="pemployee"></a><a id="PHIA NEWS2" name="PHIA NEWS2"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><span style="font-size:18px;"><strong>Phia News:</strong></span></span></p> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter: Skyla Mrosk</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 Skyla Mrosk, The Phia Group’s 2022 Q2 Employee of the Quarter! </p> <p class="bodytext" style="text-align: justify;">Here is what one person had to say about Skyla: “Skyla is an absolute ROCK STAR in Claims Analysis! In her almost two-year tenure with Phia, she has learned the ins & outs of the department. Not only is she a top producer, but she's also started taking on other duties to help Ben (inclusive of letter batching & JLS notifications... & she also doesn't shy away from jumping on the phones as back-up when we need it). The department is currently down a full-time resource & Skyla's efforts have undoubtedly allowed the team to stay afloat while we wait to welcome a new team member. Despite being on the more reserved side, she is an absolute force to be reckoned with & we are beyond lucky to have her as a part of our team. Kudos Skyla - thank you for everything you do for Phia!”</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/sky1.jpg?ver=ccWf4-YYpkreqrEkQQ4a8g%3d%3d" style="width: 390px; height: 460px;" /></p> <p class="bodytext">Congratulations Skyla, 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>Job Opportunities:</span></p> <p class="bodytext">• Plan Drafter (MA) </p> <p class="bodytext">• Health Benefit Attorney (MA) </p> <p class="bodytext">• Pace Appeal Specialist (ID) </p> <p class="bodytext">• Claim Analyst (MA) </p> <p class="bodytext">• Claim and Case Support Analyst (MA) </p> <p class="bodytext">• Claim Recovery Specialist (MA & KY)</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">• Jessica Grande has been promoted from Intake Specialist to Team Lead, Project Coordinator </p> <p class="bodytext">• Emily Rodriguez has been promoted from Intake Specialist to Project Coordinator</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Darren Aubrey was hired as a Sr. Claims Recovery Specialist </p> <p class="bodytext">• Ujwal Shrestha was hired as a VP, Business Analytics and Data Services </p> <p class="bodytext">• Colin Froment was hired as a Case Investigator </p> <p class="bodytext">• Maggie Montalto was hired as an Accounting Intern</p> <p class="bodytext">• Jordyn Forte was hired as a Plan Drafter </p> <p class="bodytext">• Justin Goldstein was hired as a Case Investigator</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> <p class="bodytext"><a name="story"> </a></p> <hr class="horiz" /> <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">Cleveland Opening Day BBQ</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">It has become a tradition at The Phia Group to celebrate Opening Day! We invite all Phia employees to dress up in their favorite sports team gear. As you may know, Phia’s staff includes lots of baseball fans who cheer for a wide variety of teams, including the Cleveland Guardians, Boston Red Sox, Philadelphia Phillies and (unfortunately) even the New York Yankees. Each year, the Phia Family comes together outside of our office to celebrate with hot dogs, cold beverages, and great conversations. </p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/cleveland.jpg?ver=ccWf4-YYpkreqrEkQQ4a8g%3d%3d" style="width: 599px; height: 419px;" /> <p class="boldtext"> </p> <p class="boldtext">Six Sigma Black Belts</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">We are excited to announce that four of our employees have been certified as Lean Six Sigma Black Belts! This process included eight months of training projects, learning the Six Sigma Black Belt methodology, executing a project using the Black Belt toolset, and passing an exam on Black Belt methodology. Congratulations to Kelsey Dillion, Toussaint Anderson, Mitch Hilbert, and Ttrina Garcia. The Phia family made sure to celebrate with a delicious cake in both Kentucky and Massachusetts!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/blackbelt.jpg?ver=LxQM0PXJAYvy50W8df1uAQ%3d%3d" style="width: 599px; height: 419px;" /> <p class="boldtext"> </p> <p class="boldtext">Pride at Phia</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">June is Pride Month, and the Phia family has a lot to be proud of! On Wednesdays, we encouraged employees to wear their favorite pride apparel, and as you can see below, we had some great outfits! This beautiful picture was taken outside of the Canton, MA office, and I think it is safe to say that the level of pride is high at Phia!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2022/pride.jpg?ver=aqFf_kcTHU_RgL58Km3Z-Q%3d%3d" style="width: 599px; height: 419px;" /> <p class="bodytext"><strong> </strong></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"><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.<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> </td> </tr> </tbody> </table> 1170The 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> 1169Should Plans Better Address Mental Health Benefits? | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1168/should-plans-better-address-mental-health-benefits-the-phia-groupPodcastsFri, 22 Jul 2022 13:34:13 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/vLesZF9OCao" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt">In the wake of the COVID-19 pandemic, the government has announced that we are facing another crisis – one on mental health. Participants are clamoring for more access to mental health care than ever before. The COVID-19 pandemic only highlighted the lack of availability of mental health care in the US, including care that is covered by plans. Ron Peck, Chief Legal Officer, and attorney Kaitlyn MacLeod are here to talk about what plans are doing to address the mental health crisis and how mental health parity comes into play for plans, patients, and providers. </span><br /> <br /> <a href="https://www.youtube.com/watch?v=vLesZF9OCao" style="color:blue; text-decoration:underline"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=vLesZF9OCao" style="color:blue; text-decoration:underline"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span></p> 1168Supreme Decisions – A Proactive Approach for Health Plans to Dobbs and Mariettahttps://www.phiagroup.com/Media/Posts/PostId/1166/supreme-decisions-a-proactive-approach-for-health-plans-to-dobbs-and-mariettaWebinarsTue, 19 Jul 2022 16:23:59 GMT<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="color:black">The U.S. Supreme Court may be in recess until October, but its landmark healthcare rulings over the past month continue to reverberate across the country and across our industry. These decisions will have strong implications for plan sponsors in particular and The Phia Group is here to explain how your health plan, and its administrators, may be affected by these momentous developments. Please join us as we delve into such current affairs (not to mention history in the making) from a unique healthcare cost containment perspective.</span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><a href="https://attendee.gotowebinar.com/recording/4245067484797016333"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></a></p> <p><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></p> 1166Stop Loss and Subrogation | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1164/stop-loss-and-subrogation-the-phia-groupPodcastsFri, 08 Jul 2022 13:03:28 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/FpsuPOb7OHM" title="YouTube video player" width="560"></iframe></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%">In this episode of the Empowering Plans podcast, attorneys Chris Aguiar and Cindy Merrell discuss potential obligations of health plans to their stop-loss carriers in the event of a recovery through subrogation.</span></span></span></span></span></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/FpsuPOb7OHM" style="color:blue; text-decoration:underline"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://youtu.be/FpsuPOb7OHM" style="color:blue; text-decoration:underline"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span></span></p> 1164Book of Russo: Chapter 2https://www.phiagroup.com/Media/Posts/PostId/1163/book-of-russo-chapter-2PodcastsWed, 06 Jul 2022 18:12:59 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/c_sxjjC0_80" title="YouTube video player" width="560"></iframe></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif">In the latest episode of The Book of Russo, tune in to find out what The Phia Group’s CEO, Adam Russo, and guest host, Dr. Marty Makary, have to say about price transparency, price gouging, and who is typically responsible for the high cost of care.</span></span></span></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><a href="https://www.youtube.com/watch?v=c_sxjjC0_80" style="color:blue; text-decoration:underline"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=c_sxjjC0_80" style="color:blue; text-decoration:underline"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span></span></p> 1163The Dobbs Case – What Group Health Plans and Employers Need to Know | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1162/the-dobbs-case-what-group-health-plans-and-employers-need-to-know-the-phia-groupPodcastsFri, 01 Jul 2022 16:18:28 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/pX3RibGm0mo" title="YouTube video player" width="560"></iframe></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 calibri="" style="font-family:">On June 24th, the U.S. Supreme Court handed down one of its most controversial and impactful decisions in half a century by overturning <u>Roe v. Wade</u>. This decision has sweeping implications for group health plans. In this special edition of the Empowering Plans podcast, The Phia Group’s Chief Legal Officer, Ron Peck, is joined by attorneys Jen McCormick and Brady Bizarro to unpack the Court’s opinion, what’s likely to happen next, and most importantly, how health plans should respond to this historic ruling.</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></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><span style="color:#0563c1">Click here to check out the podcast!</span>  (Make sure you subscribe to our <span style="color:#0071ce"><span style="color:#0563c1">YouTube</span> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span><span style="font-family:"Calibri",sans-serif"></span></span></span></p> 1162U.S. Supreme Court Rules on Dialysis Carve-outs | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1161/us-supreme-court-rules-on-dialysis-carve-outs-the-phia-groupPodcastsFri, 24 Jun 2022 13:19:50 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/QhibJ6DWEnY" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">In this episode of the Empowering Plans podcast, attorneys Brady Bizarro and Andrew Silverio break down the Supreme Court’s ruling in the <u>Marietta</u> case on dialysis carve-outs. What does the ruling mean for self-funded plans that wish to carve out dialysis claims? Our experts dig deep into the legal analysis and explain how plans can stay within the parameters of this decision. Finally, they address important points raised by the dissent and consider the broader impact on the industry.</span></span></p> <p style="text-align:justify; margin:0in"> </p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=QhibJ6DWEnY" style="color:blue; text-decoration:underline"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=QhibJ6DWEnY" style="color:blue; text-decoration:underline"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span><span style="font-family:"Calibri",sans-serif"></span></span></span></p> 1161The Book of Russo: Chapter 1https://www.phiagroup.com/Media/Posts/PostId/1160/the-book-of-russo-chapter-1PodcastsFri, 17 Jun 2022 12:32:59 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/7-8Y_jpykOM" title="YouTube video player" width="560"></iframe></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">In the first episode of The Book of Russo, tune in to find out what The Phia Group’s CEO, Adam Russo, has to say about the new podcast series, healthcare transparency, and so much more. </span></span></p> <p style="margin:0in"> </p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=7-8Y_jpykOM"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=7-8Y_jpykOM"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span><span style="font-family:" calibri",sans-serif"=""></span></span></span></p> 1160Breaking Down Breaks in Service | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1158/breaking-down-breaks-in-service-the-phia-groupPodcastsWed, 08 Jun 2022 19:34:08 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/EeST38EoGcA" title="YouTube video player" width="560"></iframe></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 calibri="" style="font-family:">In this episode of Empowering Plans, join Kelly Dempsey and Kevin Brady as they discuss the important considerations surrounding rehired employees and breaks in service. This dynamic duo covers a number of items including the 13/26 week rule, the rule parity, and the need to add plan provisions which account for these situations.</span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=EeST38EoGcA"><span style="color:#0563c1">Click here to check out the podcast!</span></a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=EeST38EoGcA"><span style="color:#0563c1">YouTube</span></a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span><span style="font-family:"Calibri",sans-serif"></span></span></span></p> 1158The Benefits of Direct Primary Care | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1155/the-benefits-of-direct-primary-care-the-phia-groupPodcastsFri, 27 May 2022 13:35:19 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/4s16Zb-QuVI" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin:0in; margin-right:0in; margin-left:0in"><span style="color:#000000;"><span style="font-size:11pt"><span calibri="" style="font-family:">In this episode of The Phia Group’s Empowering Plans podcast, attorneys Nick Bonds and Corey Crigger discuss Direct Primary Care (DPC). This was a hot topic at a recent conference Nick attended and a subject near and dear to Corey. Join them as they discuss the benefits and practical issues to consider when looking at this tremendous option for augmenting your employee benefits plan. </span></span></span><br />  </p> <p style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in; text-align:justify"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.0pt"><a href="https://www.youtube.com/watch?v=4s16Zb-QuVI" style="color:#0563c1; text-decoration:underline">Click here to check out the podcast!</a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://www.youtube.com/watch?v=4s16Zb-QuVI" style="color:#0563c1; text-decoration:underline">YouTube</a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span> </a>Channels!)</span></span></span></p> 1155Fiduciary Liability & The No Surprises Act | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1154/fiduciary-liability-the-no-surprises-actWebinarsTue, 24 May 2022 13:20:24 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:18px;"><span style="line-height:107%"><span calibri="" style="font-family:">Spring is in full swing, and flowers aren’t the only things emerging.  The No Surprises Act continues to evolve, creating additional obligations for plan administrators and those that serve them.  At the same time, the courts are determining that good faith errors made by administrators may still constitute fiduciary breaches.  These trends are on a crash course.  Don’t get caught in the crossfire. Listen in as the team engages in a candid roundtable discussion; providing both guidance and real case studies regarding the NSA, requirements, and best practices for dealing with balance bills… all while avoiding administrative errors that could result in serious penalties.</span></span></span></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in"><a href="https://attendee.gotowebinar.com/recording/9082879063354209808"><span style="font-size:18px;"><span new="" roman="" style="font-family:" times="">Click Here to View Our Full Webinar</span></span></a></p> <p style="margin-top:0in; margin-right:0in; margin-bottom:8.0pt; margin-left:0in"><span style="font-size:18px;"><span new="" roman="" style="font-family:" times="">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></p> 1154Changing Laws & Changing Relationships | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1153/empowering-plans-p134-changing-laws-changing-relationshipsPodcastsFri, 13 May 2022 12:13:34 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/-dvNXO2MXf8" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">In this episode of The Phia Group’s Empowering Plans podcast, attorneys Jen McCormick and Jon Jablon discuss some emerging law and trends that impact the self-funded industry, with an emphasis on what it means for the TPA/employer dynamic. Relationships are key in this industry, but since the law imposes responsibilities on health plans that often can’t be met without significant help from a TPA, things can get a bit messy. There’s a lot of content to cover on this one, and Jen and Jon try to at least scratch the surface of this complex topic.</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/-dvNXO2MXf8" style="color:blue; text-decoration:underline">Click here to check out the podcast!</a>  (Make sure you subscribe to our <span style="color:#0071ce"><a href="https://youtu.be/-dvNXO2MXf8" style="color:blue; text-decoration:underline">YouTube</a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce;">Apple Podcasts</span> </a>Channels!)</span></span></span></p> 1153The 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> 1148Healthcare Opportunities and Concerns | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1146/spring-cleaning-a-candid-roundtable-discussion-of-industry-opportunities-and-concernsWebinarsTue, 19 Apr 2022 16:24:01 GMT<p style="text-align: justify;"><span style="font-size:16px;"><span style="color:#000000;">As we open the windows and roll up our sleeves for some spring cleaning, so too is The Phia Group’s team opening up and tossing out their thoughts.  The team shares real case studies and candidly discusses recent industry developments, their hopes and concerns.  From relationships to regulations; from plans to politics, and beyond… the subject matter will resonate.  The Phia Group’s team of experts will not pull punches as they provide their thoughts on the most pressing topics.  Do not miss this one.</span></span></p> <p style="margin:0in 0in 8pt"><a href="https://attendee.gotowebinar.com/recording/5641309811106308098"><span style="font-size:18px;"><span style="line-height:107%"><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></a></p> <p style="margin:0in 0in 8pt"><span style="font-size:18px;"><span style="line-height:107%"><span calibri="" style="font-family:">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=March%202022%20Webinar%20Slides">mpainten@phiagroup.com</a>.</span></span></span></p> 1146Congress’ Proposals to Limit Insulin Costs | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1145/empowering-plans-p133-will-congress-proposals-to-limit-insulin-costs-make-a-differencePodcastsFri, 15 Apr 2022 13:08:20 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/VQWQeFSXblw" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times="">Congress has proposed a $35 cap on patient cost-sharing for a month supply of insulin. Join Attorneys Cindy Merrell and Micah Iberosi-Parnell, as they discuss the insulin cost crisis, Congress’ band-aid on insulin prices, and what’s really needed to lower costs for employers and patients.<br /> <br /> <a href="https://youtu.be/VQWQeFSXblw">Click here to check out the podcast!</a>  (Make sure you subscribe to our <span style="color:#0071ce;"><a href="https://youtu.be/VQWQeFSXblw">YouTube</a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce;">Apple Podcasts </span></a>Channels!)</span></span></span></p> 1145Empowering Plans: P132 - The Enhanced DOL Enforcement Efforthttps://www.phiagroup.com/Media/Posts/PostId/1141/empowering-plans-p132-planning-for-parity-exploring-the-enhanced-dol-enforcement-effortsPodcastsFri, 01 Apr 2022 12:58:52 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/KKYjpbfkJ-g" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""></span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;">The CAA, passed in part due to the rising mental health issues, added enhanced DOL enforcement mechanisms.  Join special guest Jen Berman of MZQ, and Jen McCormick, as they discuss the DOL’s evolving approach on MHPAEA which is moving from a "compliance assistance" model to a "proactive enforcement" model.  This approach puts a ton of pressure on plan sponsors – administrative, compliance, logistical – and plans need to be prepared. </span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""></span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""><a href="https://youtu.be/KKYjpbfkJ-g">Click here to check out the podcast!</a>  (Make sure you subscribe to our <span style="color:#0071ce;"><a href="https://youtu.be/KKYjpbfkJ-g">YouTube</a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce;">Apple Podcasts </span></a>Channels!)</span></span></span></p> 1141Empowering Plans: P131–Reduction Requests | Fiduciary Dutieshttps://www.phiagroup.com/Media/Posts/PostId/1137/empowering-plans-p131-a-balancing-act-of-reduction-requests-and-plans-fiduciary-dutiesPodcastsFri, 18 Mar 2022 15:50:30 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/cZtFHZMRHPI" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""></span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"> </span><span style="font-size:16px;">On this week’s episode of Empowering Plans, Attorneys Chris Aguiar and Cindy Merrell, discuss the balancing act of health plan members’ reduction requests and a Plan’s fiduciary duties, why a reduction can be in the Plan’s best interest, and more. Listen in as we dive deep into reduction requests and Plan’s fiduciary duties. </span><span style="font-size:16px;">  </span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""></span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""><a href="https://www.youtube.com/watch?v=cZtFHZMRHPI">Click here to check out the podcast!</a>  (Make sure you subscribe to our <span style="color:#0071ce;"><a href="https://www.youtube.com/watch?v=cZtFHZMRHPI">YouTube</a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce;">Apple Podcasts </span></a>Channels!)</span></span></span></p> 1137Winner of the 2022 Top Workplaces USA Award | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1136/energage-names-the-phia-group-a-winner-of-the-2022-top-workplaces-usa-awardPress ReleasesFri, 18 Mar 2022 15:22:27 GMT<p style="text-align: justify;">For Immediate Release</p> <p style="text-align: justify;">3/18/2022</p> <p style="text-align: justify;">Canton, MA – Energage Names The Phia Group, LLC a Winner of the 2022 Top Workplaces USA Award.</p> <p style="text-align: justify;"><span style="font-family:" calibri",sans-serif"=""></span></p> <p style="text-align: justify;">Today The Phia Group announced 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 their 15-year history of surveying more than 20 million employees across 54 markets, to award this prize during what is the prestigious honor’s inaugural year.</p> <p style="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 style="text-align: justify;">“The Phia Group’s mission is to reduce medical costs and improve the quality of health care.  That mission starts and ends with our people.  Our job is to help other employers secure the best benefits for their employees and families; it behooves us to do the same for our own team,” The Phia Group’s CEO, Adam Russo, remarked.  “This award is proof that our focus on benefits, opportunities, and general employee satisfaction is not misguided.  While employee satisfaction is valuable in and of itself, it is equally important as a crucial element of improving our company’s overall value.  If our team doesn’t share our passion or buy into our principles, that reflects in the work product.  Employer success is therefore built upon a foundation of employee success.  By emphasizing an atmosphere of employee satisfaction, we generate better outcomes, satisfied clients and success for all.”</p> <p style="text-align: justify;">To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> or by phone at 781-535-5644.</p> <p style="text-align: justify;"><strong>About The Phia Group:</strong></p> <p style="text-align: justify;">The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</p> <p style="text-align: justify;"><strong>About Energage:</strong></p> <p style="text-align: justify;">Making the world a better place to work together.™</p> <p style="text-align: justify;">Energage is a purpose-driven company that helps organizations turn employee feedback into useful business intelligence and credible employer recognition through Top Workplaces. Built on 14 years of culture search and the results from 22 million employees surveyed across more than 66,000 organizations,  Energage delivers the most accurate competitive benchmark available. With access to a unique combination of patented analytic tools and expert guidance, Energage customers lead the competition with an engaged work force and an opportunity to gain recognition for their people-first approach to culture. For more information or to nominate your organization, visit energage.com or topworkplaces.com.</p> 1136Empowering Plans: P130 – Healthcare Policy | The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/1132/empowering-plans-p130-healthcare-policy-in-the-state-of-the-union-addressPodcastsFri, 04 Mar 2022 15:48:58 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/n0dVv_3yL9A" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""> With one year under his belt, President Biden delivered his first State of the Union address, in which he showcased his domestic policy agenda. In this episode of the Empowering Plans podcast, Brady Bizarro and Andrew Silverio break down the important healthcare policy items the president discussed, and as importantly, which ones he did not. </span></span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span new="" roman="" times=""><a href="https://youtu.be/n0dVv_3yL9A">Click here to check out the podcast!</a>  (Make sure you subscribe to our <span style="color:#0071ce;"><a href="https://youtu.be/n0dVv_3yL9A">YouTube</a> </span>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce;">Apple Podcasts </span></a>Channels!)</span></span></span></p> 1132The 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> 1118Empowering Plans: P126 – Challenges and Opportunities with Value-Based Care for 2022https://www.phiagroup.com/Media/Posts/PostId/1116/empowering-plans-p126-challenges-and-opportunities-with-value-based-care-for-2022PodcastsThu, 06 Jan 2022 20:16:10 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/54Q6GK_hElo" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"></span></p> <p style="margin:0in"><span style="font-size:18px;"><span calibri="" style="font-family:">Kicking off the first episode of Empowering Plans in 2022, Phia’s Chief Legal Officer, Ron E. Peck, and Attorney Micah Iberosi-Parnell, talk value-based care, what it is, where it’s at right now, and where it’s headed. Listen for a preview of what action self-funded plans can begin taking now to reduce costs without sacrificing the quality of coverage.</span></span></p> <p style="text-align: justify;"> </p> <p style="text-align: justify;"><span style="font-size:18px;"><a href="https://www.youtube.com/watch?v=54Q6GK_hElo">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=54Q6GK_hElo">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcasts </a>Channels!)</span></p> 1116Empowering Plans: P125 – The Night Before an Emergency Room Visithttps://www.phiagroup.com/Media/Posts/PostId/1113/empowering-plans-p125-the-night-before-an-emergency-room-visitPodcastsWed, 22 Dec 2021 13:57:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/RdHUuzVhaSI" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"> This week on Empowering Plans, 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. Listen in to hear Rebekah's holiday story and how this story relates to multiple subrogation cases. </span></p> <p style="text-align: justify;"><span style="font-size:16px;"><a href="https://www.youtube.com/watch?v=RdHUuzVhaSI">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=RdHUuzVhaSI">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcasts </a>Channels!)</span></p> 1113The 11th Hour - Last Minute Moves to Make for 2022 as a New Era in Cost Containment Beginshttps://www.phiagroup.com/Media/Posts/PostId/1110/the-11th-hour-last-minute-moves-to-make-for-2022-as-a-new-era-in-cost-containment-beginsWebinarsTue, 14 Dec 2021 00:27:00 GMT<p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:18px;"><span new="" roman="" style="font-family:" times="">Ready or not here it comes! As the final countdown to 2022 begins, we both look forward to a new era in cost containment, and prepare for increased regulatory attention and enforcement. From vaccine mandates to transparency; mental health parity to the No Surprises Act; this is our last chance to make the necessary moves and identify the tools we will need before the new year begins.  With solutions at every stage, together we will centralize workflows and tie it all together; regardless of where you are in the process. Join The Phia Group as we learn, plan, save and protect your plans – now and in the future. Also, some fresh faces will share fresh ideas – Introducing our new VP of Provider Relations, Scott Bennett! This is one you won’t want to miss.</span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><a href="https://attendee.gotowebinar.com/recording/7707771543981118223"><span style="font-size:18px;"><span new="" roman="" style="font-family:" times=""><strong>Click Here to View Our Full Webinar</strong></span></span></a></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:18px;"><span style="line-height:107%"><span calibri="" style="font-family:">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%2FBreakout%20Slides%20Request%20-%20June%202021" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></p> 1110Empowering Plans: P124 – Healthcare Subrogation and Plan Document Requestshttps://www.phiagroup.com/Media/Posts/PostId/1109/empowering-plans-p124-healthcare-subrogation-and-plan-document-requestsPodcastsFri, 10 Dec 2021 14:23:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/obrKJssNfCM" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"> In this episode of Empowering Plans, Attorneys 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. Tune in for all of the details! </span></p> <p style="text-align: justify;"><span style="font-size:16px;"><a href="https://www.youtube.com/watch?v=obrKJssNfCM">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=obrKJssNfCM">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcasts </a>Channels!)</span></p> 1109The Boston Globe Names The Phia Group as a Top Place to Work for 2021https://www.phiagroup.com/Media/Posts/PostId/1108/the-boston-globe-names-the-phia-group-as-a-top-place-to-work-for-2021Press ReleasesMon, 06 Dec 2021 20:27:00 GMT<p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">12/6/2021</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Canton, MA – The Boston Globe Names The Phia Group as a Top Place to Work for 2021.<br /> <br /> 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​.<br /> <br /> Each year, The Boston Globe publishes in its “Top Places to Work” ​issue, a list of employers it recognizes as being the most admired workplaces in the state, voted on by the people who know them best – their employees.  The survey measures employee opinions about their company’s direction, execution, connection, management, work, pay and benefits, and engagement.<br /> <br /> “This was a particularly challenging year to be a great place to work, and the companies that made our list went above and beyond to keep their employees safe, engaged, and cared for,” said Katie Johnston, the Globe’s Top Places to Work editor. “From offering help with childcare to making the workplace more equitable, to holding virtual events, these employers showed that the best get better in crisis.”<br /> <br /> The rankings ​are based on confidential survey information collected by Energage (formerly Workplace Dynamics), an independent company specializing in employee engagement and retention, from more than 80,000 individuals at hundreds of Massachusetts organizations.  The winners share a few key traits, including offering progressive benefits, giving their employees a voice, and encouraging them to have some fun while they’re at it.<br /> <br /> “This is one of the proudest days of my life.” The Phia Group’s CEO, Adam Russo, remarked.  “I say this team is like family; but we don’t usually get to choose who is a part of our family.  Our employees choose to be part of this family.”<br /> <br /> “Ensuring that people have access to the best health care at the lowest cost possible is our purpose.  It’s what we provide to our clients, and it’s what we provide to our own staff.” Adam continued.  “When your people are happy, your clients are happy.  It’s not always the easiest or quickest path to success, but it is a lot more permanent.” <br /> <br /> Additional information can be found at Globe.com/TopPlaces. <br /> <br /> To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com" style="color:#0563c1; text-decoration:underline">ghunt@phiagroup.com</a> or by phone at 781-535-5644.<br /> <br /> About The Phia Group:<br /> <br /> The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"><br /> <br /> About Boston Globe Media Partners LLC:<br /> <br /> Boston Globe Media Partners, LLC provides news and information, entertainment, opinion and analysis through its multimedia properties. BGMP includes The Boston Globe, Globe.com, Boston.com, STAT and Globe Direct.</span></span></p> 1108Empowering Plans: P123 – Supreme Court Takes Major Dialysis Casehttps://www.phiagroup.com/Media/Posts/PostId/1105/empowering-plans-p123-supreme-court-takes-major-dialysis-casePodcastsTue, 23 Nov 2021 14:05:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/iM3KmLJR2Vo" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"> <span calibri="" style="font-family:">In this episode of the Empowering Plans podcast, join attorneys Brady Bizarro and Andrew Silverio as they discuss important developments in dialysis case law. Earlier in November, the Supreme Court agreed to hear arguments in a case which could settle an important question about the Medicare Secondary Payer Act and have important ramifications for plan language and payment methodologies. Brady and Andrew trace the history of the case and the differences in legal interpretation by the lower courts. Finally, they offer some predictions about how the Court may rule and the impact it could have on the industry.</span></span></p> <p style="text-align: justify;"><span style="font-size:16px;"><a href="https://www.youtube.com/watch?v=iM3KmLJR2Vo">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=iM3KmLJR2Vo">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcasts </a>Channels!)</span></p> 1105The Phia Group is Proud to Announce that Scott Bennett has Joined their Teamhttps://www.phiagroup.com/Media/Posts/PostId/1102/the-phia-group-is-proud-to-announce-that-scott-bennett-has-joined-their-teamPress ReleasesFri, 12 Nov 2021 13:38:00 GMT<p style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt"><span calibri="">For Immediate Release<br /> <br /> 06/15/2021</span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">Canton, MA – The Phia Group, LLC adds Scott Bennett to The Team.</span></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">Today The Phia Group announced that Scott Bennett has joined their already robust team of health benefit professionals, as its Vice President of Provider Relations.   Scott will strengthen The Phia Group’s efforts to empower plans by leading a team that enhances the overall provider experience.  With a focus on quality and cost metrics, their mission is to make benefits more affordable and accessible.  Under Scott’s leadership, The Phia Group’s Provider Relations team will continue to support plans and partners that utilize or manage innovative pricing methodologies, while also providing Phia Group based solutions such as Claim Negotiation and Signoff, Phia Unwrapped, and Balance Bill Support.    </span></span></span></p> <p class="xx" style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">As new laws and regulations impact how health benefit plans process and pay medical claims, Scott and his team will develop new approaches to the future of claims processing, while continuing to provide ancillary support to other programs as well.  Relevant to this mission, Scott boasts an impressive background as an attorney, data analyst, and a certified professional coder. Scott's past experience includes: Vice President at a national third party administrator, a Director of dispute resolution, and the designated company witness for six years at a nationwide medical bill review company focused on commercial reimbursement and workers’ compensation fee schedules and disputes.</span></span></span></p> <p class="xx" style="margin: 0in; text-align: justify;"> </p> <p><span style="color:#000000;"></span></p> <p class="xx" style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt"></span></span></span></p> <p class="xx" style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">In addition to designing and defending cost containment programs, Scott has successfully litigated and participated in trials, depositions, negotiations, and mediations concerning medical billing disputes among providers, patients and payors involving reference-based pricing, workers compensation, ERISA, antitrust law, and personal injury damages.</span></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">“Adding Scott to the team solidifies The Phia Group as a leader in the industry.  It means we can continue to develop and offer solutions and services that empower plans,” remarked The Phia Group’s CEO, Adam Russo.  “We have always been proud of our ability to stay ahead of regulatory hurdles; the hurdles are getting bigger, but adding Scott ensures we can conquer whatever comes next.” </span></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">Regarding his new role at The Phia Group, Scott Bennett remarked, <span style="background:white">“I am thrilled to be part of such a respected company, and look forward to working with this expert team to further develop their already extensive products and services, especially at a time where increased data transparency and new regulations will challenge the industry to innovate.​”</span></span></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">To learn more about The Phia Group, what it is doing to empower plans, and to learn more about its Provider Relations solutions, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com" style="color:blue; text-decoration:underline">ghunt@phiagroup.com</a> or by phone at 781-535-5644.</span></span></span></p> <p style="margin-right: 0in; margin-left: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11pt">About The Phia Group: </span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:11.0pt">The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></span></span></p> 1102The 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> 1098A Spooky Surprise: NSA Regulations on IDR Releasedhttps://www.phiagroup.com/Media/Posts/PostId/1096/a-spooky-surprise-nsa-regulations-on-idr-releasedWebinarsTue, 19 Oct 2021 12:59:00 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">On September 30th, the federal government released a long-awaited interim final rule to enact additional components of the <a href="https://www.phiagroup.com/Media/The-No-Surprises-Act-Explained">No Surprises Act</a>. This rule outlines many critical processes of which self-funded health plans and other industry players must be aware, including the independent dispute resolution process and expanded rights to external review. Join the Phia team as they 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. This is one monster mash you do not want to miss.</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><a href="https://attendee.gotowebinar.com/recording/8660788639279264775"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><strong><span style="font-size:10.5pt">Click Here to View Our Full Webinar</span></strong></span></span></a></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%2FBreakout%20Slides%20Request%20-%20June%202021" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></p> 1096Empowering Plans: P118 – You Can’t Always Get What You Wanthttps://www.phiagroup.com/Media/Posts/PostId/1089/empowering-plans-p118-you-cant-always-get-what-you-wantPodcastsFri, 17 Sep 2021 12:21:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/mUJII8EhtmU" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"></span></p> <p><span style="font-size:14px;">This week on Empowering Plans, Attorneys Chris Aguiar and Cindy Merrell, discuss what happens when limited settlement funds force Plans to consider a reduction. Listen in to get all of the details. </span></p> <p><span style="font-size:14px;"><a href="https://youtu.be/hGi5DyyN3KI">Click here to check out the podcast</a>!  (Make sure you subscribe to our <a href="https://youtu.be/mUJII8EhtmU">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcasts </a>Channels!)</span></p> 1089The Provider Perspective – Analysis and Response to How Providers are Reacting to Recent Rule Changes and Reformhttps://www.phiagroup.com/Media/Posts/PostId/1085/the-provider-perspective-analysis-and-response-to-how-providers-are-reacting-to-recent-rule-changes-and-reformWebinarsTue, 24 Aug 2021 14:04:00 GMT<p style="text-align: justify;"><span style="font-size:14px;">For months we have been dissecting new and forthcoming rule changes, to address their impact on the health benefits industry.  Yet, everything from laws regarding transparency to surprise balance bills will also substantially impact the provider community as well, right?  Maybe… Maybe not?  Join The Phia Group for another complimentary webinar, as they 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.  </span></p> <p style="text-align: justify;"><a href="https://attendee.gotowebinar.com/recording/3789341898039468560"><strong><span style="font-size:14px;">Click Here to View Our Full Webinar</span></strong></a></p> <p style="text-align: justify;"><span style="font-size:14px;">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%2FBreakout%20Slides%20Request%20-%20June%202021">mpainten@phiagroup.com</a>.</span></p> <p style="text-align: justify;"><strong><span style="font-size:14px;">To obtain a recording of our Breakout Sessions, please use the links below:</span></strong></p> <p style="text-align: justify;"><span style="font-size:14px;">Breakout #1: <a href="https://us02web.zoom.us/rec/share/Br8UZAOMhfzJ55NeJeiN9bbmtj06uAzFUr5E3PBYzi3O0xIIrbSb13qbFFYmnj0r.F0wZ31iJr9tg7h7S">A Failure to Negotiate</a></span></p> <p style="text-align: justify;"><span style="font-size:14px;">Breakout #2: <a href="https://us02web.zoom.us/rec/share/thDyridtWjGGg7luz-4Thtyoy6g-gVHg1WCm2RweB8Y_WMniKZl5OOe89BUCaBTy.LO-TurbDB9WH-iwj">Ready, Set, Comply</a></span></p> 1085Empowering Plans: P116 – Right to Repair and Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/1084/empowering-plans-p116-right-to-repair-and-healthcarePodcastsFri, 20 Aug 2021 15:19:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/PjI7xzVjgoY" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"> This week, take a break from COVID headlines with Andrew Silverio and Nick Bonds, as they discuss President Biden’s recent executive order on right to repair. How does promoting right to repair, a policy traditionally thought of in the context of automobiles and consumer electronics, factor into the healthcare space? Can right to repair reduce healthcare expenses, or is it a threat to the patient safety and intellectual property rights? </span></p> <p style="text-align: justify;"><span style="font-size:16px;"><a href="https://www.youtube.com/watch?v=PjI7xzVjgoY">Click here to check out the podcast</a>!  (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=PjI7xzVjgoY">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcasts </a>Channels!)</span></p> 1084Empowering Plans: P114 – Time to Vent!https://www.phiagroup.com/Media/Posts/PostId/1081/empowering-plans-p114-time-to-ventPodcastsFri, 23 Jul 2021 14:46:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/WzcZovaSd70" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:16px;"><span style="line-height:107%"><span calibri="" style="font-family:"> In one of the most energetic Phia podcasts to date, our Chief Legal Office – Ron Peck, and our Sr. VP of Consulting – Jen McCormick, discuss key mistakes and false beliefs dominating the media, politics, and the general public, before dissecting how those errors have impacted recent rulemaking. If you want to be both entertained and enlightened, this is the must-listen episode! </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:16px;"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/WzcZovaSd70" style="color:#0563c1; text-decoration:underline">Click here to check out the podcast</a>!  (Make sure you subscribe to our <a href="https://youtu.be/WzcZovaSd70" style="color:#0563c1; text-decoration:underline">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">Apple Podcasts </a>Channels!)</span></span></span></p> 1081The 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> 1078Surprise, surprise! Analyzing the No Surprises Act Part Deuxhttps://www.phiagroup.com/Media/Posts/PostId/1077/surprise-surprise-analyzing-the-no-surprises-act-part-deuxWebinarsMon, 12 Jul 2021 15:42:00 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">In the afternoon hours of July 1st, 2021, several U.S. departments released some much-anticipated surprise billing regulations, meant to implement the <a href="https://www.phiagroup.com/Media/The-No-Surprises-Act-Explained">No Surprises Act</a>. When that act was first outlined in the Consolidated Appropriations Act of 2021, The Phia Group was there to provide you with a detailed assessment of the rules.  Now, join The Phia Group as they once again 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).</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><a href="https://attendee.gotowebinar.com/recording/8276274027715555074"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></a></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:" calibri",sans-serif"=""></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%2FBreakout%20Slides%20Request%20-%20June%202021">mpainten@phiagroup.com</a>.</span></span></span></p> 1077Empowering Plans: P113 – Ahlborn Revisitedhttps://www.phiagroup.com/Media/Posts/PostId/1076/empowering-plans-p113-ahlborn-revisitedPodcastsFri, 09 Jul 2021 16:26:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/n4j0bok1T8g" title="YouTube video player" width="560"></iframe></p> <div style="text-align: justify;"><span style="font-size:16px;">In this episode of Empowering Plans, Rebekah McGuire-Dye and Lisa Hill talk about Medicaid and subrogation & reimbursement. SCOTUS has recently agreed to hear a Medicaid case involving conflicting state court and federal court decisions out of Florida, and whether or not the term “medical expenses” covers ALL medical expenses, or only past medical expenses, for purposes of subrogation & reimbursement. Listen in as Rebekah and Lisa discuss this case and its potential ramifications.</span></div> <div> </div> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:16px;"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://youtu.be/n4j0bok1T8g" style="color:#0563c1; text-decoration:underline">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://youtu.be/n4j0bok1T8g" style="color:#0563c1; text-decoration:underline">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">iTunes </a>Channels!)</span></span></span></p> 1076Back on Track: Plan Sponsor Priorities for the Second Half of 2021https://www.phiagroup.com/Media/Posts/PostId/1074/back-on-track-plan-sponsor-priorities-for-the-second-half-of-2021WebinarsMon, 21 Jun 2021 15:43:00 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">With the pandemic (mostly) in the rear-view mirror, it is time for plan sponsors and their partners to get back on track. Shoring up traditional cost-containment solutions will be important, but in this new environment, that will not be enough. New methods are needed to deal with new challenges. Two of the most serious threats to plan compliance and viability are now mental health parity requirements and rising prescription drug prices. In this webinar, The Phia Group’s legal team will examine 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.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin:0in 0in 8pt"><a href="https://attendee.gotowebinar.com/recording/492535445596884482"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Click Here to View Our Full Webinar</span></span></span></a></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Webinar%2FBreakout%20Slides%20Request%20-%20June%202021">mpainten@phiagroup.com</a>.</span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin:0in 0in 8pt"><strong><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">To obtain a recording of our Breakout Sessions, please use the links below:</span></span></span></strong></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Breakout #1: <a href="https://us02web.zoom.us/rec/share/qy9Jqnm5atoRdexSVSPZtOtDmHZIblpYE9fSW-yivCGFMUdhazlVKMjvbDrzp-Yp.e1zY51_CXGQpv5kD">Mental Health Parity – A Litigation Survey</a></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Breakout #2: <a href="https://us02web.zoom.us/rec/share/BMhKsbFJLoABFjv4Twakv2SUnozLU-qeZT1JLkPZaZPga-bkbP9FtrkepAAPeDVk.4erq2dJod2NxLShZ">FAQs on Prescription Drug Importation</a></span></span></span></p> 1074Louisville Business First Names The Phia Group, LLC a Best Place to Work in Greater Louisvillehttps://www.phiagroup.com/Media/Posts/PostId/1073/louisville-business-first-names-the-phia-group-llc-a-best-place-to-work-in-greater-louisvillePress ReleasesTue, 15 Jun 2021 16:03:00 GMT<p style="text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">For Immediate Release<br /> <br /> 06/15/2021<br /> <br /> Louisville, KY – Louisville Business First Names The Phia Group, LLC a Best Place to Work in Greater Louisville.</span><span style="font-family:"Calibri",sans-serif"></span></span><br /> <br /> <span style="font-size:11pt"><span calibri="" style="font-family:">Today The Phia Group announced 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.<br /> <br /> “Has The Phia Group in the past won awards and enjoyed recognition for our services?  Yes.”  The Phia Group’s CEO, Adam Russo, remarked.  “Do they compare to this?  Not even close. At The Phia Group, we recognize that the services we provide to benefit plans, employers, employees, and their families will only continue to exceed expectations when our own team is happy and thriving.  Awards like this therefore say less about the state of our company now, and tell us more about what lies ahead.  That is because a vibrant staff today means a bright future tomorrow.”<br /> <br /> Mr. Russo went on to say, “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.”<br /> <br /> To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com" style="color:#0563c1; text-decoration:underline">ghunt@phiagroup.com</a> or by phone at 781-535-5644.<br /> <br /> About The Phia Group:<br /> <br /> The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and – of course – Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.<br /> <br /> About Louisville Business First:</span><span style="font-family:"Calibri",sans-serif"></span></span><br /> <br /> <span style="font-size:11.0pt"><span calibri="" style="font-family:">Louisville Business First is the leading source for business news, data and networking for the Greater Louisville area. Providing a Weekly Edition, Afternoon and Morning Editions, email newsletters, a multimedia website, social media channels, as well as events and awards programs, Louisville Business First is a one-stop-shop to gather information, insights and connections you need to succeed in business. </span></span><span style="font-size:11.0pt"><span calibri="" style="font-family:"></span></span></p> 1073Empowering Plans: P111 – Breaking Down Drug Importation!https://www.phiagroup.com/Media/Posts/PostId/1071/empowering-plans-p111-breaking-down-drug-importationPodcastsFri, 11 Jun 2021 16:34:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/xmIZ2-Mp_50" title="YouTube video player" width="560"></iframe></p> <p><span style="font-size:11pt"><span calibri="" style="font-family:"> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"> In this episode of Empowering Plans, Attorneys Chris Aguiar and Andrew Silverio, discuss 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. </span></span></span></span></span></p> <p><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><a href="https://youtu.be/xmIZ2-Mp_50" style="color:#0563c1; text-decoration:underline">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://youtu.be/xmIZ2-Mp_50" style="color:#0563c1; text-decoration:underline">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">iTunes </a>Channels!)</span></span></span></span></span></p> 1071Empowering Plans: P110 – NQTL? MHPAEA?! OMG, IDK!https://www.phiagroup.com/Media/Posts/PostId/1066/empowering-plans-p110-nqtl-mhpaea-omg-idkPodcastsThu, 27 May 2021 17:26:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/u-l7P9R_sOg" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">In this episode of Empowering Plans, attorneys Nick Bonds and Jon Jablon discuss one of the most mysterious topics of the CAA: the <a href="https://www.phiagroup.com/Media/Understanding-Non-Quantitative-Treatment-Limitations-NQTLs">Non-Quantitative Treatment Limitation</a> analysis now required by the <a href="https://www.phiagroup.com/Media/Mental-Health-Parity-and-Addiction-Equity-Act-Explained">Mental Health Parity and Addiction Equity Act</a>. Not surprisingly, this analysis is anything but straightforward, and certainly no easy task for health plans – especially with very little helpful regulatory guidance. Jon and Nick are here to talk about what the heck NQTLs actually are, what the analysis entails, and how health plans can best protect themselves from the DOL’s wrath!<br /> <br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><a href="https://youtu.be/u-l7P9R_sOg" style="color:#0563c1; text-decoration:underline">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://youtu.be/u-l7P9R_sOg" style="color:#0563c1; text-decoration:underline">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#0563c1; text-decoration:underline">iTunes </a>Channels!)</span></span></span></span></span></p> 1066Empowering Plans: P108 – A Win/Win Proposition – Better Quality for Patients, Real ROI for Planshttps://www.phiagroup.com/Media/Posts/PostId/1062/empowering-plans-p108-a-winwin-proposition-better-quality-for-patients-real-roi-for-plansPodcastsTue, 11 May 2021 19:03:46 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/AB4Qyf2oeXA" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;">In this episode of the Empowering Plans Podcast, Tim Callender is joined by Jordan Feldman, the CEO and Co-Founder of Rightway Healthcare, along with Linda Pestana, the Director of HR at Phia. For the past two years, Phia has been a Rightway client, reporting a 6.8X ROI. Tim and Jordan discuss why Rightway got started and how it's delivering a "doctor in the family" experience for all members. Linda also shares the impact it's had on her — both as the HR / Benefits leader and as a direct user of the service. Tune in to hear how Rightway is making an impact!</span><u1:p></u1:p><span style="font-size:16px;"></span></p> <p><span style="font-size:16px;"></span></p> <p><span style="font-size:16px;"><a href="https://youtu.be/AB4Qyf2oeXA">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://youtu.be/AB4Qyf2oeXA">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</span></p> 1062Face the Change – Plan Design, Administrative Claims Processing and Payment Changes Needed in Light of COVID-19 and New Regulatory Obligationshttps://www.phiagroup.com/Media/Posts/PostId/1058/face-the-change-plan-design-administrative-claims-processing-and-payment-changes-needed-in-light-of-covid-19-and-new-regulatory-obligationsWebinarsTue, 27 Apr 2021 15:52:19 GMT<p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times="">Health benefit plans and the entities that serve them are feeling the squeeze.  Federal and State lawmakers are issuing new regulations on an almost monthly basis, including but not limited to the American Recovery Plan Act (ARPA), COBRA, Mental Health Parity, and the No Surprises Act.  Meanwhile, health care providers are making adjustments in response to the economic damage they suffered during the COVID-19 pandemic.  Join The Phia Group as they share 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.  In addition, The Phia Group will immediately host two breakout sessions following the webinar, with one session addressing ARPA, COBRA, regulatory updates and requisite plan updates in greater detail, and the other session will ensure attendees know what to do to maintain compliance with Mental Health Parity in the face of ever-changing provider practices.</span></span></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><a href="https://attendee.gotowebinar.com/recording/8437437141876947207">Click Here to View Our Full Webinar</a><br /> <br /> To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times="">To obtain a recording of our <strong>Breakout Sessions</strong>, please use the links below:</span></span></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><strong>Breakout #1</strong>: <a href="https://us02web.zoom.us/rec/share/8K_7-734BLSg0Px-msPiMhk8uzUDnKmyAVD89bEUj8y9BE-yX-XDD9RbORFQugTO.sTwxFXHxcooCsARy">New Regulations Impose Additional MHPAEA Compliance Requirements – Act Now!</a></span></span></p> <p style="margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><strong>Breakout #2</strong>: <a href="https://us02web.zoom.us/rec/share/x2mFmPHgDkbfdz3F7Y92AEyKQHLrXFHoVRlxQPlSrXK3AKz2YzcbjmYlwyXBb8KU.lpvo3ZF4NrigKy1r">COBRA Changes Under ARPA – What You Need to Know</a></span></span></p> 1058The Phia Group's 2nd Quarter 2021 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1057/the-phia-groups-2nd-quarter-2021-newsletterNewslettersMon, 26 Apr 2021 15:53:03 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 Q2 2021/icons66.png?ver=AFXuDXR4qX5IEWSu-GJ9Sg%3d%3d" style="width: 650px; height: 149px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#EOTQ"><img src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/block12021.png?ver=i9xkw99OKa3BSzp8MVIOMw%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pdef"><img src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/block22021.png?ver=nFNqX-FpfdeS9lpYzCRH1A%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="299" src="/Portals/phiagroup/Newsletter 2019 Q1/adam9.jpg?ver=d5VGoFOPUXcIVu6YdsX-0Q%3d%3d" width="264" /></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;">Spring has sprung! The weather in Boston has already reached a balmy 70 degrees, (though I know it will likely be 40 degrees tomorrow). For me, nothing says springtime quite like seeing fans in the stands at Cleveland Indians’ games and at Fenway Park; a sight with more meaning this season than ever before – even if it is only at 20% stadium capacity. Meanwhile, I am sitting here in my office at The Phia Group headquarters, thinking about how there are less than 50 people in a beautiful facility that can fit 300. Will we ever return to what some of us consider a state of normalcy? Will I once again enjoy the sense of camaraderie that comes with a bustling workplace? Should we promote such a return to on-site work, or embrace a movement towards an off-site future?</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;">When is the right time to ask these questions, and to begin developing a blueprint for whatever that future will be? Then my mind turns to the vaccine. What do I do as an employer? Promote vaccinations? Require it? How handcuffed am I by the limits set by law, can we rely on common sense, and for how long can I rely on my belief in human decency? From liability to legality to doing what is right.</p> <p class="bodytext" style="text-align: justify;">These same concerns and issues are being pondered by employers across the Nation and beyond. Nobody really knows what they will or should do, but they are hoping with time it will “just come to them.” Just as employees are split between those that can’t wait to emerge from their basement offices and return to the watercooler, and those that have become comfortably accustomed to (and embrace) their remote workplace, so too do we in the health benefits industry see a spectrum of patients – from those anxiously awaiting the day they can comfortably seek in-person care, to those that will happily utilize virtual care indefinitely… I’ll admit, it’s hard to argue with no commute, no expensive clothes, and no showering!!! I am interested – professionally and personally – to see what occurs over the next few months… but for now, please enjoy this quarter’s newsletter. 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 Q1 2018/inthisissue.png?ver=n5HSLKiVNAfWV5tv5BtrZA%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><a href="#EOTQ">Enhancements of the Quarter: Phia Unwrapped & No Surprises Act Consulting</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 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="bodytext"><strong></strong></p> <p class="bodytext"><strong><strong><a id="EOTQ" name="EOTQ"></a></strong></strong></p> <p class="bodytext"><strong>Enhancement of the Quarter: Phia Unwrapped & No Surprises Act Consulting </strong></p> <p class="bodytext" style="text-align: justify;">From COVID related expenses and processing issues, to expanded timeframes for providers to submit claims, few can deny that these are trying times for health plans and those that service them. With this as a backdrop, we were called upon once again to make sudden and severe adjustments in response to the impending No Surprises Act.</p> <p class="bodytext" style="text-align: justify;">The Phia Group has been Empowering Plans since 2000, and twenty-one years later we continue our quest 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 of 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 requisite Independent Dispute Resolution (or IDR) process.</p> <p class="bodytext" style="text-align: justify;">IDR is still a mystery to providers and health plans alike. 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 proposed payment.</p> <p class="bodytext" style="text-align: justify;">The self-funded industry has changed every year, and the impending effective date of the No Surprises Act is slated to bring some of the biggest changes since the ACA. This year, and beyond, make sure you’re prepared to help your clients and bolster your business by providing the services health plans need. Our offer to provide complimentary consultative services, as it relates to this new and confusing rule, is extended to all current Phia Unwrapped clients, as well as those that become clients on or before September 1, 2021.</p> <p class="bodytext" style="text-align: justify;">For more information on Phia Unwrapped, please contact our Senior VP of Provider Relations, Jason Davis, at <a href="mailto:jdavis@phiagroup.com" target="_blank">jdavis@phiagroup.com</a>.</p> <p class="bodytext" style="text-align: justify;">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" target="_blank">PGCReferral@phiagroup.com</a> – or, for clients of our Independent Consultation and Evaluation (ICE) service, via your dedicated ICE intake address.</p> <p class="bodytext"> </p> <hr class="horiz" />_ <p class="bodytext"><strong>Service Focus of the Quarter: PACE and Subrogation</strong></p> <p class="bodytext" style="text-align: justify;">In case you’re not familiar with The Phia Group’s Plan Appointed Claim Evaluator (PACE) service, it is designed to shift the fiduciary duty for second-level internal appeals to Phia, so the plan can ensure that a neutral third-party expert is the one making the most important appeal determinations.</p> <p class="bodytext" style="text-align: justify;">You might think that the PACE service is completely unrelated to our subrogation and recovery services, but we don’t believe that’s the case. While the PACE service is designed to make sure the health plan and TPA have correctly adjudicated a given claim, our subrogation and recovery services focus not on the correctness of a payment, but on the correct coordination between the plan and any other applicable payors. Put simply, PACE helps the plan comply with its fiduciary duties (by removing the responsibility to adjudicate final-level appeals from the Plan Administrator to begin with), and recovery services help the plan recover money it has paid when another party is responsible. We think of these as two sides of the same coin: protection both before the appeals process is finalized (PACE), and protection after a claim is paid (recovery).</p> <p class="bodytext" style="text-align: justify;">Over a year since the COVID crisis began, People are traveling again and living their lives. COVID claims are getting processed, are substantial in volume and cost, and are impacting our industry in unforeseen ways. COVID claims are routinely denied or paid incorrectly, since consultants, plans, and payors are faced with a larger-than-usual influx of claims due to the delayed claim and appeal submission timeframes allowed by the federal government. The Phia Group’s PACE service entails the utilization of attorneys, expert plan drafters, and seasoned appeals professionals to help you navigate these difficult appeals and avoid costly fiduciary liability. PACE ensures that plan determinations are defensible and accurate.</p> <p class="bodytext" style="text-align: justify;">In addition, and not unexpectedly, COVID has created a new world for subrogation and coordination of benefits. When COVID claims are paid, complex state law is triggered regarding if and when COVID claims are, whether presumptively or not, an occupational expense. The Phia Group has built a custom process, backed by its in-house legal team. This process flags COVID claims, highlights the patient’s job (i.e. a first responder or front line worker), and cross references this information against up-to-date state laws. By focusing on identifying COVID health claims, and understanding applicable laws, we are able to quickly determine whether workers compensation or other responsible parties may exist for payment of said COVID claims. The Phia Group has been following this new process since June of 2020. Without an innovative subrogation solution in place, plans are needlessly losing money.</p> <p class="bodytext" style="text-align: justify;">To learn more about the Plan Appointed Claim Evaluator service, subrogation/recovery, or any other services The Phia Group offers, please contact <a href="mailto:info@phiagroup.com" target="_blank">info@phiagroup.com</a>.</p> <p class="bodytext"><strong><br /> Success Story of the Quarter: Reviewing Proposed Service Agreements</strong></p> <p class="bodytext" style="text-align: justify;">Using the COVID third-party liability identification tools (as described within the Service Focus of the Quarter section), The Phia Group identified a COVID claim for which an applicable Workers’ Compensation carrier should have paid as primary, but these particular claims were submitted only to the health plan, and not to Workers’ Compensation.</p> <p class="bodytext" style="text-align: justify;">Using our considerable resources and time-tested strategies, we managed to identify a $210,000 payment made by the health plan, which we worked diligently to have the Workers’ Compensation carrier adjudicate and ultimately reimburse – resulting in a full recovery, and truly significant savings for the health plan.</p> <br /> <a name="pdef"></a> <p class="bodytext"><strong>Phia Case Study: Keeping PACE with Your COVID-19 Appeals</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group’s PACE team was recently presented with a final, second-level internal appeal from one of its clients. In this scenario, a plan member was required by her school to obtain a weekly negative COVID test in order to attend the school in person. A local hospital offered drive-through testing (which is exponentially less expensive than testing in a facility), but the member choose to obtain her tests in an emergency room setting, resulting in bills totaling about $11,000 per visit, for five visits.</p> <p class="bodytext" style="text-align: justify;">The medical records, as expected, documented that these services were not in response to emergencies. Further, because the tests were in response to the school requiring it, rather than being in response to the member showing symptoms, they were not medically necessary. The health plan denied the initial claim and the first appeal, on that basis.</p> <p class="bodytext" style="text-align: justify;">When the appeal reached the PACE team, it was analyzed from scratch, and a medical review was obtained. The PACE team reached the same conclusion as the Plan: despite the FFCRA and CARES Act, this testing was not required to be covered by the Plan, nor was the ER visit medically necessary. We appreciate that services were performed and that resources were expended by the emergency department, but that does not change the Plan’s unambiguous requirement of medical necessity as a condition of coverage.</p> <p class="bodytext" style="text-align: justify;">The PACE team issued its directive accordingly, and the Plan could rest easy knowing that its previous denials were affirmed by an objective third-party, and that even if somehow overturned by a court or IRO (which we have no reason to expect), the Plan would not be liable for any penalties resulting from the overturned decision.</p> <p class="bodytext"><strong><br /> Fiduciary Burden of the Quarter: Knowing Whether You Are A Fiduciary</strong></p> <p class="bodytext" style="text-align: justify;">The law is fairly well-settled regarding when a TPA is a fiduciary, and when it is not. In general, fiduciary duties are ascribed to TPAs that exercise discretion or control over plan decisions, and TPAs that perform purely ministerial duties are generally not held to be fiduciaries. It’s essentially a rule akin to “if it walks like a duck…”.</p> <p class="bodytext" style="text-align: justify;">Or so we thought...</p> <p class="bodytext" style="text-align: justify;">A recent case out of the US District Court for the Northern District of California takes a slightly different approach than usual. In Jane Doe v. United Behavioral Health, No. 4:19-cv-07316 (N.D. Ca. March 5, 2021), the court does apply the full fiduciary status analysis that has been around for decades, but reaches a different conclusion. The issue in this case is that United Health, acting as the TPA, administered a provision of the Plan Document that is alleged to be in violation of federal law. The compliance issue is separate, but the facts of the case tend to indicate that United Health simply did exactly what the Plan Document requires, without exercising discretion.</p> <p class="bodytext" style="text-align: justify;">Despite citing to controlling case law that “claims administrator does not exercise fiduciary responsibilities in the consideration of claims if it performs only administrative functions, processing claims within a framework of policies, rules, and procedures established by the employer”, this court somehow concluded that United Health is, in fact, a fiduciary, simply by virtue of being the one to make the decision. UnitedHealth argued that it didn’t actually make any decision, but instead simply communicated the decision that the Plan had required via the Plan Document – but the court wasn’t swayed, despite the virtual mountain of case law to support UnitedHealth’s argument.</p> <p class="bodytext" style="text-align: justify;">Although this can be expected to reach the 9th Circuit Court of Appeals for review, something we all need to keep in mind is that the law is fluid, and different courts take different interpretations – and TPAs, brokers, and consultants can be considered fiduciaries even when they don’t expect it. Courts read precedent differently all the time; although we believe there is a good chance this will be reversed on appeal, we can’t say that for sure. As a result, we advise that whatever you do, do it well. If you act prudently and in good faith, there’s a very good chance that even if you are ultimately held to be a fiduciary, you will have satisfied your duties.<br />  </p> <hr class="horiz" /> <p><a id="pwebinars" name="pwebinars"></a><a id="p5" name="p5"></a></p> <p class="heading1">Webinars:</p> <p class="bodytext" style="text-align: justify;">• On March 25, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/fallout-in-the-spring-covid-claim-disputes-surprise-billing-rbp-opportunities-return-to-work-vaccine-mandates" target="_blank">Fallout in the Spring – COVID Claim Disputes, Surprise Billing RBP Opportunities & Return to Work Vaccine Mandates</a>,” where we discussed post-COVID era regulations applicable to benefit plans, as well as industry issues emerging from this new chapter in the pandemic saga.</p> <p class="bodytext" style="text-align: justify;">• On February 25, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/a-blueprint-for-success-lessons-from-2020-expectations-for-2021" target="_blank">A Blueprint for Success – Lessons from 2020, Expectations for 2021</a>,” where we discussed President Biden’s first month in office, identify whom he has appointed for key roles (and examine their track records on healthcare), as well as dissect the issues that were most relevant in 2020.</p> <p class="bodytext" style="text-align: justify;">• On January 20, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-no-surprises-act-covid-relief-and-plan-design-changes-impacting-your-business-in-2021" target="_blank">The “No Surprises Act,” COVID Relief, and Plan Design Changes Impacting Your Business in 2021</a>,” where we discussed the COVID-19 relief bill, the impact on the industry, and everything in between.</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> <p class="bodytext"><strong><br /> Breakout Sessions</strong></p> <p class="bodytext" style="text-align: justify;">• Following our March webinar, The Phia Group presented two breakout sessions, “Stop-loss Claims, Fiduciary Obstacles & COVID-19” and “Surprise Billing & RBP Opportunities.” If you would like a copy of the recording or slide deck, please reach out to, Matthew Painten, at <a href="mailto:mpainten@phiagroup.com">mpainten@phiagroup.com</a>.</p> <p class="bodytext" style="text-align: justify;">• Following our February webinar, The Phia Group presented two breakout sessions, “Plan Document Evolution” and “Conflict & Compromise.” If you would like a copy of the recording or slide deck, please reach out to, Matthew Painten, at <a href="mailto:mpainten@phiagroup.com">mpainten@phiagroup.com</a>.</p> <p class="bodytext" style="text-align: justify;">• Following our January webinar, The Phia Group presented two breakout sessions, “Plan Design Changes” and “Hot Topics in Claims.” If you would like a copy of the recording or slide deck, please reach out to, Matthew Painten, at <a href="mailto:mpainten@phiagroup.com">mpainten@phiagroup.com</a>.</p> <p><a id="ppodcast" name="ppodcast"></a></p> <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 17, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p104-covid-19-vaccine-candidates-vaccinating-vulnerable-populations" target="_blank">COVID-19 Vaccine Candidates – Vaccinating Vulnerable Populations</a>,” where our hosts, Jen McCormick and Andi Goodman, discuss the future of vaccinating vulnerable populations such as pregnant women and children, and the importance of vaccinating children in achieving herd immunity.</p> <p class="bodytext" style="text-align: justify;">• On March 2, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p103-one-step-forward-two-steps-back-the-lockdown-and-its-effect-on-children-with-disabilities" target="_blank">One Step Forward; Two Steps Back - The Lockdown and its Effect on Children with Disabilities</a>,” where our hosts, Garrick Hunt and Timothy Pope, hold a candid discussion about the harmful effects that the sweeping lockdown has had on families, and in particular on children with disabilities.</p> <p class="bodytext" style="text-align: justify;">• On February 12, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p102-cya-cover-your-assets" target="_blank">CYA: Cover Your Assets</a>,” where our hosts, Nick Bonds and Brady Bizarro, talk through some developing trends in ERISA litigation.</p> <p class="bodytext" style="text-align: justify;">• On February 4, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p101-groundhog-day-a-year-of-covid-19" target="_blank">Groundhog Day - A Year of COVID-19</a>,” where our hosts, Brady Bizarro and Jen McCormick, have a conversation about the impact of COVID-19 on employers, health plans, and employees.</p> <p class="bodytext" style="text-align: justify;">• On January 22, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p100-president-bidens-first-100-days-what-to-expect" target="_blank">President Biden's First 100 Days - What to Expect</a>,” where our hosts, Ron Peck and Brady Bizarro discuss the inauguration of President Biden and what his presidency could mean for healthcare policy.</p> <p class="bodytext" style="text-align: justify;">• On January 13, 2021, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p99-balance-bills-medical-tourism-and-vaccines-oh-my" target="_blank">Balance Bills, Medical Tourism, and Vaccines – Oh My!</a>,” where our hosts, Ron Peck and Corey Crigger discuss balance billing in the COVID world, medical tourism, and vaccine passports.</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"> </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/2021/03/31/the-no-surprises-act-taking-control-of-rate-setting/" target="_blank">The No Surprises Act: Taking control of rate-setting</a> – March 31, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/03/30/the-no-surprises-act-when-negotiations-break-down/" target="_blank">The No Surprises Act: When negotiations break down</a> – March 30, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/03/29/the-no-surprises-act-what-is-a-surprise/" target="_blank">The No Surprises Act: What is a ‘surprise’?</a> – March 29, 2021</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Pharmacy_Deserts-_by_Nick_Bonds%2C_Esq.pdf" target="_blank">Pharmacy Deserts: A vicious cycle threatens to bottleneck vaccine rollout</a> – March 5, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/03/02/born-during-a-pandemic-covids-impact-on-pregnant-employees-and-their-employers/" target="_blank">Born during a pandemic: COVID's impact on pregnant employees and their employers</a> – March 2, 2021</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Mental_Health_Parity_Compliance_in_The_ERA_of_COVID-19_by_Corrie_Cripps.pdf" target="_blank">Mental Health Parity Compliance In The ERA of COVID-19</a> – February 5, 2021</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2021/01/26/the-semi-resurrection-of-irs-notice-2020-29/" target="_blank">The semi-resurrection of IRS Notice 2020-29</a> – January 26, 2021</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Supreme_Court_Upholds_State_Regulation_of_PBMS-Other_Vendors_Could_Be_Next_by_Brady_Bizarro%2C_Esq.pdf" target="_blank">Supreme Court Upholds State Regulations of PBMS - Other Vendors Could Be Next</a> – January 2, 2021<br /> <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/a-cobra-conundrum" target="_blank">A COBRA Conundrum!</a> COBRA continuation coverage has never been intuitive.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/so-the-outbreak-period-ended" target="_blank">So the Outbreak Period Ended?</a> In case you haven’t heard, the Employee Benefits Security Administration (EBSA) released Disaster Relief Notice 2021-01.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/hipaa-compliance-audits-good-news-and-bad-news" target="_blank">HIPAA Compliance Audits – Good News and Bad News.</a> The government recently released findings of the extensive HIPAA compliance audit performed in 2016 and 2017.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/addition-by-division" target="_blank">Addition By Division</a>. Learn all about what a "spinoff" is when it comes to health benefit plans.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/choose-your-own-adventure-president-bidens-healthcare-agenda" target="_blank">Choose Your Own Adventure: President Biden’s Healthcare Agenda</a>. There are a few different outcomes for big developments the Biden administration is planning in the healthcare sector.<br /> <br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pstacks" name="pstacks"></a></span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">The Stacks:</span></p> <p class="bodytext"><strong>Pharmacy Deserts: A Vicious Cycle Threatens To Bottleneck Vaccine Rollout</strong><br />  </p> <p class="bodytext" style="text-align: justify;">By: Nick Bonds, Esq.– March 2021– <a href="https://www.sipconline.net/files/Pharmacy_Deserts-_by_Nick_Bonds%2C_Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a><br /> <br /> One of the brightest spots in the headlines over the past few months has been the success of several vaccine candidates to inoculate the world against the scourge of the coronavirus pandemic. These vaccines have been developed at an unprecedented pace in the face of an unprecedented public need. They are truly a marvel of modern medical technology, and likely our most direct path back to some semblance of normalcy.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-2nd-quarter-2021" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>Mental Health Parity Compliance In The ERA of COVID-19</strong></p> <p class="bodytext" style="text-align: justify;">By: Corrie Cripps – February 2021 – <a href="https://www.sipconline.net/files/Mental_Health_Parity_Compliance_in_The_ERA_of_COVID-19_by_Corrie_Cripps.pdf" target="_blank">Self-Insurers Publishing Corp.</a><br /> <br /> The COVID-19 (“coronavirus”) pandemic has led to a spike in mental health and substance use disorder (“MH/SUD”) challenges, especially in the employer/employee realm, which highlights the importance of MH/SUD benefits in health plans. Even before the coronavirus pandemic, many health plans struggled in the area of Mental Health Parity and Addiction Equity Act (MHPAEA) compliance, especially since case law is being developed in this area on a regular basis across the country.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-2nd-quarter-2021" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>Supreme Court Upholds State Regulations of PBMS - Other Vendors Could Be Next </strong></p> <p class="bodytext" style="text-align: justify;">By: Brady Bizarro, Esq. – January 2021 – <a href="https://www.sipconline.net/files/Supreme_Court_Upholds_State_Regulation_of_PBMS-Other_Vendors_Could_Be_Next_by_Brady_Bizarro%2C_Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a><br /> <br /> The United States Supreme Court has experienced a whirlwind of a year. Early on, the threat of COVID-19 forced the Court to take the unprecedented step of hearing oral argument via telephone conference call. Other notable headlines throughout the year included the Court deciding important cases on abortion, religion, and immigration, hearing a crucial case on the Affordable Care Act, rejecting an urgent case on the 2020 presidential election, mourning the loss of an esteemed colleague, and welcoming a new justice to the bench. You would be forgiven, then, if you missed the case of Rutledge v. Pharmaceutical Care Management Association, decided on December 10, 2020. For employer-sponsored health plans and the healthcare industry as a whole, this 8-0 decision may prove to be the most important of its kind in the last several years because of what it foreshadows – more state regulation of PBMs and the possible regulation of other third-party vendors involved in ERISA plan administration.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-2nd-quarter-2021" target="_blank">Click here to read the rest of this article</a><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"><span class="heading1">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"><br /> <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 will be awarded a $5,000 scholarship and a new laptop, courtesy of The Phia Group. The Boys and Girls Clubs of Metro South will announce the Boys & Girls Clubs of Metro South’s 2021 Youth of the Year on April 29, 2021. Make sure you check out our next newsletter to find out who won!</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 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 the Boys & Girls Club kids and their amazing potential. Adam realizes first-hand the struggles and challenges to overcome obstacles, facing adverse circmstances and the determination for self-perseverance. The Phia Group Great Futures Scholarship recognizes one graduating senior annually for their commitment to education and dedication to a better future. With Adam's vision, the Boys & Girls Club of Metro South annually awards a $10,000 scholarship to assist one student in the pursuit of their educational dreams, development of strong work ethic, and development of self-appreciation. The Boys and Girls Clubs of Metro South will announce The Phia Group Great Futures Scholarship winner on April 29, 2021. <br /> <br /> <br /> <a href="#top">Back to top ^</a><span class="heading1"><a id="pemployee" name="pemployee"></a></span></p> <p class="heading1"> </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter:<br /> Andrew Mead</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 Andrew Mead, The Phia Group’s 2021 Q1 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;">Andrew was hired as an intern about 6 months ago, with the intent to only stay with us until June. In his short time here he has made a pretty big impact on Phia… and people were not shy about letting Explore know! We received tons of feedback & outreach regarding Andrew this quarter, and brought it all to Adam’s attention. I am happy to announce that Andrew has been offered a full time position and starting May 3rd he will no longer be an intern! Congrats Andrew- we are very excited to have you as an “official” member of the Phia Phamily!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/andrew2.png?ver=GRXgQrP1Ooph4rR6-wt_nA%3d%3d" style="width: 409px; height: 506px;" /></p> <p class="bodytext"> </p> <p class="bodytext">Congratulations Andrew, 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> <p class="bodytext"> </p> <hr class="horiz" /> <p><strong>Job Opportunities:</strong></p> <p class="bodytext">• Claim Recovery Specialist</p> <p class="bodytext">• Case Investigator</p> <p class="bodytext">• Legal Intern – Contracts</p> <p class="bodytext">• Customer Service Representative</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">• Hannah Sedman has been promoted from Legal Services Coordinator to Contracts Administration Manager</p> <p class="bodytext">• Mattie Tigges has been promoted from Director of Recovery Services to Senior Director of Recovery Services</p> <p class="bodytext">• Jennifer Armstrong has been promoted from Senior Subrogation Attorney to Director of Recovery Services</p> <p class="bodytext">• Daiana Williams has been promoted from Manager of Recovery Services to Director of Recovery Services</p> <p class="bodytext">• Andrew Fine has been promoted from Team Lead, Intake to Data Analyst, PGC</p> <span class="heading1"><a id="pnews" name="pnews"></a></span> <hr class="horiz" /> <p class="bodytext"><span class="heading1">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 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.<br />  </p> <p class="bodytext"><strong>Scripta Going to Work for Phia</strong></p> <p class="bodytext" style="text-align: justify;">Scripta is a partner of The Phia Group that monitors plan participant spending on pharmaceutical drugs and devices. They identify unnecessary expenditures, inappropriate charges, and opportunities to replace or alter medications with equally effective - or more effective - options. Thanks to their services the Scripta program generated a 3.8x ROI for The Phia Group in 2020. Scripta expects at least a 4x ROI in 2021 as well.</p> <p class="bodytext" style="text-align: justify;">Take a look at how The Phia Group is doing:</p> <p class="bodytext"> </p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2021/roi.png?ver=W-REop1PHooOr566WhhHOg%3d%3d" style="width: 650px; height: 222px;" /></p> <p class="bodytext">If you are interested in learning more about Scripta and how they can help your health plan, please contact our Sales Manager, Garrick Hunt, at 781-535-5644 or <a href="mailto:GHunt@phiagroup.com" target="_blank">GHunt@phiagroup.com</a>.</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.</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 Q2 2017/footerlogo.png?ver=OxLB4uHMsucMuajNCkmz3g%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> 1057The Stacks – 2nd Quarter 2021https://www.phiagroup.com/Media/Posts/PostId/1055/the-stacks-2nd-quarter-2021NewslettersTue, 20 Apr 2021 14:58:00 GMT<p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><strong><span style="color:#0071ce;"><span style="font-size:11pt"><span calibri="">Supreme Court Upholds State Regulation of PBMs – Other Vendors Could Be Next</span></span></span></strong></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span><span style="font-size:11pt"><span calibri="" style="font-family:">By: Brady Bizarro, Esq.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">The United States Supreme Court has experienced a whirlwind of a year. Early on, the threat of COVID-19 forced the Court to take the unprecedented step of hearing oral argument via telephone conference call. Other notable headlines throughout the year included the Court deciding important cases on abortion, religion, and immigration, hearing a crucial case on the Affordable Care Act, rejecting an urgent case on the 2020 presidential election, mourning the loss of an esteemed colleague, and welcoming a new justice to the bench. You would be forgiven, then, if you missed the case of <u>Rutledge v. Pharmaceutical Care Management Association</u>, decided on December 10, 2020. For employer-sponsored health plans and the healthcare industry as a whole, this 8-0 decision may prove to be the most important of its kind in the last several years because of what it foreshadows – more state regulation of PBMs and the possible regulation of other third-party vendors involved in ERISA plan administration.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">At its core, <u>Rutledge</u> involved an attempt by a state to regulate its own healthcare market in the face of federal preemption under the Employee Retirement Income Security Act of 1974 (“ERISA”). To properly understand the context of the state law at issue, a brief overview of drug pricing and the process by which many Americans get their prescription drugs is required. Most Americans are covered by private health insurance (specifically, employer-sponsored health plans) and they purchase prescription drugs from retail pharmacies. Hardly any health plans contract directly with pharmacies. Instead, they contract with pharmacy benefit managers (“PBMs”). PBMs are an integral part of this process, serving as intermediaries between health plans and the pharmacies that plan members use.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">When a plan member fills a prescription at a pharmacy, the pharmacy checks with the contracted PBM to confirm insurance coverage and determine any cost sharing requirements. After the plan member’s transaction is complete, the PBM reimburses the pharmacy for the prescription (less any cost sharing). Finally, the health plan reimburses the PBM. The amount at which a PBM reimburses a pharmacy for a drug is set by a contract between the PBM and the pharmacy. In that contract, rates are set according to a list specifying the maximum allowable cost (“MAC”). Similarly, the amount at which a health plan reimburses a PBM is set by contract. These contractual arrangements are often crucial to the success of each entity because each relies on access and steerage to some degree.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">Consider the following scenario: a pharmacy pays a drug manufacturer $250 to obtain a drug. The PBM has set a MAC of $200 for the drug. If a plan member pays a $15 copay for the drug, the PBM would reimburse the pharmacy $185. Under its contract with the PBM, the health plan reimburses the PBM $300, which includes a spread price or fee for the drug (in some cases a manufacturer rebate is involved). In this example, the pharmacy lost money because the MAC was less than the price the pharmacy paid the manufacturer to obtain the drug in the first place. How or why this occurs is disputed by pharmacies and PBMs alike; however, this situation has caused many independent and rural pharmacies to lose money and close over the past few decades.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">In 2015, the Arkansas state legislature took action to protect its independent pharmacies (which are common in rural Arkansas) from this fate. It passed Act 900, which regulates the price at which PBMs reimburse pharmacies for the cost of drugs covered by health plans. Specifically, the bill requires that PBMs reimburse pharmacies at or above their acquisition costs, and it included three key enforcement mechanisms. First, the law requires PBMs to tether reimbursement rates to pharmacies’ acquisition costs by timely updating their MAC lists when drug wholesale prices increase. Second, PBMs must provide administrative appeal procedures for pharmacies to challenge MAC reimbursement prices that are below the pharmacies’ acquisition costs. Finally, the law permits a pharmacy to decline to sell a drug to a beneficiary if the PBM at issue will reimburse the pharmacy at less than its acquisition cost. <u>Ark. Code Ann. § 17-92-507(c)-(e)</u>.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">Soon after the law passed, the Pharmaceutical Care Management Association (“PCMA”), representing the eleven largest PBMs in the country, filed suit against the state, alleging that Act 900 was pre-empted by ERISA. Under <u>29 U.S.C. § 1144(a)</u>, ERISA pre-empts “any and all [s]tate laws insofar as they may now or hereafter relate to any employee benefit plan.” Courts have broadened the scope of pre-emption over time to include state laws that have a “connection with” or “reference to” an ERISA plan; though the Supreme Court’s jurisprudence in this area has arguably been conflicting. The lower courts, including the Eighth Circuit Court of Appeals, sided with the PCMA, ruling that the Arkansas law had an impermissible “connection with” ERISA plans by interfering with central plan functions and nationally uniform plan administration, as well as an impermissible “reference to” ERISA plans by regulating PBMs that administered benefits for those plans. Arkansas appealed this decision to the U.S. Supreme Court.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">To resolve this case, the Court considered whether the Arkansas law had an impermissible “connection with” or “reference to” an ERISA plan. In its brief to the Court, PCMA argued that Act 900 impermissibly affected plan design by mandating a particular pricing methodology for pharmacy benefits. Then, it argued that the law’s appeal procedure interfered with central matters of plan administration. Further, PCMA asserted that the enforcement mechanisms interfered with nationally uniform plan administration by creating “operational inefficiencies.” Finally, PCMA contended that by allowing pharmacies to decline to dispense prescriptions in certain cases, the law effectively denied plan members their benefits.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">Writing for a unanimous Court (Justice Amy Cony Barret took no part in the consideration or decision of the case), Justice Sonia Sotomayor first outlined the Court’s ERISA pre-emption scheme. Then, she dealt with the two issue in turn. First, she noted that “not every state law that affects an ERISA plan or causes some disuniformity in plan administration has an impermissible connection with an ERISA plan . . . especially so if a law merely affects costs.” <u>Rutledge</u>, 2020 U.S. LEXIS 5988, at 10. For support, she cited to <u>New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co.</u>, 514 U.S. 645 (1995). In that case, New York state imposed a surcharge of up to 13% on hospital billing rates for patients covered by insurers other than Blue Cross and Blue Shield (“BCBS”). The Court presumed that the surcharges would be passed on to ERISA plan members, which in turn would incentivize ERISA plans to steer their plan members to BCBS networks. Still, the Court found that the “indirect economic influence” did not create an impermissible connection between the state law and ERISA plans because it did not “bind plan administrators to any particular choice.” <u>Travelers</u>, at 659. </span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">Justice Sotomayor reasoned that the Arkansas law in this case was merely a form of cost regulation, much like the New York law which had been upheld by the Supreme Court in <u>Travelers</u>. She rejected all of PCMA’s arguments, finding that Act 900, as a form of cost regulation, and despite its enforcement mechanisms, did not require plan administrators to structure their benefit plans in any particular manner and did not lead to anything more than potential operational inefficiencies, which by themselves are insufficient to trigger ERISA pre-emption.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">Having dealt with the first issue, Justice Sotomayor then easily dispatched the second issue; whether Act 900 impermissibly referenced an ERISA plan. She argued that the law does not act immediately and exclusively upon ERISA plans because it applies to PBMs whether or not they manage an ERISA plan. It affects ERISA plans only insofar as PBMs pay pass along higher pharmacy rates to plans with which they contract. <u>Rutledge</u>, at 12.</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">After the Court’s decision, the PCMA released a statement expressing disappointment and noting, “As states across the country consider this outcome, we would encourage they proceed with caution and avoid any regulations around prescription drug benefits that will result in higher healthcare costs for consumers and employers.” It is possible, as the Court noted, that one consequence of this decision will be higher drug prices for employer-sponsored health plans and their plan members as PBMs look to recoup losses in revenue. It is far more likely, however, that more states will pass laws modeled on Arkansas’s Act 900, without fear of them being pre-empted by ERISA (though additional litigation is likely to ensue).</span></span><br />  </p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p class="MsoNoSpacing" style="margin: 0in; text-align: justify;"><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:">Having announced a distinction between cost regulations and dictating plan choices, the Court has also opened up the possibility that states may try to regulate other third-party vendors involved in ERISA plan administration; from third party administrators to provider networks to audit firms. As we in the self-funded space have been saying for years, on issues where the federal government and the relevant industry players have failed to provide relief; prescription drug pricing, balance billing, and price transparency (just to name a few), states will step in to fill the void. Now, with a unanimous Supreme Court restricting the scope of ERISA pre-emption, those state have new latitude to enact laws which may ultimately prove unpopular or even counterproductive for all involved in the fight to contain healthcare costs.</span></span></span></p> <hr /> <p style="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="color:#0071ce;"><b>Mental Health Parity Compliance in the Era of COVID-19</b></span><br /> By: Corrie Cripps</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:normal"><span calibri="" style="font-family:">The COVID-19 (“coronavirus”) pandemic has led to a spike in mental health and substance use disorder (“MH/SUD”) challenges, especially in the employer/employee realm, which highlights the importance of MH/SUD benefits in health plans. Even before the coronavirus pandemic, many health plans struggled in the area of <a href="https://www.phiagroup.com/Media/Mental-Health-Parity-and-Addiction-Equity-Act-Explained">Mental Health Parity and Addiction Equity Act </a>(MHPAEA) compliance, especially since case law is being developed in this area on a regular basis across the country. </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:"><b>Background</b></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:"><b></b></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:">The MHPAEA, as amended by the Affordable Care Act (ACA), generally requires that group health plans ensure that the financial requirements and treatment limitations on MH/SUD benefits they provide are no more restrictive than those on medical or surgical benefits. These are also referred to as quantitative and <a href="https://www.phiagroup.com/Media/Understanding-Non-Quantitative-Treatment-Limitations-NQTLs">non-quantitative treatment limitations </a>(“QTL” and “NQTL” respectively).</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="font-family:"Calibri",sans-serif"></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:">MHPAEA generally applies to group health plans that provide coverage for MH/SUD benefits in addition to medical/surgical benefits. Some self-insured plans are exempt from MHPAEA, such as those with 50 or fewer employees.<a href="#_ftn1" name="_ftnref1" style="color:#0563c1; text-decoration:underline" title=""><sup><sup><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:">[1]</span></span></span></sup></sup></a> MHPAEA does not require that self-insured group health plans cover MH/SUD benefits; it only requires that if a plan does cover MH/SUD benefits that the benefits are in parity with the medical/surgical benefits. </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="font-family:"Calibri",sans-serif"></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:">The U.S. Department of Labor (DOL), specifically the Employee Benefits Security Administration (EBSA), has primary enforcement authority with regard to MHPAEA over private sector employment-based group health plans.</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="font-family:"Calibri",sans-serif"></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:normal"><span calibri="" style="font-family:"><b>Expansion of the Regulations</b></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:normal"><span calibri="" style="font-family:">The Consolidated Appropriations Act, 2021, (“the Act”) further enhances federal mental health parity protections, with an emphasis on compliance regarding NQTLs on MH/SUD benefits.<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 calibri="" style="font-family:">[2]</span></span></span></span></span></a>  On and after February 10, 2021, health plans that impose an NQTL on MH/SUD benefits must perform and document a comparative analysis of the NQTL’s design and application. The comparative analysis and other plan information (such as applicable plan provisions and evidentiary standards relied upon to design and apply the NQTL) must be made available to the applicable state or federal agency upon request.</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:normal"><span calibri="" style="font-family:">At the time of this publication, we are currently waiting for additional guidance from the federal agencies on this comparative analysis documentation requirement. In the meantime, plan sponsors should continue their MHPAEA compliance efforts.</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:normal"><span calibri="" style="font-family:"><b>NQTLs</b></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:normal"><span calibri="" style="font-family:">NQTLs are generally limits on the scope or duration of benefits for treatment that are not expressed numerically, such as medical management techniques, provider network admission criteria, or fail-first policies. In terms of MHPAEA compliance, plans should ensure that any NQTLs applicable to MH/SUD benefits are comparable to the limitations that apply to the medical/surgical benefits in the same classification.</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:normal"><span calibri="" style="font-family:">NQTLs are commonly the area where health plans fall short of MHPAEA compliance. In its “Warning Signs” document, the DOL provides examples that serve as a “red flag” that a plan may be imposing an impermissible NQTL.<a href="#_ftn3" name="_ftnref3" 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 calibri="" style="font-family:">[3]</span></span></span></span></span></a> The examples include preauthorization and pre-service notification requirements; fail-first protocols; probability of improvement; written treatment plan required; patient non-compliance; residential treatment limits; geographical limitations; and licensure requirements. This is a good resource for plans to use when reviewing their plan documents for MHPAEA compliance.</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:normal"><span calibri="" style="font-family:">Another helpful DOL resource is its self-compliance tool for evaluating compliance with the MHPAEA, which was just updated in October 2020.<a href="#_ftn4" name="_ftnref4" 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 calibri="" style="font-family:">[4]</span></span></span></span></span></a> The tool includes best practices, warning signs/red flags, guidance for developing internal plan compliance procedures, and a table for evaluating provider reimbursement rates in the MHPAEA context. However, plans should note that the self-compliance tool is not intended to be a substitute for full MHPAEA compliance testing.</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:normal"><span calibri="" style="font-family:">In terms of a Plan’s Plan Document/Summary Plan Description, you will often find NQTL language in the utilization management/pre-certification/preauthorization section as well as in the sections that describe the medical benefits and medical exclusions. Some plans make the mistake, when reviewing their documents for MHPAEA compliance, to only update the medical benefit grids, unaware that other sections of the document have an impermissible NQTL on a MH/SUD benefit.</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:normal"><span calibri="" style="font-family:"><b>MH/SUD and the Coronavirus Pandemic</b></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:normal"><span calibri="" style="font-family:">There have been several recent studies on the MH/SUD crisis that is linked to the coronavirus pandemic. A U.S. Centers for Disease Control and Prevention study, published in August 2020, found that almost 41% of respondents are struggling with mental health issues stemming from the pandemic.<a href="#_ftn5" name="_ftnref5" 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 calibri="" style="font-family:">[5]</span></span></span></span></span></a> Similarly, the Kaiser Family Foundation (KFF) published its findings from its July 2020 poll, which concluded that “[t]he pandemic is likely to have both long- and short-term implications for mental health and substance use, particularly for groups likely at risk of new or exacerbated mental health struggles.”<a href="#_ftn6" name="_ftnref6" 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 calibri="" style="font-family:">[6]</span></span></span></span></span></a></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:normal"><span calibri="" style="font-family:">A recent article on CNN highlights that many people who had MH/SUD issues before the pandemic are experiencing their levels of uncertainty and fear double.<a href="#_ftn7" name="_ftnref7" 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 calibri="" style="font-family:">[7]</span></span></span></span></span></a> The challenges that stem from the pandemic affect eating disorders, can cause drug relapses, as well as lead to increased levels of depression. And those who may not have experienced MH/SUD issues before the pandemic may now have issues with their stress levels, depression, and sleep disturbances.</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:normal"><span calibri="" style="font-family:">As noted above, the MHPAEA does not require that self-insured group health plans cover MH/SUD benefits. Some self-insured group health plans choose not to cover any MH/SUD benefits; however, this is not a common plan design. What these recent studies and polls indicate is that now, more than ever, health plans should consider not only the physical aspects of the pandemic but also the mental health and substance abuse struggles many plan participants are facing. If your current plan design excludes all MH/SUD benefits, maybe now is the time to reevaluate this decision. Alternatively, if your current plan design does cover MH/SUD benefits, it is recommended that you perform of audit of the plan to ensure parity between the medical/surgical and MH/SUD benefits, which also includes any medical necessity standards. </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:normal"><span calibri="" style="font-family:"><b>Compliance Actions</b></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:normal"><span calibri="" style="font-family:">The DOL and the Centers for Medicare & Medicaid Services (CMS) issues an annual “MHPAEA Enforcement Fact Sheet”. The fiscal year 2019 Fact Sheet was issued on March 16, 2020.<a href="#_ftn8" name="_ftnref8" 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 calibri="" style="font-family:">[8]</span></span></span></span></span></a> In fiscal year 2019, the EBSA conducted 183 MHPAEA-related investigations. Of these, 68 investigations involved fully-insured plans, 91 investigations involved self-insured plans, and 24 investigations involved plans of both types (the plan or service provider offered both fully-insured and self-insured options). EBSA cited 12 MHPAEA violations in 9 of these investigations.</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:normal"><span calibri="" style="font-family:">This Fact Sheet gives a glimpse into the kinds of compliance issues that the DOL is seeing in health plans. The main issues for MHPAEA compliance still appear to be dollar limitations/visit limits and NQTLs on MH/SUD benefits that are not similarly applied to the medical/surgical benefits. Employers can use this information to ensure they do not have these same issues in their plans.</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:"><b>Conclusion</b></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:"><b></b></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:normal"><span calibri="" style="font-family:">The 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. This is especially important since the Consolidated Appropriations Act, 2021, added a new requirement for comparative analysis of the NQTL’s design and application (if the health plan has an NQTL on MH/SUD benefits). Due to the coronavirus pandemic, MH/SUD issues will be in the limelight in 2021, which may mean even more health plan investigations by EBSA. Plan sponsors should review cost-containment techniques with counsel to ensure they are designed to mitigate risk in this area while ensuring compliance.</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:normal"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <div> <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="text-align:justify; margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[1]</span></span></span></span></span></a> <i>Mental Health and Substance Use Disorder Parity,</i> <a href="https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity" style="color:#0563c1; text-decoration:underline">https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity</a>, (last visited January 5, 2021).</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><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 calibri="" style="font-family:">[2]</span></span></span></span></span></a>    <i>H.R.133 - Consolidated Appropriations Act, 2021,</i> December 27, 2020, <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">https://www.congress.gov/bill/116th-congress/house-bill/133/text</a>, (last visited January 5, 2021).</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><a href="#_ftnref3" name="_ftn3" 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 calibri="" style="font-family:">[3]</span></span></span></span></span></a> <i>Warning Signs – Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) that Require Additional Analysis to Determine Mental Health Parity Compliance</i>, <a href="https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/warning-signs-plan-or-policy-nqtls-that-require-additional-analysis-to-determine-mhpaea-compliance.pdf" style="color:#0563c1; text-decoration:underline">https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/warning-signs-plan-or-policy-nqtls-that-require-additional-analysis-to-determine-mhpaea-compliance.pdf</a>  (last visited January 5, 2021).</span></span></p> </div> <div id="ftn4"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><a href="#_ftnref4" name="_ftn4" 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 calibri="" style="font-family:">[4]</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 January 5, 2021).</span></span></p> </div> <div id="ftn5"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><a href="#_ftnref5" name="_ftn5" 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 calibri="" style="font-family:">[5]</span></span></span></span></span></a>    <i>Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020, </i>August 14, 2020, <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm?s_cid=mm6932a1_w" style="color:#0563c1; text-decoration:underline">https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm?s_cid=mm6932a1_w</a>, (last visited January 5, 2021).</span></span></p> </div> <div id="ftn6"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><a href="#_ftnref6" name="_ftn6" 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 calibri="" style="font-family:">[6]</span></span></span></span></span></a>    <i>The Implications of COVID-19 for Mental Health and Substance Use,</i> August 1, 2021, <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/" style="color:#0563c1; text-decoration:underline">https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/</a>, (last visited January 5, 2021).</span></span></p> </div> <div id="ftn7"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><a href="#_ftnref7" name="_ftn7" 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 calibri="" style="font-family:">[7]</span></span></span></span></span></a>    <i>Mental Health is One of the Biggest Pandemic Issues We’ll Face in 2021, </i>CNN Health, January 4, 2021, <a href="https://www.cnn.com/2021/01/04/health/mental-health-during-covid-19-2021-stress-wellness/index.html" style="color:#0563c1; text-decoration:underline">https://www.cnn.com/2021/01/04/health/mental-health-during-covid-19-2021-stress-wellness/index.html</a>, (last visited January 5, 2021).</span></span></p> </div> <div id="ftn8"> <p class="MsoFootnoteText" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:10pt"><span calibri="" style="font-family:"><a href="#_ftnref8" name="_ftn8" 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 calibri="" style="font-family:">[8]</span></span></span></span></span></a>    <i>FY2019 MHPAEA Enforcement Fact Sheet, </i>March 16, 2020, <a href="https://www.hhs.gov/guidance/document/fy2019-mhpaea-enforcement-fact-sheet" style="color:#0563c1; text-decoration:underline">https://www.hhs.gov/guidance/document/fy2019-mhpaea-enforcement-fact-sheet</a>, (last visited January 5, 2021).</span></span></p> <hr /> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#0071ce;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><b><span new="" roman="" style="font-family:" times="">Pharmacy Deserts: A Vicious Cycle Threatens to Bottleneck Vaccine Rollout</span></b></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">By: Nick Bonds, Esq. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">One of the brightest spots in the headlines over the past few months has been the success of several vaccine candidates to inoculate the world against the scourge of the coronavirus pandemic. These vaccines have been developed at an unprecedented pace in the face of an unprecedented public need. They are truly a marvel of modern medical technology, and likely our most direct path back to some semblance of normalcy. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">Even so, the promised miracle of these vaccines cannot be fulfilled until the doses find their way into the arms of the public. As dramatic </span><a href="https://www.npr.org/2021/01/08/955005344/biden-vows-to-distribute-100-million-covid-19-vaccine-doses-in-his-first-100-day" style="color:#0563c1; text-decoration:underline"><span new="" roman="" style="font-family:" times="">efforts</span></a><span new="" roman="" style="font-family:" times=""> are being undertaken to ensure adequate supplies of vaccines, the rollout of a mass vaccination campaign is impeded by logistics. Individuals otherwise eligible to receive the vaccine struggle to schedule appointments, are discouraged by long lines at administration sites, or they struggle to make their way to one such site to begin with. These are all problems at least partially amplified by a dilemma that has been quietly festering within the healthcare industry for years: the pharmacy desert. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">The “pharmacy desert” is a companion of the “food desert” – a concept utilized by the U.S. Department of Agriculture to denote a geographic area with insufficient access to fresh, healthful food. Residents living in these food deserts experience a number of negative impacts from this phenomenon, including significantly higher food expenses, and substantially inadequate nutrition, as well as a myriad of related detrimental health and developmental complications. These food deserts disproportionately impact low-income and minority communities, in both urban and rural settings.</span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">In 2014 article, Dr. Dima M. Qato and her co-authors expanded on this concept, coining the term “pharmacy desert” to describe a parallel anomaly in the health care space.<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 new="" roman="" style="font-family:" times="">[1]</span></span></span></span></span></a> Through their research, they identified a trend in areas around Chicago where whole communities were losing access to pharmacies. Residents of these pharmacy deserts found themselves with little or no avenue to obtain not just prescription drugs, but also the other myriad services for which had come to depend upon their local pharmacy: over-the-counter products, diagnostic services, even a level of preventive and urgent care services. For some in these low-access areas, even a pharmacy more than two miles away could be completely inaccessible in an urban setting where individuals lack readily available personal vehicles or efficient public transportation. For rural pharmacy deserts the distances may be even greater, with the nearest pharmacy upwards of ten miles away. Simply being unable to physically reach a pharmacy could make it impossible to complete a course of pharmaceutical treatment.  </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">While the 2014 article focused on Chicago, the trend they detailed were troubling. About 32% of the census tracts they observed were located within a pharmacy desert, translating to roughly a million Chicagoans with little to no ability to easily fill their prescriptions at a pharmacy.<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 new="" roman="" style="font-family:" times="">[2]</span></span></span></span></span></a> Development of these pharmacy desserts is driven by a number of factors. Lower income and minority neighborhoods tended to have lower rates of insurance coverage and pharmacy providers in those areas experienced lower rates of reimbursement for prescription drug claims. Smaller pharmacy operating on relatively thin margins struggle to stay afloat, with many selling out to larger chains or closing entirely. Areas with higher reliance on Medicare and Medicaid also tended to have lower rates of reimbursement for prescription drugs, and saw their local pharmacies going dark. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">While the hardships faced by smaller pharmacies led to increased consolidation by the massive chain stores like CVS, Duane Reade, and Walgreens, these pharmaceutical behemoths were not immune to the negative economic forces. These chains have resorted to closing substantial numbers of their locations in areas where they are less profitable, thus expanding the radius of the pharmacy deserts. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">On top of relatively mundane market forces, the companies administering state Medicaid plans have made changes that effectively cut off access for individuals relying on Medicaid for prescription drug coverage. As </span><a href="https://www.chicagotribune.com/lifestyles/ct-life-aetna-cuts-pharmacy-access-medicaid-tt-12292020-20201230-ezco45aqwvdcrkyset7u6tjjbu-story.html" style="color:#0563c1; text-decoration:underline"><span new="" roman="" style="font-family:" times="">detailed</span></a><span new="" roman="" style="font-family:" times=""> by the Chicago Tribune, near the end of last year, Aetna drooped Walgreens from its pharmacy network, meaning about 400,000 Medicaid members could no longer fill their prescriptions at a Walgreens location. These new holes in prescription drug available effectively riddled Illinois with a new swath of pharmacy desserts just as the economic impacts of the coronavirus pandemic drove more and more pharmacies to shutter their doors, spurring the cycle of contributing factors faster still. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">For self-funded plans, these developments are especially troubling. Prescription drug spending is a huge expense for many plans, particularly those with older employee populations – the same populations that are at elevated risk of infection by the coronavirus. The expansion of pharmacy desserts serves to drive up prescription drug prices. Additionally, many plans are already struggling to contend with the cost of coronavirus testing, a service frequently performed at local pharmacies. For populations in a pharmacy desert, the associated cost of this testing – which self-funded plans are mandated to cover – will also continue to be pushed ever higher. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">Perhaps most importantly, the efforts to vaccinate the public are also being exacerbated by pharmacy deserts, blunting the impact of one of our key weapons to address this public health struggle. Pharmacies like CVS and Walgreens are two of the biggest vectors through with many are likely to seek their coronavirus vaccine. For individuals living in a pharmacy desert, this avenue may be prohibitively difficult, thus delaying distribution of the vaccine to some of our most vulnerable populations. The virus has already hit lower income communities the </span><a href="https://assets.oxfamamerica.org/media/documents/The-Inequality-Virus-English.pdf" style="color:#0563c1; text-decoration:underline"><span new="" roman="" style="font-family:" times="">hardest</span></a><span new="" roman="" style="font-family:" times="">, and areas caught in a pharmacy desert will struggle to share equitably in the most effective solution. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">Urban communities tend to be hot spots of viral transmission. Where these hot spots overlap with a pharmacy desert, not only are efforts at testing and treating that community greatly hindered, on top of the effort to vaccinate that community being hamstrung as well. In other words, a pharmacy desert becomes a vaccine desert, and these communities are hit doubly as hard. This perpetuates a vicious cycle of ever-burgeoning risk alongside the intractability of the underlying problem: the economic havoc wrought by the pandemic squeezes out small, local pharmacies. The reduced pharmacy access expands the radius of pharmacy deserts. And the diminishing access to pharmacies and all the services they offer (e.g., vaccinations) intensifies the health and financial impacts of the pandemic, ad infinitum.  </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span new="" roman="" style="font-family:" times="">This quandary will inevitably begin having an impact on self-funded plans covering individuals in these urban pharmacy deserts similar to the struggles faced by plans whose participants are in more remote rural areas. As participants find themselves with ever more limited access to pharmacies, the plan’s spending on prescription drugs will begin creeping higher. Furthermore, as the pandemic rolls on and plans find themselves covering more and more coronavirus testing, treatment, and vaccinations, the ultimate costs of those services will be driven higher as well. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">Where an individual lives should not determine their access to prescription drugs, let alone the coronavirus vaccine. Ultimately, the only solution is to break this particular wheel. In the near term, that means overcoming the coronavirus, which necessarily requires a significant push in testing, tracing and vaccinating – all of which appear to be priorities of the Biden administrations pandemic response. Beyond that, addressing the expansion of pharmacy deserts will require a broad policy push, including: funding to expand pharmacy access in underserved communities; expansion of telemedicine and direct shipment of prescription drugs; adjustment to Medicaid and Medicare requirements on when and where prescriptions can be filled; and continued efforts to rein in the total cost of prescription drugs.</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 calibri="" style="font-family:"><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 calibri="" style="font-family:">[1]</span></span></span></span></span></a> <i>See </i><a href="https://doi.org/10.1377/hlthaff.2013.1397" style="color:#0563c1; text-decoration:underline">https://doi.org/10.1377/hlthaff.2013.1397</a></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" 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 calibri="" style="font-family:">[2]</span></span></span></span></span></a> <i>See</i> <i>id. </i></span></span></p> </div> </div> </div> </div> 1055Empowering Plans: P106 – A No-Surprises Party – The No Surprises Act Dissectedhttps://www.phiagroup.com/Media/Posts/PostId/1054/empowering-plans-p106-a-no-surprises-party-the-no-surprises-act-dissectedPodcastsFri, 16 Apr 2021 13:18:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/lYKMenYvDgE" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:16px;"><span calibri="" style="font-family:">In this episode we welcome back to the mic EVP and General Counsel, Ron Peck, as well as SVP of Consulting, Jen McCormick.  These industry legends discuss the <a href="https://www.phiagroup.com/Media/The-No-Surprises-Act-Explained">No Surprises Act</a>, 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.</span><br /> <br /> <a href="https://youtu.be/lYKMenYvDgE">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://youtu.be/lYKMenYvDgE">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</span></p> 1054A Blueprint for Success – Lessons from 2020, Expectations for 2021https://www.phiagroup.com/Media/Posts/PostId/1043/a-blueprint-for-success-lessons-from-2020-expectations-for-2021WebinarsThu, 25 Feb 2021 13:31:10 GMT<p style="text-align: justify;"><span style="font-size:16px;">Join The Phia Group to learn from the past, and plan for the future!  In this webinar, The Phia Group will both examine what has happened as well as predict what is to come, as they help you identify what needs to be done to ensure the best possible outcomes for this coming year.  They will discuss President Biden’s first month in office, identify whom he has appointed for key roles (and examine their track records on healthcare), as well as dissect the issues that were most relevant in 2020 – ensuring we learn from both the victories and losses of the year that has ended.</span></p> <p><a href="https://attendee.gotowebinar.com/recording/1038731038247232016"><span style="font-size:16px;">Click Here to View Our Full Webinar</span></a><br /> <br /> <span style="font-size:16px;">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com">mpainten@phiagroup.com</a>.</span></p> <p><span style="font-size:16px;"><span style="line-height:107%"><span calibri="">To obtain a recording of our <strong>Breakout Sessions</strong>, please reach out to <a href="mailto:mpainten@phiagroup.com?subject=Breakout%20Session%20Recording%20Request">mpainten@phiagroup.com</a>. </span></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"></span></p> 1043Empowering Plans: P102 – CYA: Cover Your Assetshttps://www.phiagroup.com/Media/Posts/PostId/1042/empowering-plans-p102-cya-cover-your-assetsPodcastsFri, 12 Feb 2021 13:54:30 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/OcUDb5T09hk" width="560"></iframe></p> <p style="text-align: justify;">In this episode of the Empowering Plans podcast, Nick and Brady talk through some developing trends in ERISA litigation. Do fiduciary duties apply to the protection of plan data? Could a data breach lead to claims under ERISA and HIPAA? What steps do ERISA fiduciaries need to take? Listen in as we explore where things stand, and where they might be heading.</p> <p style="text-align: justify;"><a href="https://youtu.be/OcUDb5T09hk">Click here to check out the podcast!</a>  (Make sure you subscribe to our <a href="https://youtu.be/OcUDb5T09hk">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 1042Energage Names The Phia Group a Winner of the 2021 Top Workplaces USA Awardhttps://www.phiagroup.com/Media/Posts/PostId/1038/energage-names-the-phia-group-a-winner-of-the-2021-top-workplaces-usa-awardPress ReleasesThu, 28 Jan 2021 19:46:36 GMT<p style="text-align: justify;">For Immediate Release</p> <p style="text-align: justify;">1/28/2021</p> <p style="text-align: justify;">Canton, MA – Energage Names The Phia Group, LLC a Winner of the 2021 Top Workplaces USA Award.</p> <p style="text-align: justify;"><span style="font-family:"Calibri",sans-serif"></span></p> <p style="text-align: justify;">Today The Phia Group announced that it has earned a 2021 Top Workplaces USA award, issued by Energage.  Energage, an organization that develops solutions to build and brand a vast array of companies, leveraged their 14-year history of surveying more than 20 million employees across 54 markets, to award this prize during what is the prestigious honor’s inaugural year.</p> <p style="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 style="text-align: justify;">“The Phia Group’s mission is to reduce medical costs and improve the quality of health care.  That mission starts and ends with our people.  Our job is to help other employers secure the best benefits for their employees and families; it behooves us to do the same for our own team,” The Phia Group’s CEO, Adam Russo, remarked.  “This award is proof that our focus on benefits, opportunities, and general employee satisfaction is not misguided.  While employee satisfaction is valuable in and of itself, it is equally important as a crucial element of improving our company’s overall value.  If our team doesn’t share our passion or buy into our principles, that reflects in the work product.  Employer success is therefore built upon a foundation of employee success.  By emphasizing an atmosphere of employee satisfaction, we generate better outcomes, satisfied clients and success for all.”</p> <p style="text-align: justify;">To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> or by phone at 781-535-5644.</p> <p style="text-align: justify;">About The Phia Group:</p> <p style="text-align: justify;">The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</p> <p style="text-align: justify;">About Energage:</p> <p style="text-align: justify;">Making the world a better place to work together.™</p> <p style="text-align: justify;">Energage is a purpose-driven company that helps organizations turn employee feedback into useful business intelligence and credible employer recognition through Top Workplaces. Built on 14 years of culture search and the results from 22 million employees surveyed across more than 66,000 organizations,  Energage delivers the most accurate competitive benchmark available. With access to a unique combination of patented analytic tools and expert guidance, Energage customers lead the competition with an engaged work force and an opportunity to gain recognition for their people-first approach to culture. For more information or to nominate your organization, visit energage.com or topworkplaces.com.</p> 1038The Phia Group's 1st Quarter 2021 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1034/the-phia-groups-1st-quarter-2021-newsletterNewslettersTue, 19 Jan 2021 14:46:42 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 Q1 2021/icons66.png?ver=Ri9hIFoZ8gTYKa5f8apj9Q%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo"><img src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/topblock1020_1.png?ver=h5FpDIL2YZmwOoIhJRm00g%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pdef"><img src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/topblock1020_2.png?ver=XLBqTo_3eGsmMNRd9EOgmA%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> </p> <p><br /> <img height="323" src="/Portals/phiagroup/Newsletter 2019 Q1/adam9.jpg?ver=d5VGoFOPUXcIVu6YdsX-0Q%3d%3d" width="268" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"></span><br /> <span style="font-size:16px;"><span class="heading1" style="font-weight: bold;">The Book of Russo: </span></span></p> <p class="bodytext" style="text-align: justify;">When asked whether I believe the “glass is half empty, or half full,” I’m “positive” that I am an optimist. I realize that it can annoy people, but I assume it’s in a good way. Whoops; there I go again.<br /> <br /> Looking at 2020, I can’t help but note the positives that emerged from the previous year. Though I wasn’t able to travel (and my stockpile of hotel pens and miniature bottles of shampoo have reached an all-time low), The Phia Group still saw its client base expand, and retained the talents of many new Phia Group team members. That in turn means I got to meet and spend time with so many new employees and clients (albeit over Zoom, Skype, Ring Central, and a million other programs with which I’m not yet familiar). In truth – this led to me likely spending even more time with those great people than I would have spent pre-pandemic.</p> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Perhaps, most important, I truly got to enjoy more quality time with my four kids and incredible wife. I saw how my children have persevered through the pandemic and rolled with the punches. They did the best they could with virtual birthday parties, distanced Halloween trick or treating, and intimate Christmas celebrations.<br /> <br /> So – in addition to positivity – I also feel pride. Pride in my family. Pride in my colleagues. Pride in our industry.<br /> <br /> Speaking of The Phia Group, and how it too has rolled with the punches – our Friday “Staff Zoom Meetings” will never go away; even after we’ve all been vaccinated and are once again occupying the same physical space. People love them, especially when the kids (including the furry four legged ones) join the calls. You can only truly get to know your employees by examining what is in their “home office” backgrounds!<br /> <br /> Additionally, in 2020 we moved into two new beautiful offices, we already hired almost 40 people, we added close to 3 million lives of business, we more than doubled our technological power and added two successful service lines.<br /> <br /> This experience and our ability to keep pushing forward, showed me that The Phia Group is truly a family that can conquer anything.<br /> <br /> Oh! I almost forgot to mention that we were named a 2020 Best Place to Work by the Boston Globe. This would be a tremendous honor any other year, but this year – it’s “next level” amazing. While other employers are cutting staff, pulling back benefits, withholding information, and always a little “too late” to respond to the needs of their team – The Phia Group approached how it deals with its own staff in the same way it approaches its clients and services. With innovation, and thinking ahead; with empathy and generosity, speed and customization.<br /> <br /> This, then, was one of my proudest moments and verified for me that our emphasis on amazing benefits and employee satisfaction proved successful. If your staff is happy, their worst product will still be better than the competitions’ best. Your clients will feel the love, and remain beyond satisfied. Internally and externally, that is the foundation of loyalty.<br /> <br /> I truly thank all of you – partners and Phia team members – for believing in Phia and partnering with us; it means the world to me. Be well. Be safe. Happy reading.</p> <p class="bodytext" style="text-align: justify;"> </p> <p class="bodytext"><span style="font-size:16px;"><strong>The Phia Group Named as a Top Place to work 2020<a id="russo" name="russo"></a> </strong></span></p> <p class="bodytext" style="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 13th 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="bodytext" style="text-align: justify;"> </p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/bestplacetowork.png?ver=XLBqTo_3eGsmMNRd9EOgmA%3d%3d" style="width: 550px; height: 132px;" /></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 2018 Q2/inthisissue.png?ver=4_c-EncNsuJUxrT1QINLVg%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><a href="#pdef">Enhancements of the Quarter: Patient Defender</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 2021 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#pemployee">Employee of the Quarter & Year</a><br /> <a href="#Phia News">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p> </p> <p class="heading1">Enhancement of the Quarter: Patient Defender Value Reports<a name="pdef"></a></p> <p class="bodytext" style="text-align: justify;">Clients of Patient Defender will be excited to hear that we have created a brand new report for them. Clients of The Phia Group’s innovative Patient Defender service can access this quarterly snapshot of the service and the client’s activity. It contains a myriad of data, including both currently active and historical items.<br /> <br /> While the Patient Defender service itself can be a life-saver for groups subject to claims being balance-billed, this report provides information that demonstrates the true value of the service, allowing users to continue to make informed decisions about their actions.<br /> <br /> With over 35,000 employee lives represented in these reports, we have already received positive feedback, and we will continue to monitor clients’ usage and feedback!<br /> <br /> To learn more about these reports or to receive a sample report, please contact our Sales Manager, Garrick Hunt, at 781-535-5644 or <a href="mailto:GHunt@phiagroup.com">GHunt@phiagroup.com</a>. Likewise, to learn more about Patient Defender, Phia Unwrapped, balance-billing support services or any other services The Phia Group offers, Garrick is available to you.</p> <p class="bodytext"> </p> <hr class="horiz" />_ <p> </p> <p class="bodytext"><span style="font-size:16px;"><strong>Service Focus of the Quarter: Phia Unwrapped</strong></span></p> <p class="bodytext" style="text-align: justify;">If you’re not familiar with reference-based pricing (or “RBP”), get familiar. RBP started as an outlier in the industry, but it’s getting more and more popular, even being embraced by many networks and providers as the new norm. As helpful as RBP can be for non-contracted claims, however, it is not without the risk of balance-billing and member disruption – which is why many TPAs and groups that would otherwise embrace RBP instead shy away from it.<br /> <br /> To anyone who sees the value in RBP but can’t tolerate the risks: The Phia Group is here to help!<br /> <br /> The Phia Group has for decades provided services meant to supplement and enhance RBP programs; from balance billing support – which is plugged into plans that choose not to use any network, to Phia Unwrapped. Phia Unwrapped is designed to pair with plans that opt to supplement, rather than replace, a primary PPO, targeting out of network claims and allowing a health plan to shed its wrap network … and with it the meager but expensive discounts it allows providers to charge (or requires plans to pay, depending upon how you look at it).<br /> <br /> Phia Unwrapped is anything but traditional; by replacing wrap network access and modifying non-network payment methodologies, this service enables health plans to secure payable amounts that are unbeatably low. Phia Unwrapped places no minimum threshold on claims to be repriced, and sets no limit on balance bills eligible for negotiation. Looking at those instances in particular, The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full.<br /> <br /> Out-of-network claims run through The Phia Group's Unwrapped program yield an average savings of 74% off billed charges (three times the average wrap discount). There’s very little member disruption to boot, since the plan would keep its existing PPO and use Phia Unwrapped only for non-contracted claims. Phia Unwrapped can also be a way for a plan to switch from a traditional ”mega” network, with no meaningful steerage and therefore no meaningful discounts, to a narrower network with real steerage and real discounts, recognizing that a narrow network potentially means more non-network claims – which is exactly what Phia Unwrapped is designed to not only address, but leverage.</p> <p> </p> <p class="bodytext"><span style="font-size:16px;"><strong>Success Story of the Quarter: Reviewing Proposed Service Agreements</strong></span></p> <p class="bodytext" style="text-align: justify;">The Phia Group’s consulting department (via PGCReferral@phiagroup.com) was recently asked by a broker to review a proposed service agreement between an employer group and a vendor. After the broker confirmed our written scope of work and flat fee quote, we got to work, and immediately noticed some odd provisions in the vendor’s draft agreement.<br /> <br /> Chief among them was a provision that guaranteed the vendor a certain PEPM fee per contract that the vendor was able to enter into with any medical provider. Percentage-of-savings fees are the norm as payment for obtaining contracts, since payment should ideally depend on the value added, but the PEPM fee increase per contract seemed unusual. Although there is a possible world in which that provision benefitted the group, there were no provisions whatsoever to qualify the extent of this requirement. The example we provided to the group (based in New York) when discussing the language was that if the vendor calls fifty doctors in California and negotiates 1% discounts with all of them, that’s fifty contracts, and fifty separate additions to the PEPM cost of the vendor’s service – despite the fact that the CA-based doctors would be unusable by the NY-based employees, and, maybe more importantly, that those negotiated discounts would be a joke.<br /> <br /> We provided the broker with a full explanation of our issues with this language, as well as numerous other problematic or otherwise notable things we saw within the agreement. The broker subsequently requested from the vendor a list of its contracted discounts, with which it received and was thoroughly dissatisfied. The vendor refused to change its payment model to a percent-of-savings, and the deal was terminated.</p>   <p class="bodytext"><span style="font-size:16px;"><strong>Phia Case Study: A Common Claim with Complications</strong></span></p> <p class="bodytext" style="text-align: justify;">A plan participant was involved in a motor vehicle accident while riding a motorcycle, and suffered severe injuries. The Plan suspended payment until the police report was received, after which the Plan excluded claims due to the report indicating that the participant had been driving recklessly, and based on witness testimony, may have been intoxicated. Worth note is that this exclusion was applied despite the accident apparently being primarily caused by another driver rather than the plan participant’s own recklessness.<br /> <br /> The police report also noted that the participant’s injuries were too emergent for the officer on scene to be able to determine the participant’s sobriety (or lack thereof), so the police report was not conclusive on the question of intoxication. As a result, the Plan sought the medical records.<br /> <br /> The ER physician’s report vaguely mentioned that intoxication was a possibility, but the physician did not have concrete evidence. Subsequently, the lab results came back and lacked any evidence of intoxication.<br /> <br /> The Plan felt that the physician’s initial comment about possible intoxication was sufficient to allow the Plan Administrator to deny the claims on the basis of DUI, but the TPA sought out the opinion of The Phia Group regarding whether the claims were deniable on this basis. The TPA correctly noted that while the Plan did not need evidence that proved intoxication “beyond a reasonable doubt,” it did need “some” evidence.<br /> <br /> After a review of the file and relevant facts, we concluded that the physician’s initial speculation absent any real basis would not likely constitute evidence upon which a decision could be based without risking arbitrariness; it does not constitute a medical opinion that the patient was in fact intoxicated, nor is it substantiated by the physical evidence provided. We therefore opined that it would likely not be reasonable for the Plan to deny the claim on the basis of intoxication, since there was no evidence of intoxication upon which the Plan Administrator could reasonably rely.<br /> <br /> Ultimately, based on this information, the Plan paid the claims, and the participant’s attorney subsequently agreed to reimburse the Plan from any settlement ultimately received from the driver who caused the accident.</p> <p class="bodytext"> </p> <p class="bodytext"><span style="font-size:16px;"><strong>Fiduciary Burden of the Quarter: Complaint Remark Codes</strong></span></p> <p class="bodytext" style="text-align: justify;">Adjudicating health claims is hard work. It can get complicated, especially in light of what can sometimes be tight timeframes within which EOBs must be provided. For that reason, in the face of numerous possibilities for why certain line items might be denied, it can difficult to comply with ERISA’s regulations requiring certain information within a remark code. Compliance with those regulations, however, is still very important.<br /> <br /> The Plan Administrator has a duty to ensure that the plan provides reasonable claim procedures, in accordance with regulations found at 29 CFR §2560.503-1. Among other things, these regulations provide that an EOB must provide both “The specific reason or reasons for the adverse determination” and “Reference to the specific plan provisions on which the determination is based.” We often encounter EOBs that identify a given line item as denied or partially denied with a justification such as “denied pursuant to the Plan Document”, and generally something so vague would tend to not satisfy these regulations. It’s also somewhat common for plans utilizing reference-based pricing methodologies to use a remark code to the effect of “denied due to reference-based pricing,” which in our opinion is similarly vague and likely noncompliant. Remark codes like these fail to identify the plan language to justify the denial, and they fail to provide the required level of specificity in rendering a denial.<br /> <br /> The purpose of these claims regulations is to promote a “meaningful dialogue” between the plan and claimant such that the claimant may formulate an appeal of a denial if necessary; for that reason, a remark code like “denied pursuant to the Plan Document” cannot possibly suffice, since it does not provide nearly enough information to allow the claimant to have that “reasonable dialogue” and formulate any meaningful appeal of a denial.<br /> <br /> The practical effect of issuing remark codes that are too broad or vague to meet the requirements of the claims regulations is that the plan will have failed to provide reasonable claims procedures, and the claimant will be deemed to have exhausted its administrative remedies (i.e. the claimant can jump straight to a lawsuit, since the plan has effectively denied the claimant its right to appeal), effectively nullifying the plan’s internal appeals requirements.<br /> <br /> For those of you with children, remark codes like the examples here roughly equate to the classic “because I said so.” That can work well in the parenting context, but not so well under ERISA; luckily, parents are not required by law to provide the child proper reasoning and an opportunity to appeal the decision – but health plans are.<br /> <br /> If your remark codes include “denied because the plan said so”, please don’t hesitate to have them reviewed. The Phia Group is here to help!<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 December 16, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/a-transparent-2021-further-analysis-of-the-year-to-come" target="_blank">A Transparent 2021 - Further Analysis of the Year to Come</a>,” where we discussed the rules that will impact 2021, including the recently released transparent pricing rules.</p> <p class="bodytext" style="text-align: justify;">• On November 16, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/desperately-looking-forward-to-2021" target="_blank">Desperately Looking Forward to 2021</a>,” where we discussed hot topics, forecasting what we expect to see in 2021, and giving you a head start as you – like we – plan, and look forward, to 2021.<br /> <br /> • On October 19, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/new-opportunities-to-save-create-revenue-avoid-scary-practices" target="_blank">New Opportunities to Save, Create Revenue & Avoid Scary Practices</a>,” where we discussed some of the industry’s scariest blunders and gruesome 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> <br /> <br />   <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 23, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p98-balance-billing-during-covid-and-beyond" target="_blank">Balance Billing During COVID-19 and Beyond</a>,” where our hosts, Brady Bizarro and Mitch Hilbert, discuss how balance billing has been on an uptick during COVID, and how patients can possibly prevent this from occurring.<br /> <br /> • On November 30, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p97-covid-19-vaccine-candidates-what-health-plans-need-to-know" target="_blank">COVID-19 Vaccine Candidates – What Health Plans Need to Know</a>,” where our hosts, Brady Bizarro Andrew Silverio, discuss current COVID-19 vaccine candidates and everything health plans and employers need to know about them.<br /> <br /> • On November 13, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p96-election-aftermath-where-things-stand" target="_blank">Election Aftermath – Where Things Stand</a>,” where our hosts, Ron Peck, Brady Bizarro, and Nick Bonds reunite to discuss their developing thoughts on the presidential election results.<br /> <br /> • On November 9, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p95-2020-election-results-so-far-our-takeaways" target="_blank">2020 Election Results (So Far) – Our Takeaways</a>,” where our hosts, Ron Peck and Brady Bizarro, are joined by Nick Bonds, to discuss the 2020 election results.<br /> <br /> • On October 26, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p94-the-final-debate-election-predictions" target="_blank">The Final Debate & Election Predictions</a>,” where our hosts, Brady Bizarro and Nick Bonds, break down the final presidential debate of the campaign season, focusing in on the candidates’ healthcare plans.<br /> <br /> • On October 19, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p93-behind-the-scenes-towns-halls-nominees-medicare-for-all" target="_blank">Behind the Scenes – Town Halls, Nominees & Medicare-for-All</a>,” where our hosts, Ron Peck and Brady Bizarro take you behind the scenes, avoiding the bright lights of presidential town halls and Supreme Court confirmation hearings.<br /> <br /> • On October 13, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p92-healthcare-on-stage-covid-19-in-the-white-house" target="_blank">Healthcare on Stage & COVID-19 in the White House</a>,” where our hosts, Ron Peck and Brady Bizarro guide you through a chaotic week for healthcare news, including the first presidential debate, COVID-19 infecting the President and much of the West Wing, and more.</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"> </p> <p class="bodytext"><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;">• BenefitsPro – <a href="https://www.benefitspro.com/2020/12/17/leave-entitlements-under-the-ffcra-set-to-expire/" target="_blank">https://www.benefitspro.com/2020/12/17/leave-entitlements-under-the-ffcra-set-to-expire/</a> – December 17, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/12/07/hispanic-and-latino-health-and-the-affordable-care-act/" target="_blank">Hispanic and Latino health and the Affordable Care Act</a> – December 07, 2020<br /> <br /> • Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Best_Practices_For_Updating_The_Employee_Handbook_In_A_Pandemic_by_Philip_Qualo%2C_J_D.pdf" target="_blank">Best Practices For Updating The Employee Handbook In A Pandemic</a> – December 3, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/11/20/remembering-why-we-do-it-employer-sponsored-health-plans/" target="_blank">Remembering why we do it: Employer-sponsored health plans</a> – November 20, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/11/11/aca-in-court-reactions-from-aroudn-the-industry/" target="_blank">ACA in court: Reactions from around the industry</a> – November 11, 2020<br /> <br /> • Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/COBRA_COVERAGE_AND_COVID-19.pdf" target="_blank">Cobra Coverage and COVID-19</a> – November 5, 2020</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Planning_Ahead-_COVID-19_and_other_considerations_for_2021_Health_Plan_Renewals_by_Jennifer_M__McCormick%2C_Esq.pdf" target="_blank">Planning Ahead: COVID-19 And Other Considerations For 2021 Health Plan Renewals</a> – October 2, 2020</p> <p class="bodytext"><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/offer-more-for-more" target="_blank">Offer More for More!</a> If and when private health benefits cannot compete with a public option on price, they will need to re-invent the industry.<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/updating-the-employee-handbook-in-unprecedented-times" target="_blank">Updating the Employee Handbook in Unprecedented Times</a>. Have you made your updates yet?<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/there-is-no-such-thing-as-a-1099-employee" target="_blank">There is no Such Thing as a 1099 Employee.</a> A 1099 employee isn’t an employee of yours at all!<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/ffcra-leave-entitlements-set-to-expire-december-31-2020" target="_blank">FFCRA Leave Entitlements Set to Expire December 31, 2020</a>. How much do you know about the Families First Coronavirus Response Act?<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/i-hate-surprises" target="_blank">I Hate Surprises!</a> Surprise billing expected to come to a halt.</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"><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>Best Practices For Updating The Employee Handbook In A Pandemic</strong></p> <p class="bodytext" style="text-align: justify;">By: Philip Qualo, J.D. – December 2020 – <a href="https://www.sipconline.net/files/Best_Practices_For_Updating_The_Employee_Handbook_In_A_Pandemic_by_Philip_Qualo%2C_J_D.pdf" target="_blank">Self-Insurers Publishing Corp.</a><br /> <br /> For many employers, the start of the holiday season usually brings forth the time of year to brush the dust off of the employee handbook and determine what changes are desired, and required, for the upcoming year. Although employers have generally been quick to adopt and enforce policies addressing COVID-19, the rapidly changing guidance and onslaught of personal and professional restrictions necessitate swift revisions as best practices and requirements continue to change from day to day.<br /> <br /> In general, employers should review and revise their employee handbooks at least annually to account for changes in local, state, and federal laws and workplace safety requirements. After an unprecedented year that unleashed a pandemic on the world, however, employers and their compliance teams are scanning their employee handbooks, scratching their heads, and wondering where to begin. In finalizing our own employee handbook for a hopefully better 2021, I thought it would be helpful to share some lessons I learned on updating an employee handbook in challenging times..</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2021" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>Cobra Coverage and COVID-19</strong></p> <p class="bodytext" style="text-align: justify;">By: Kevin Brady, Esq. – November 2020 – <a href="https://www.sipconline.net/files/COBRA_COVERAGE_AND_COVID-19.pdf" target="_blank">Self-Insurers Publishing Corp.</a><br /> <br /> It is an unfortunate, but well-known, fact that the COVID-19 pandemic has had a significant impact on the U.S. economy. With the unemployment rate reaching a high of 14.7% in April, it is no surprise that many hard-working Americans lost their jobs. Given that many Americans rely on those jobs for their health plan coverage, the loss of income, combined with the loss of health coverage, has been and could continue to be catastrophic for many.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2021" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext"><strong>Planning Ahead: COVID-19 And Other Considerations For 2021 Health Plan Renewals </strong></p> <p class="bodytext" style="text-align: justify;">By: Jennifer M. McCormick, Esq – October 2020 – <a href="https://www.sipconline.net/files/Planning_Ahead-_COVID-19_and_other_considerations_for_2021_Health_Plan_Renewals_by_Jennifer_M__McCormick%2C_Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a><br /> <br /> As summer fades away and the leaves start to fall, many of us must start planning for 2021. The expectations and goals we set in January of 2020 have likely required review and adaptation. As a result of COVID-19, employers encountered unprecedented hurdles. In addition to the economic costs facing employers due to this pandemic, employers need action plans to address the logistical and morale challenges of COVID-19. While financial considerations are typically on the list of perpetual concerns, employers must now ensure they have action plans for employees needing to balance work and childcare, workplace safety, and the continually evolving regulations regarding COVID-19. Thankfully, with 2021 around the corner, employers have an amazing opportunity to boost employee morale and mitigate costs with thoughtful plan design. Employers can (and should) use the upcoming renewal opportunity to let their health benefits shine and invite excitement for employees about their 2021 health benefits.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-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"><br /> <span style="font-size:16px;"><strong>Thanksgiving Dinner Delivery </strong></span></span></p> <p class="bodytext" style="font-weight: normal">Thanksgiving dinner delivery to The Boys & Girls Club of Metro South was a little different this year. The Phia Family was out and about the week of Thanksgiving, delivering dinners to the 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 Louisville were out and about spreading the same cheer to five families in the Boise area and five families in the Louisville area. In total, we delivered 32 meals this year! Check out the great picture we were able to get from that special day! We hope everyone had a wonderful Thanksgiving!</p> <p class="bodytext" style="font-weight: normal"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/thanksgiving2020.jpg?ver=w9Bqx8ci0qyb_dfiAu7atA%3d%3d" style="width: 500px; height: 316px;" /></p> <p><strong><span style="color:null;"><span style="font-size:16px;">Angel Tree</span></span></strong></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 main lobby. On those tags are names, ages and the wish lists of children from The Salvation Army. This year we had over 130 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> <p class="bodytext" style="font-weight: normal"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/angeltree.jpg?ver=ysBZhLNiZP74AbvyEfwtJQ%3d%3d" style="width: 500px; height: 240px;" /></p> <p><span class="bodytext"><strong><br /> <span style="font-size:16px;">Christmas Came Early</span></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 virtually passed out hundreds of gifts to over 130 children. We hope these children enjoy their new toys as much as they enjoyed spending time with virtual Santa!</p> <p class="bodytext" style="font-weight: normal"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/xoomxmass.jpg?ver=LRKzG2YBU5bCKl97EciMIw%3d%3d" style="width: 500px; height: 322px;" /><br /> <br /> <br /> <a href="#top">Back to top ^</a></p> <p class="heading1"> </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Get to Know Our Employee of the Quarter:<br /> <br /> Kaitlyn Lucier </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.<br /> <br /> The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Kaitlyn Lucier, The Phia Group’s Q4 Employee of the Quarter!<br /> <br /> Kaitlyn has been able to handle any challenge that has been thrown at her with ease. She has done a phenomenal job training the new hires in CSD. She is always available to help others in need and being able to rapidly answer a question along with giving informative answers, so others are not lost. She is a valuable asset to CSD and is an outstanding hard worker.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/employee2020.jpg?ver=11SyMNh4XJ4YjlLRlzxVRg%3d%3d" style="width: 400px; height: 514px;" /></p> <p class="bodytext">Congratulations Kaitlyn, and thank you for your many current and future contributions.</p> <p><strong><span style="font-size:16px;">Get to Know Our Employees of the Year: Philip Qualo</span></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 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.<br /> <br /> The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Philip Qualo, The Phia Group’s 2020 Employee of the Year!<br /> <br /> Philip has done a phenomenal job with the Diversity Inclusion Committee- conducting the meetings, putting together all of the plans, reviewing with the Executive team & providing staff with the information. He has put in a lot of extra hours working late many nights, to ensure that everything was completed along with his PGC tasks. He definitely deserves recognition for all of his hard work!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/eoty.jpg?ver=8e-crYs1tFrc2Kj8M1rPDw%3d%3d" style="width: 400px; height: 440px;" /></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">• Chief Financial Officer<br /> <br /> • Customer Service Representative<br /> <br /> • Senior Vice President, Sales<br /> <br /> • Claim Analyst</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><br />  </p> <p><span style="font-size:16px;"><strong>Promotions</strong></span></p> <p class="bodytext">• Liz Pereira has been promoted from Case Investigator to Case Analyst</p> <p class="bodytext"> </p> <p><span style="font-size:16px;"><strong>New Hires</strong></span></p> <p class="bodytext">• Nathan Letourneau was hired as a Claim and Case Support Analyst<br /> <br /> • Alexander Araujo was hired as a Customer Care Representative<br /> <br /> • Brittany Farr was hired as a Customer Care Representative<br /> <br /> • Thalea Gauthier was hired as a Customer Care Representative<br /> <br /> • Alexia Holloway was hired as a Customer Care Representative<br /> <br /> • Catherine Villanueva was hired as a Customer Care Representative<br /> <br /> • Lisa Hill was hired as a Sr. Subrogation Attorney<br /> <br /> • Anthony Jean was hired as an Accounting Administrator I<br /> <br /> • Thomas Cole was hired as a Claim Analyst<br /> <br /> • Skyla Mrosk was hired as a Claim Analyst<br /> <br /> • Andrew Mead was hired as an IT Intern<br /> <br /> • Alexandre Houle was hired as a Provider Relations Clinical Claims Specialist<br /> <br /> • Aastha Vats was hired as an ETL Specialist<br /> <br /> • Julie Padden was hired as an Executive Assistant<br /> <br /> • Sheena Roberts was hired as a Sr. Administrative Assistant<br /> <br /> • Kristen Melanson was hired as a Claim and Case Support Analyst<br /> <br /> • Hillary Burmester was hired as a Claim Recovery Specialist<br /> <br /> • Kaitlyn MacDonald was hired as a Health Benefit Plan Consultant I</p> <p class="bodytext"> </p> <p class="bodytext"> </p> <hr class="horiz" /> <p><span class="heading1"><a id="Phia News" name="Phia News"></a></span></p> <p class="bodytext"><span class="heading1">Phia News:</span></p> <p><strong><span style="font-size:16px;"> Candy Corn Contest</span></strong></p> <p class="bodytext">We set up our annual Candy Corn Contest in the front lobby of our Canton office and asked everyone to guess how many pieces of candy corn were in the jar! For those working from home, we sent out pictures of the candy jar with measurements, and had over 100 submissions. The winner of this contest was Lisa Decristoforo, and the total count was 811. Lisa guessed that there were 803 pieces of candy corn. It’s hard to believe that all of those pieces of candy fit into that small jar!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/candycorn.jpg?ver=qwir4I5gfxJtuD0Tj9HogQ%3d%3d" style="width: 500px; height: 322px;" /></p> <p class="bodytext"><span style="font-size:16px;"><strong>Pumpkin Carving Contest</strong></span></p> <p class="bodytext">In October, The Phia Group held its first Pumpkin Carving contest. We had over 20 submissions and it was a tough decision to make, but the Phia family had to pick one. Congratulations to the winner, Catherine Baskerville. We are all so impressed with your creativity and carving skills. We look forward to our next Pumpkin Carving contest!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/pumpkincarve.jpg?ver=KNVhFCZokndC3WwRvK_qXA%3d%3d" style="width: 400px; height: 367px;" /><br />  </p> <p class="bodytext"><span style="font-size:16px;"><strong>Mask Contest</strong></span><br /> <br /> With everyone being asked to work from home, we wanted to make sure we kept all employees engaged and entertained. We put our thinking caps on and asked everyone to submit photos of their most creative masks, and we had the Phia family vote for their favorite mask during a virtual staff meeting. We are proud to announce that Regina Cattel was the winner of this contest, with her super fun tiger mask!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2021/mask.jpg?ver=vYtmJYuF7b-EsNuhTIqSOA%3d%3d" style="width: 400px; height: 434px;" /></p> <p class="bodytext"><strong></strong></p> <p class="bodytext"><span style="font-size:16px;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong></span></p> <p class="bodytext" style="text-align: justify;">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.<br /> <br /> 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.<br /> <br /> 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.<br /> <br /> 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> 1034The Stacks – 1st Quarter 2021https://www.phiagroup.com/Media/Posts/PostId/1033/the-stacks-1st-quarter-2021NewslettersTue, 19 Jan 2021 14:34:05 GMT<p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:20px;"><span style="color:#0071ce;"><span style="line-height:115%"><span calibri="" style="font-family:"><b><span style="line-height:115%">Best Practices for Updating the Employee Handbook in a Pandemic</span></b></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;"><span calibri="" style="line-height: 115%; font-family: ">By Philip Qualo, J.D. </span></span></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;"></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.5pt"><span style="color:#333333">For many employers, the start of the holiday season usually brings forth the time of year to brush the dust off of the employee handbook and determine what changes are desired, and required, for the upcoming year. Although employers have generally been quick to adopt and enforce policies addressing COVID-19, the rapidly changing guidance and onslaught of personal and professional restrictions necessitate swift revisions as best practices and requirements continue to change from day to day.<br /> <br /> In general, employers should review and revise their employee handbooks at least annually to account for changes in local, state, and federal laws and workplace safety requirements<b>. </b>After an unprecedented year that unleashed a pandemic on the world, however, employers and their compliance teams are scanning their employee handbooks, scratching their heads, and wondering where to begin. In finalizing our own employee handbook for a hopefully better 2021, I thought it would be helpful to share some lessons I learned on updating an employee handbook in challenging times</span></span></span></span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><b><span style="font-size:11.5pt"><span style="color:#333333"></span></span></b></span></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span style="background:white"><span new="" roman="" style="font-family:" times=""><b><span style="font-size:11.5pt"><span style="color:#333333">Avoid Non-Static COVID-19 Provisions </span></span></b></span></span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.5pt"><span style="font-size:11.5pt"><span style="color:#333333">As updating an employee handbook multiple times within a fiscal year can be an administratively burdensome task, a best practice is to ensure all policies included or updated in the handbook are relevant, as well as static, for the duration of the applicable fiscal year. This has been simple in most years, however, in response to the COVID-19 pandemic, the federal government passed a series of comprehensive laws</span></span><span style="font-size:11.5pt"><span calibri="" style="font-family:"><span style="color:#333333">, </span></span></span><span style="color:#333333"><span style="color:#333333">with rapidly approaching expiration dates, aimed at protecting American workers by regulating group health plans and imposing new leave paid entitlements on covered employers, such as the Families First Coronavirus Response Act (FFCRA). In addition to the FFCRA, state and local laws guidance continue to be updated at an unpredictable frequency that often necessitates a quick and temporary change to workplace rules in order to comply safety requirements. For employers that sponsor self-funded plans, it is also important to keep in mind that for any newly enacted leave entitlements that continue coverage, the applicable Plan Document should be amended to reflect this continuation of coverage and communicated to the stop-loss carrier so ensure no gaps in coverage. </span><br /> <br /> In order to avoid the challenge of updating and re-distributing an employee handbook multiple times within a single year, it may be helpful to limit specific references to COVID-19. For example, I chose to use terms such as “Public Health Emergency” and “Pandemic” where possible. If COVID-19 has taught us anything, it is that life is unpredictable. Now that we have collectively experienced and continue to endure this pandemic, we now know that public health emergencies and pandemics can happen to us… yes, even to us. As such, including language in an employee handbook referencing an employer’s responsibility to contain a public health emergency or pandemic would apply to COVID-19 and other critical health crisis that poses a threat to workplace safety.<br /> <br /> For policies with an approaching expiration date, or that are likely to change frequently based on changing guidance, it may be helpful to generally reference them in the employee handbook and detail them in a separate platform or notice that can be updated and re-distributed with ease. For example, we use an intranet platform to house our most up to date COVID-19 policies. This allows for quick enhancements of relevant policies and immediate notification to employees. Although any platform accessible to all employees may be appropriate, an employer should take the additional step of distributing, announcing, or where applicable, requiring sign-off for each and every change to document compliance with notification requirements.<br /> <br /> For example, I expanded the handbook to include language that referenced the “Direct Threat Exception” to Americans with Disabilities Act (ADA) limitations to explain my employer’s ability to temperature check and inquire about health status. In this provision, I chose to leave out the term “COVID-19” because the direct threat exception would likely apply to any other declared public health emergency that may arise. The temperature check policies, on the other hand, may not be applicable in a different type of pandemic. </span></span></span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.5pt"><span style="color:#333333"></span></span></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><b><span style="font-size:11.5pt"><span style="color:#333333">So You’re Saying Not to Include Any COVID-19 Language? </span></span></b></span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.5pt"><span style="color:#333333">Employee handbooks are more than just a collection of policies for most employers, they are a snapshot of that year, a yearbook of sorts. Although some memories are better left … <i>not</i> remembered…employers may one day want to reminisce on challenging year. On the other hand, as COVID-19 is likely not going anywhere as soon as we hoped for, it may be a good idea to include some static references to COVID-19. So I would <i>not</i> recommend pretending COVID-19 does not exist when it comes to the employee handbook. </span></span></span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:11.5pt"><span style="color:#333333"></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:11.5pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="color:#333333">For example, in our own employee handbook, I developed a paragraph that describes COVID-19, briefly, and details our companies commitment to follow all state, local, federal and Centers for Disease Control (CDC) guidance. As this guidance is subject to change, and has from day to day since the start, I did not include specific references to our face mask policy. Is this important? – absolutely. Is the handbook, however, the best place to house a policy that may be outdated by the time it is distributed? – probably not.<br /> <br /> In summary, there are rarely two employee handbooks that are entirely alike in this world. There are not many rules surrounding what needs to go in one, or what needs to go out. For the most part, employee handbooks are not even legally required. It is, however, a strongly recommended best practice for an employer to maintain one and ensure appropriate policies as determined by their specific compliance needs. Therefore, employers are free to include any and every COVID-19 policy and language they desire. In minimizing the non-static language, however, employers can demonstrate compliance with all applicable rules while sparing the administrative burden involved in reconciling existing handbook provisions with the day to day changes to mandated workplace safety guidance.</span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="text-align: justify;"><span style="color:#0071ce;"><span style="font-size:20px;"><b><span style="line-height:115%"><span calibri="" style="font-family:">COBRA Coverage and COVID-19</span></span></b></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;">By: Kevin Brady, Esq. </span></strong></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">It is an unfortunate, but well-known, fact that the COVID-19 pandemic has had a significant impact on the U.S. economy. With the unemployment rate reaching a high of 14.7% in April, it is no surprise that many hard-working Americans lost their jobs. Given that many Americans rely on those jobs for their health plan coverage, the loss of income, combined with the loss of health coverage, has been and could continue to be catastrophic for many. </span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">On the (somewhat) bright side of things, those who lose their jobs are not always left optionless, as most individuals who lose their employer-sponsored health coverage will generally be eligible for continued coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA provides workers and their families the option to continue group health plan coverage (for a limited period of time) under certain circumstances which cause a loss in group health plan coverage. Further, the employee, rather than a combination of the employee and employer, bears the full cost of coverage when enrolled in COBRA. From the individual’s perspective, the cost alone, especially in the midst of the pandemic and the resulting economic uncertainty makes COBRA a tough sell for former employees, especially those who have other coverage options available.  </span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">From an employer’s perspective, administering COBRA coverage effectively- and most importantly, correctly is a difficult task. Employers have strict obligations under COBRA. They must provide adequate notice of a “qualifying event” to ensure that their former employees and their dependents are offered coverage. What makes things even more complicated, is that employers who self-fund their health plan coverage actually serve as both the employer under COBRA (subject to certain obligations), and the plan administrator (subject to a distinct set of obligations) as well. This nuance only adds to the multitude of obligations and the resulting confusion that an employer must contend with. As is this case with a great many other things, those obligations have become even more difficult to understand and satisfy in the wake of the COVID-19 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 calibri="" style="font-family:">As mentioned above, COBRA provides the opportunity to continue group health plan coverage if certain criteria are satisfied. Private employers who employ 20 or more workers, are generally subject to COBRA if they offer if a group health plan. COBRA must be made available for the “covered employees” of the employer, and their dependents, if they experience what is known as a qualifying event. </span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">The COBRA regulations provide that a qualifying event may be any of the following occurrences:</span></span></span></p> <ul> <li style="margin: 0in 0in 0.0001pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"> Voluntary or involuntary termination of the covered employee’s employment other than by reason of gross misconduct;</span></span></span></li> <li style="margin: 0in 0in 0.0001pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"> Reduction of hours of the covered employee’s employment; Divorce or legal separation of the covered employee from the employee’s spouse;</span></span></span></li> <li style="margin: 0in 0in 0.0001pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"> Death of the covered employee;</span></span></span></li> <li style="margin: 0in 0in 0.0001pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"> A dependent child ceases to be a dependent under the generally applicable requirements of the plan;</span></span></span></li> <li style="margin: 0in 0in 0.0001pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"> A covered employee becomes entitled to benefits under Medicare; and</span></span></span></li> <li style="margin: 0in 0in 8pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"> An employer’s bankruptcy, but only with respect to health coverage for retirees and their families.</span></span></span></li> </ul> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">While the situations and occurrences which are considered qualifying events may be widely known, what is often overlooked is that the qualifying event must also cause a loss of coverage under the plan. Therefore, if plan coverage does not terminate as a result of the qualifying event, then the individual does not become eligible for an offer of COBRA coverage from the employer. </span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">One instance where this principle is becoming more and more relevant, relates to employees who are furloughed or laid off. Given the economic uncertainty surrounding the COVID-19 pandemic, an unprecedented number of employers have turned to workforce reduction measures such as furloughs and/or layoffs to ensure business continuity.</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">On the surface, a layoff or furlough may appear to be a qualifying event which triggers an offer of COBRA coverage to the affected individuals. While it may very well be a qualifying event, it very much depends on the facts and circumstances of the given case. For example, many health plans choose to continue plan coverage in the event of a leave of absence, or even a temporary layoff or furlough. This approach is actually quite common. Although typically outlined within an employer handbook or policy manual, effectively outlining the instances in which plan coverage will be continued within the plan document can mitigate the risk of a potential dispute with the stop loss carrier.</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">In essence, the employer must review the plan document to determine whether it properly allows for continued coverage while an individual is furloughed or laid off. If the plan outlines said continuation, then the individual has not experienced a qualifying event and the employer’s obligation to offer COBRA coverage has not been triggered. </span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">Of course, the individual may become eligible for COBRA continuation coverage if they do not ultimately return to work or if their continued plan coverage expires during the maximum coverage period of COBRA. If that is the case, the employer’s obligations would then be triggered, and the employer would be required to offer coverage in accordance with COBRA’s requirements. Fortunately for employers, there is some flexibility in the timeframe in which the offer of coverage must be made.</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">The Internal Revenue Service (IRS) along with the Department of Labor (DOL) issued final rules which extend a number of important benefit plan timeframes. As it relates to COBRA, plan administrators do have some flexibility as it relates to their obligation to notify the individual of COBRA coverage. </span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">On the other hand, the rules also extend the period in which individuals can elect COBRA coverage, as well as the period of time in which an individual must pay their premiums. These extensions are sure to make administering COBRA eligibility another difficult task for the foreseeable future. </span></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="line-height:107%"><span calibri="" style="font-family:">Any way you look at it, COBRA continuation coverage generally imposes a number of obligations on employers, plan administrators, and those who would enroll in COBRA coverage as well. Determining what those obligations are, how to apply them, and who may be eligible for them is no small feat even without the regulatory and economic uncertainty of the COVID-19 pandemic factored in. In order to avoid potential compliance issues, as well as mitigating the risk of reimbursement issues down the road, plan administrators should pay special attention to these COVID-19 related issues. Review the plan document to determine whether individuals furloughed and laid off are eligible to continue coverage under the plan, or alternatively under COBRA. Until the economic consequences of the pandemic dissipate, the complications and nuances associated with COBRA continuation coverage are sure to persist along with it.</span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="margin-bottom:.0001pt; margin:0in 0in 8pt"><span style="color:#0071ce;"><span style="font-size:20px;"><strong><span style="line-height:normal"><span calibri="" style="font-family:">Planning Ahead:  COVID-19 and Other Considerations for 2021 Health Plan Renewals</span></span></strong></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;">By: Jennifer M. McCormick, Esq. </span></strong></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"></span></span></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">As summer fades away and the leaves start to fall, many of us must start planning for 2021.  The expectations and goals we set in January of 2020 have likely required review and adaptation. As a result of COVID-19, employers encountered unprecedented hurdles. In addition to the economic costs facing employers due to this pandemic, employers need action plans to address the logistical and morale challenges of COVID-19.  While financial considerations are typically on the list of perpetual concerns, employers must now ensure they have action plans for employees needing to balance work and childcare, workplace safety, and the continually evolving regulations regarding COVID-19. Thankfully, with 2021 around the corner, employers have an amazing opportunity to boost employee morale and mitigate costs with thoughtful plan design.  Employers can (and should) use the upcoming renewal opportunity to let their health benefits shine and invite excitement for employees about their 2021 health benefits. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">In planning for the upcoming benefit year, design modifications can generally be categorized into two categories: (1) regulatory changes; and (2) recommended changes.  Lingering uncertainty and future unknowns make both categories of design modifications equally important.  </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><i>Regulatory Changes  </i></b></span></span></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">While the list of regulatory items that <i>must</i> be changed may seem overwhelming, some of the changes may ultimately be welcomed by employers or employees. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">For example, benefit updates for COVID-19 related services and modified rules regarding continuation coverage were likely well received by employees.  In addition to the benefits and continuation coverage provided for by The Coronavirus Aid, Relief, and Economic Security (CARES) Act and Families First Coronavirus Response Act (FFCRA), the Department of Labor (DOL) and Internal Revenue Service (IRS) issued regulations offering additional relief for participants.  Specifically, the regulations allow additional time for participants to take actions such as electing (or paying premiums for) continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) and filing an appeal of an adverse benefit determination or requesting an external review.  Relief will apply retroactively from March 30, 2020 until 60 days after the end of the national emergency.   </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Relevant regulations did specify that penalties would not be imposed if plans were administered in compliance with the extended timeframes, even if contrary to the specific terms of the underlying plan document materials.  Ambiguity surrounding deadlines, however, leads to unnecessary confusion for individuals enrolled in the health plan.   To eliminate this concern, plan materials should be updated and include details regarding the extended timeframes.  Disclosure and inclusion of such information will also function to mitigate potential gaps that may arise between plan materials and stop loss policies.</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">In addition to the tolling of certain timeframes, employees may also welcome the updated Summary of Benefits and Coverage (SBC) templates for 2021, also requiring revision and implementation.  The SBC is intended to provide uniform and consistent information regarding available plan benefits.  While modifications to the 2021 SBC template are not extensive, they do include updates to the coverage examples and the removal of information pertaining to the individual mandate. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Regarding employers, however, certain review and revision may be needed pertaining to plan out-of-pocket maximums.  Specifically, on an annual basis the Department of Health and Human Services (HHS) determines the adjustments for the Affordable Care Act (ACA) in-network out-of-pocket maximums for non-grandfathered plans.  In addition, the IRS sets the standard for high-deductible health plans. These iterations are expected annually and should be reviewed and applied in alignment with employer intentions.   </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">The interesting twist on out-of-pocket maximums that employers may be contemplating (or have already addressed) is the policy change on drug manufacturer assistance calculations for non-grandfathered plans.  An employer plan is not required, but may, count toward the out-of-pocket maximum drug manufacturer assistance, coupons, or other cost reductions. This is true even if the assistance in question is available on a drug without a generic equivalent.  This update may create an opportunity for cost-savings as plan out-of-pocket maximums are reviewed; however, employers should examine whether any other state laws require consideration. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Another regulatory update seemingly well received by both employers and employees is the relief contained within IRS Notice 2020-29. This relief, while temporary until December 31, 2020, relaxed the rules for mid-year election changes offered under Section 125 cafeteria plans.  Pursuant to this guidance, employees (if the employer decides to offer this optional election, and documents the offering accordingly by way of amendment) could revoke an existing health plan election if certain factors were met.  For employees, this opportunity might be the flexibility needed to reduce or modify coverage as finances face greater and continued uncertainty. For employers, this offering might foster goodwill among employees anxious to make plan modifications as a result of less certain financial times. </span></span></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><i></i></b></span></span></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><i>Recommended Changes</i></b></span></span></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Since the list of 2021 required regulatory changes may not be as extensive as in prior years, employers may want to consider modifying benefits to account for the evolving needs of their workforce. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Health benefits remain valuable during the pandemic.  Employers who consider implementation of 2021 updates that coalesce with employee needs and wants will only enhance goodwill.  For example, as part of end of year discussions, an employer should consider polling employees to identify benefits they consider absent or not robust enough.  It is possible the stress of a pandemic means more employees are desirous of holistic health options such as acupuncture or nutritional counseling. Identifying benefit enhancements that most effectively promote employee wellness and have the greatest potential to improve employee happiness and productivity is of paramount importance. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Incentivization of certain behaviors under the plan is one avenue employers might explore. It is evident that certain benefits were more heavily accessed than others during this past year. Heeding feedback regarding the needs of employees during this trying time poses an opportunity to incentivize utilization that benefits both the employer and the employee.  For example, many appointments with primary care physicians were postponed due to limited availability, discouraged, or canceled, and employees did not have access to care as they would under traditional circumstances.  An alternative, offering focused medical care for employees while promoting financial predictability (i.e. potential cost savings) for the health plan, is direct primary care.  As permissible per other plan agreements, the addition of a direct primary care benefit should be considered.  This additional benefit would create direct access for employees to connect with a physician and receive the customized, tailored care needed during these challenging times, simultaneously easing ‘access to care’ anxiety during a pandemic. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">In addition to direct primary care, technology offers availability of greater connections to care via telehealth and telemedicine.  Telehealth services have been valuable as this option reduces the risk of exposure or transmission of COVID-19, while still providing the necessary virtual care. For example, telehealth has been useful for screening and accessing whether potential COVID-19 patients need to be seen in a hospital setting or care can be managed from home. Over the course of the pandemic, eased restrictions encouraged providers and patients to utilize telehealth services. Employers should revisit their benefit designs to determine whether and to what extent telehealth services are currently available to participants, and whether further modifications are necessary. By way of illustration, employers should review whether telehealth is a current standalone benefit or offered only through a specific vendor.  The availability of telehealth services should be clearly addressed and denoted within the plan materials to eliminate coverage related confusion under the health plan. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">At the outset of COVID-19, many individuals feared limited supplies, supply chain disruptions, or quarantine status restrictions would impact the ability to access necessary medications.  It is very common, and for myriad reasons, however, for health plans to impose prescription refill restrictions. Limited access has the potential of leaving employees in a situation where they are without life-saving medications.  With the continued unknowns of the pandemic, employers may consider relaxing refill protocols, ensuring access to critical prescriptions.  As permissible by the relevant plan agreements, employers could allow a 90-day supply instead of a 30-day supply in certain circumstances, investigate the availability of home delivery for prescription drugs, or evaluate mail-order pharmacy services. Prescription drug design flexibility not only has the potential to safely improve employee access to medication, but also create alternative prescription options that save money for the health plan. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">Employees continue to face uncertainty as it relates to COVID-19, and this likely creates additional worry, stress and anxiety.  Many employees are parents and caregivers and entering another school year with distance and remote learning, presents challenges for everyone. Pandemic related hardships and disruptions have had a negative impact on mental and behavioral health. As a result, taking care of mental and behavioral health needs is essential.  Enhanced benefits should be prioritized as employees need access to resources to address any mental and behavioral health concerns they face during these challenging times.  Employers should examine the current health plan to determine whether revised benefits are necessary to offer increased support.</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><i>Next Steps </i></b></span></span></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">With the end of the year rapidly approaching, employers must soon make critical decisions about employee benefit offerings.  Once solidified, a review and update of the current health plan materials is necessary to ensure these benefit modifications are described accurately.</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">In addition to updating plan document materials, employers must review and revise other corresponding agreements and policies to ensure seamless and gap free benefit administration. For example, the updated plan document materials should be compared against the stop loss policies, network agreements, and vendor agreements to identify (and eliminate) coverage gaps. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:">It may seem like an overwhelming task, but by proactively revising employee benefit materials to address these items employers can generate employee enthusiasm for the upcoming 2021 benefit year.  </span></span></span></p> 1033The Boston Globe Names The Phia Group as a Top Place to Work for 2020https://www.phiagroup.com/Media/Posts/PostId/1021/the-boston-globe-names-the-phia-group-as-a-top-place-to-work-for-2020Press ReleasesFri, 20 Nov 2020 20:55:00 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"></span><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">For Immediate Release</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:">11/21/2020</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:">Canton, MA – The Boston Globe Names The Phia Group as a Top Place to Work for 2020.</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:">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 13th 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​. </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:">Each year, The Boston Globe publishes in its “Top Places to Work” ​issue, a list of employers it recognizes as being the most admired workplaces in the state, voted on by the people who know them best – their employees.  The survey measures employee opinions about their company’s direction, execution, connection, management, work, pay and benefits, and engagement. </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:">When the results were tallied and analysis was completed, The Phia Group was ranked #27 of the top 55 medium sized companies.  “This was a particularly challenging year to be a great place to work, and the companies that made our list went above and beyond to keep their employees safe, engaged, and cared for,” said Katie Johnston, the Globe’s Top Places to Work editor. “From offering help with childcare to making the workplace more equitable, to holding virtual events, these employers showed that the best get better in crisis.”  </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:">The rankings ​are based on confidential survey information collected by Energage (formerly Workplace Dynamics), an independent company specializing in employee engagement and retention, from more than 80,000 individuals at hundreds of Massachusetts organizations.  The winners share a few key traits, including offering progressive benefits, giving their employees a voice, and encouraging them to have some fun while they’re at it. </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:">“This is one of the proudest days of my life.” The Phia Group’s CEO, Adam Russo, remarked.  “I say this team is like family; but we don’t usually get to choose who is a part of our family.  Our employees choose to be part of this family.</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:">“Ensuring that people have access to the best health care at the lowest cost possible is our purpose.  It’s what we provide to our clients, and it’s what we provide to our own staff.” Adam continued.  “When your people are happy, your clients are happy.  It’s not always the easiest or quickest path to success, but it is a lot more permanent.”  </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:">Additional information can be found at Globe.com/TopPlaces. </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:">To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com" style="color:blue; text-decoration:underline">ghunt@phiagroup.com</a> or by phone at 781-535-5644.</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:">About The Phia Group:</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:">The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</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:">About Boston Globe Media Partners LLC:</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:">Boston Globe Media Partners, LLC provides news and information, entertainment, opinion and analysis through its multimedia properties. BGMP includes The Boston Globe, Globe.com, Boston.com, STAT and Globe Direct.</span></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> 1021The Phia Group Announces the Continued Offering of Free Health Benefits to Employees and Their Families in 2021https://www.phiagroup.com/Media/Posts/PostId/1017/the-phia-group-announces-the-continued-offering-of-free-health-benefits-to-employees-and-their-families-in-2021Press ReleasesThu, 12 Nov 2020 18:40:00 GMT<p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">For Immediate Release</span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">November 13, 2020</span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Canton, MA – In 2020, The Phia Group, LLC shocked the industry by announcing their intent to cover the entire cost of health benefits for their employees and families.  Now, The Phia Group is pleased to announce that it will – in 2021 – continue to offer these no-cost benefits to employees and their families.  </span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">“This past year has been difficult for everyone.  Between the pandemic, politics, and a complete lack of predictability, the one thing we don’t want our people to worry about is the cost of maintaining their own, and their families’ health,” remarked The Phia Group’s CEO, Adam V. Russo, Esq.  “When we first implemented this program a year ago, our primary goal was to make health care more affordable for our team members – and we accomplished that mission; but that victory is almost outweighed by the residual benefits.  Recruitment of the best talent has been substantially bolstered by this unrivaled benefit, retention of existing talent has never been better, and employee morale is up, despite the 2020 roller coaster.  Not to mention how highly the company is now held in our employees’ spouses’ esteem – which is, of course, the true benchmark of success.”</span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Employees who have been in enrolled in The Phia Group’s self-funded health benefit plan for a fixed number of years will, upon renewing enrollment in 2021, have their contributions paid for by The Phia Group – including coverage for dependents.  This remarkable achievement continues to be made possible thanks to the application and utilization of cost containment measures developed and provided by The Phia Group, combined with proactive efforts on the part of its own plan membership to be cost-conscious “consumers” of healthcare.</span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">Ron E. Peck, Esq., Executive Vice President and General Counsel of The Phia Group explained, “2020 was going to be an experiment for us.  We asked whether, by combining plan-based cost-containment efforts with member education, could we keep health care expenses at a level our plan could afford without shifting the burden onto our plan members and their families.  The answer is ‘yes’.”</span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">“We are very proud to be able to offer our employees and their families the types of benefits you’d be hard pressed to find anywhere else, and at the same time act as living proof that we can empower plans.” Adam concluded.</span></span><br />  </p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="text-align: justify;"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif">For more information regarding The Phia Group, it’s benefit plan, and the services that make these incredible results possible, please contact Garrick Hunt by email at <a href="mailto:ghunt@phiagroup.com" style="color:#0563c1; text-decoration:underline">ghunt@phiagroup.com</a> or by phone at 781-535-5644.<br /> <br /> About The Phia Group:<br /> <br /> The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></span></p> 1017Empowering Plans: P95 - 2020 Election Results (So Far) – Our Takeawayshttps://www.phiagroup.com/Media/Posts/PostId/1016/empowering-plans-p95-2020-election-results-so-far-our-takeawaysPodcastsMon, 09 Nov 2020 14:14:00 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/LpODql6OuPk" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"></span></span></p> <p style="margin:0in 0in 0.0001pt"><span style="color:#000000;"><span style="font-size:16px;"><span style="font-family:"Calibri",sans-serif">In this episode of Empowering Plans, Ron and Brady are joined by Attorney Nick Bonds to discuss the 2020 election results. For now, it looks like we will have a new president in 2021. What will that mean for the healthcare industry? If the Senate stays in Republican control, is a public option likely? Will Obamacare be replaced? What will happen to popular issues such as prescription drug reform and surprise billing bans? We are covering all of the angles and breaking down all of the possibilities.</span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><a href="https://youtu.be/LpODql6OuPk"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;"> </span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/LpODql6OuPk"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></span></span></p> 1016Empowering Plans: P94 - The Final Debate & Election Predictionshttps://www.phiagroup.com/Media/Posts/PostId/1012/empowering-plans-p94-the-final-debate-election-predictionsPodcastsMon, 26 Oct 2020 19:39:31 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/FeX4DLyw4zk" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"> <span style="color:#000000;">In this episode of Empowering Plans, Brady is joined by Attorney Nick Bonds. They break down the final presidential debate of the campaign season, focusing in on the candidates’ healthcare plans. They discuss “Bidencare” as well as what would actually happen if the Affordable Care Act is finally found unconstitutional. To cap things off, they offer election predictions – which states will decide the election? Will Democrats take over the Senate? This is one October surprise you don’t want to miss! </span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><a href="https://youtu.be/FeX4DLyw4zk"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;"> </span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/FeX4DLyw4zk"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></span></span></p> 1012The Phia Group's 4th Quarter 2020 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/1011/the-phia-groups-4th-quarter-2020-newslettersNewslettersWed, 21 Oct 2020 17:56:38 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 2020/header2020.jpg?ver=tsaiCQ8yobpm91V_BFCutA%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/4th%20Quarter%202020.png?ver=YfyzUUVW2L_8j8P7uIL30A%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo"><img src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/topblock1020_1.png?ver=0akRmcnt8yCOCOMo5AqwYQ%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pdef"><img src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/topblock1020_2.png?ver=YfyzUUVW2L_8j8P7uIL30A%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"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">Welcome to the Fall Season! Here in Boston, the leaves are turning color and the air is getting a bit cooler. Meanwhile, at The Phia Group we are busier than ever (even though I haven’t been on a plane since February, and haven’t worn any of my beloved suits in over six months). What I have done, however, is learn that even though I can’t fly anywhere to see clients or prospects, we are still creating new opportunities together. Additionally, though miles may separate us, I am still thrilled to remain in close contact with so many of you virtually; be it by e-mail, phone, or video conference. In fact, in some ways, I actually feel like – since this</p> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">pandemic started – I have had more contact with you – my industry friends. Please, reach out any time, as communicating with you has been and will continue to be one reminder of better times. There is no question that my relationship with many individuals here at Phia has also grown tremendously since March. For instance, where we used to do monthly staff meetings, we now do them – virtually – on a weekly basis. Unlike the past, now we also invite our staff to have their children join in on the video calls; (plus pets too). Since all of this started, I have gotten to meet so many family members – both two legged and four – that I otherwise would not have encountered. I’m not even addressing the fact that I actually get to see all of my kids every day, instead of calling them from some random hotel room or airport terminal. If you think I am a “glass half full” type of person, then you are correct. I guess I have always tried to be optimistic in life. I am looking at the silver lining, as it applies to the pandemic, but I also feel the same way about self-funding, and where it is heading. The sky is the limit for our industry and we here at The Phia Group are ready to assist you in ensuring its success. Let the following serve as proof that we can do great things together, and don’t forget to reach out soon. 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 2018 Q2/inthisissue.png?ver=4_c-EncNsuJUxrT1QINLVg%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#russo">Enhancements of the Quarter: Phia Unwrapped & Balance Billing 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 2020 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> </p> <p class="heading1"> </p> <p class="heading1">Enhancement of the Quarter: Phia Unwrapped and Balance Billing Value Reports<a id="russo" name="russo"></a></p> <p class="bodytext" style="text-align: justify;">Clients of both Phia Unwrapped and our Balance Bill resolution services will be excited to hear that we have this quarter created brand new reports for both services.</p> <p class="bodytext" style="text-align: justify;">Both the Phia Unwrapped and Balance Billing Value Reports not only highlight performance for a particular group, or across a TPA’s entire block of business, but also compare those results to various benchmarks, to provide a feel for how those results hold up in a more objective manner. These new reporte provide the user with an easy-to-read summary of successes The Phia Group has achieved for groups it services, on a quarterly and yearly basis, both in relation to Phia Unwrapped and Balance Bill resolution services. What’s more, it will be automatically provided on a regular basis, but it can also be run on-demand by contacting The Phia Group’s Customer Success Team.</p> <p class="bodytext" style="text-align: justify;">These new reporte highlight the value added by Phia Unwrapped, and conflicts resolved through Balance Bill resolution, both in an information-packed, but comprehensible, PDF. They are designed to not only be informational, but also an important client-retention and marketing tool for TPAs and brokers. Since these reports will be accurate as of the minute they were run, our clients can rest easy knowing that they will always be able to have accurate information at their disposal, whether it’s to provide progress reports to groups, to make tough payment decisions using past data for reference, to include within a renewal proposal, or simply out of curiosity.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/Sample%20Report%20Unwrapped.png?ver=hFpXypIE8NIvMfbeToe_0Q%3d%3d" style="width: 401px; height: 496px;" /></p> <p class="bodytext"> </p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/Sample%20Report%20%20BB.png?ver=96K3PI4LDPwA8IwWRsr25w%3d%3d" style="width: 404px; height: 504px;" /></p> <p class="bodytext"> </p> <p class="bodytext" style="text-align: justify;">The Phia Group is constantly seeking new ways to improve health plans’ self-funding experience; as always, we are Empowering Plans.</p> <p class="bodytext" style="text-align: justify;">To learn more about Phia Unwrapped, Balance-Billing services, or any other services The Phia Group offers, please contact our Sales Manager, Garrick Hunt, at 781-535-5644 or <a href="mailto:GHunt@phiagroup.com" target="_blank">GHunt@phiagroup.com</a>.</p> <hr class="horiz" />_ <p> </p> <a name="pdef"></a> <p class="bodytext"><strong>Service Focus of the Quarter: Patient Defender</strong></p> <p class="bodytext" style="text-align: justify;">Anyone reading this who personally uses RBP, has a client that uses RBP, or has even thought about using RBP is familiar with the concept of balance-billing. RBP is a great tool for plans to use to contain costs, and has proven monumentally successful for some groups – but the threat of balance-billing and collections still exists from some stubborn providers, no matter how effective the patient advocacy may be.</p> <p class="bodytext" style="text-align: justify;">In response to the needs of the self-funded industry’s ever-growing RBP market, The Phia Group has created Patient Defender: a true legal tool to combat the balance-billing problem. Through Patient Defender, for a nominal fee, patients have access to an attorney to represent them if they are sued or sent to collections – and even if they choose to proactively litigate against a medical provider! Gone are the days when a TPA or employer has to tell a patient that the patient can litigate, but must pay his or her own attorney’s fees. Groups that the Patient Defender have pre-paid the attorney’s fee for the patient, removing the most substantial barrier to a patient’s legal defense.</p> <p class="bodytext" style="text-align: justify;">This innovative tool is primarily designed for an RBP plan to supplement its existing patient advocacy program and further protect its members from balance-billing and collections, but it can be an add-on to any plan that pays any claims at any non-contracted rates (since it’s certainly not just RBP plans that may face balance-billing).</p> <p class="bodytext" style="text-align: justify;">For more information about this unique service offering, contact our Sales Manager, Garrick Hunt, at 781-535-5644 or <a href="mailto:GHunt@phiagroup.com" target="_blank">GHunt@phiagroup.com</a>.</p> <p> </p> <p class="bodytext"><strong>Success Story of the Quarter: Negotiating COVID-19 Test Claims</strong></p> <p class="bodytext" style="text-align: justify;">As you may know, and as you and your clients may have discovered, there is some recent federal legislation concerning payment rates for COVID-19 testing. In a nutshell, medical providers offering COVID-19 tests must post the price they charge for the test on their website, and health plans must pay those rates, absent a negotiated rate with the provider.</p> <p class="bodytext" style="text-align: justify;">The legislation has been broadly read to imply that to be applicable, a negotiated rate must be in place prior to the test being performed. We see no evidence of that, though; we have been staunch proponents of the idea that the posting of the price does not preclude negotiation of that price following treatment. If the provider refuses to negotiate, we will counsel a client not to ignore the federal regulations – but we also believe this negotiation effort is in compliance with the law.</p> <p class="bodytext" style="text-align: justify;">We have had occasion to approach a few providers in an attempt to settle, but the general response from providers has been to hold firm, under the theory of: “Why the heck would we lower this price that the law says you have to pay?!” A TPA client of ours informed us that they have a group benefit plan client that has incurred claims for a very large number of COVID-19 tests, with substantially all of them coming from the same provider. The TPA asked us if we could negotiate a better rate than the posted rate.</p> <p class="bodytext" style="text-align: justify;">We’ll skip to the interesting part: this plan was willing to steer all of its patients to another provider if this provider didn’t agree to negotiate a better rate. Despite having the knowledge that the plan did have a legal obligation to pay the full bill, these other factors and our approach led to the provider ultimately being willing to negotiate a better rate for both the tests already incurred as well as future tests.</p> <p class="bodytext" style="text-align: justify;">We knew it was possible – but seeing it happen felt good!</p>   <p class="bodytext"><strong>Phia Case Study: Unwrapping Without Unwrapped – Our Claim Negotiation & Signoff Service</strong></p> <p class="bodytext" style="text-align: justify;">A client of The Phia Group’s case-by-case negotiation service (Claim Negotiation & Signoff, or CNS) presented us with a very large hospital claim, and requested that we negotiate it. One of our experts approached the hospital to open a dialogue, but was immediately shut down with a stern note indicating the hospital’s unwavering refusal to negotiate.</p> <p class="bodytext" style="text-align: justify;">Of course, our team was not about to give up, but it was cause to strategize. It seemed clear that throwing numbers at this hospital – even supported by data such as Medicare equivalents, cost-to-charge ratios, average commercial reimbursement, and more – was not going to get us anywhere. We tried to negotiate in good faith, but the hospital refused to entertain an offer.</p> <p class="bodytext" style="text-align: justify;">Ultimately, our client wanted this to go away fairly quickly, so the Plan paid its minimum benefits and attempted a method called “accord and satisfaction,” where an additional conditional payment was made, the condition being that the hospital close its file. The theory is that negotiating in theoretical numbers is one thing, but having an actual, physical check for additional payment can yield better results. Alas, the provider rejected that conditional payment, and sent the check back.</p> <p class="bodytext" style="text-align: justify;">After a series of conversations with the group, its broker, the TPA, the stop-loss carrier, and Phia, it was decided that Phia would attempt to enforce the plan’s initial payment (pursuant to the Plan Document), and the plan would essentially walk away for now, and deal with balance-billing if it happened.</p> <p class="bodytext" style="text-align: justify;">So, we waited. And waited. And we’re still waiting. There has been no balance-billing; just angry letters from the hospital demanding that the plan pay more, but no mention of threats to balance-bill the member nor a formal appeal. That isn’t uncommon; a show of strength from a health plan can go a long way to show a provider that the plan means business. Many providers are loathe to balance-bill their patients, and the only way to find out is to test those waters. If the hospital does decide to balance-bill the patient, we’ll sic our experienced balance-billing team on it – but things are looking good for the time being.</p> <p class="bodytext" style="text-align: justify;">Now just imagine this strategy being applied to all out-of-network claims (via Phia Unwrapped), whereby a plan pays its minimum benefits, stands firm, and combats balance-billing on the back-end, as such issues arise.</p> <p class="bodytext"> </p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Determining Which Services Can Be Covered</strong></p> <p class="bodytext" style="text-align: justify;">This following decision about which we will now discuss, is not traditionally thought of as invoking a fiduciary duty, and that thought is generally accurate in most contexts. In the midst of a pandemic, however, some health plans have been delving more deeply into the question of what services they may cover. In general, ERISA and the IRS rules permit health plans to cover any medical services, and for the vast majority of services, there is no question whether or not they fall into that category. But what about things like art therapy? As some individuals seek to transition from more “traditional” medical care to alternatives, perhaps not in a traditional hospital or physician office setting, questions are arising, most relevantly whether the IRS rules even allow a health plan to cover these types of services.</p> <p class="bodytext" style="text-align: justify;">In general, the IRS has made certain rules regarding which services can be covered by a health plan; and those are, broadly, services that constitute medical care. That term is defined in terms of services designed for “the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.”</p> <p class="bodytext" style="text-align: justify;">The decision of whether or not a particular service complies with that definition (and therefore the tax rules) is left to the Plan Sponsor. The regulators generally require that Plan Sponsors use a good faith, reasonable interpretation of the relevant rules and guidance, in order to best comply when it might not be 100% clear – so unfortunately, plans (usually via the TPA) will need to scrutinize these services and determine, on a case-by-case basis, whether something like art therapy was truly medical in nature.</p> <p class="bodytext" style="text-align: justify;">What little guidance we’ve gotten from the IRS on this topic suggests that it is not necessarily the case that including things such as art therapy as line items within a Plan Document are necessarily dispositive of whether or not the plan is complying with tax rules in any given case; for instance, Mary may have a legitimate need for art therapy as a form of medical care, whereas Michael may be a rambunctious child whose parents send him to a two-week insurance-funded art therapy retreat in lieu of expensive summer camp. For Mary, the art therapy was medical care, and therefore the IRS rules permit the plan to cover it – but for Michael, the IRS rules would not permit it.</p> <p class="bodytext" style="text-align: justify;">The moral of this strange story is that a health plan may only cover medical care, and the plan will need to be careful if it lists any non-traditional treatment in the SPD. There is nothing inherently noncompliant about simply listing that care – but benefits should only be actually paid by the health plan if the care truly meets the definition of “medical care.”<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 September 22, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/benefits-on-the-ballot-a-political-update-for-health-benefits-professionals" target="_blank">Benefits on the Ballot – A Political Update for Health Benefits Professionals</a>,” where we discussed the most important elections (including candidates’ positions on health), ongoing legal cases, and proposed laws.<br /> <br /> • On August 17, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/conflicts-abound-providers-facilities-fight-back" target="_blank">Conflicts Abound – Providers & Facilities Fight Back</a>,” where we discussed new aggressive tactics used by providers and facilities, as well as the conflicts they are causing with networks and stop-loss.<br /> <br /> • On July 15, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/the-underlying-regulatory-landscape-dont-get-lost-in-the-new-normal" target="_blank">The Underlying Regulatory Landscape - Don’t Get Lost in the New Normal</a>,” where we discussed statutes, regulations, and case law that have been and continue to be considered, debated, and finalized; resulting in serious, lasting effects.</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> <p><br /> <br />  </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 24, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p91-the-pandemic-the-employer-mandate" target="_blank">The Pandemic & The Employer Mandate</a>,” where our hosts, Kelly Dempsey and Brady Bizarro, discuss a particularly damaging impact of the pandemic that does not get much media attention: with many businesses forced to operate at reduced capacity, they still have to comply with the ACA's employer mandate.<br /> <br /> • On September 15, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p90-irs-notice-2020-29-covid-19-and-cafeteria-plans-self-funded-plans-beware" target="_blank">IRS Notice 2020-29, COVID-19 and Cafeteria Plans: Self-Funded Plans Beware!</a>,” where our hosts, Jennifer McCormick and Philip Qualo, discuss how the COVID-19 pandemic has brought about an unprecedented wave of federal legislation in a short period of time specifically aimed at regulating employer-sponsored group health plan coverage.<br /> <br /> • On September 2, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p89-healthcare-policy-at-the-dncrnc" target="_blank">Healthcare Policy at the DNC/RNC</a>,” where our hosts, Ron Peck and Brady Bizarro, assess what we learned from the candidates on healthcare policy at the virtual Democratic and Republican national conventions..<br /> <br /> • On August 3, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p88-scotus-hhs-icymi" target="_blank">SCOTUS & HHS – ICYMI</a>,” where our hosts, Jennifer McCormick and Nick Bonds, discuss significant developments in nondiscrimination regulations, and the implications for those in the self-funding industry.<br /> <br /> • On July 23, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p87-covid-19s-catch-22" target="_blank">COVID-19’s Catch-22</a>,” where our hosts, Ron and Brady, discuss a Catch-22 emerging in the midst of the global pandemic - as more government intervention is needed to deal with COVID-19, calls for a public option and Medicare for All grow louder.</p> <p class="bodytext" style="text-align: justify;">• On July 17, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p86-covid-floyd-and-the-fight-for-social-justice" target="_blank">COVID, Floyd, and the Fight for Social Justice</a>,” where our hosts, Ron Peck and Brady Bizarro, address recent events that have altered the world as we knew it in a matter of months, and in one notable case, in one day.</p> <p class="bodytext" style="text-align: justify;">• On July 10, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p85-catching-up-with-the-courts" target="_blank">Catching up with the Courts</a>,” where our hosts, Ron Peck and Brady Bizarro, jump into a discussion about recent high-profile court cases that could shape our industry: from requiring hospitals to post their negotiated rates with insurers online to the Trump administration's latest action in the Supreme Court case that could spell the end of the entire Affordable Care Act.</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"> </p> <p class="bodytext"><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;">• BenefitsPro – <a href="https://www.benefitspro.com/2020/09/24/president-trumps-latest-eo-on-drug-prices-whats-changing/" target="_blank">https://www.benefitspro.com/2020/09/24/president-trumps-latest-eo-on-drug-prices-whats-changing/</a> – September 24, 2020</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Rise_and_Shine_by_Ron_E__Peck.pdf" target="_blank">RISE AND SHINE: Employment-Based Health Benefits In A Post-COVID Future</a> – September 3, 2020</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2020/09/01/how-cobra-premium-subsidies-can-protect-employer-sponsored-coverage/" target="_blank">How COBRA premium subsidies can protect employer-sponsored coverage</a> – September 1, 2020</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Subrogation-_The_oldest_and_most_effective_form_of_cost_containment_by_Maribel_Echeverry_McLaughlin%2C_Esq.pdf" target="_blank">SUBROGATION: The oldest and most effective form of cost containment</a> – August 6, 2020</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2020/07/24/considerations-for-group-health-plans-in-2021/" target="_blank">Considerations for group health plans in 2021</a> – July 24, 2020</p> <p class="bodytext" style="text-align: justify;">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/COVID-19%2C_Balance_Billing%2C_Out-of-Network_Claims%2C_and_Confusing_Charges_-_An_Ugly_Combination_by_John_Jablon_Esq__and_Tim_Callender_Esq.pdf" target="_blank">COVID-19, Balance Billing, Out-Of-Network Claims, and Confusing Charges - An Ugly Combination</a> – July 7, 2020</p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2020/07/02/workers-comp-recovery-in-a-covid-19-world-it-depends/" target="_blank">Worker’s comp recovery in a COVID-19 world? It depends!</a> – July 2, 2020</p> <p class="bodytext"><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/plan-mirroring-what-does-it-really-mean" target="_blank">Plan Mirroring: What Does It Really Mean?</a> Is your stop-loss carrier mirroring your SPD Language?</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/returning-to-work-safely-and-smartly-who-bears-the-cost" target="_blank">Returning to Work Safely and Smartly. Who Bears the Cost?</a> How is it possible to keep everyone in your office safe?</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/new-rules-on-prescription-drug-importation-are-released-or-are-they" target="_blank">New Rules on Prescription Drug Importation Are Released – Or Are They?</a> At first glance, the order seems to take sweeping steps to facilitate the importation of prescription drugs, but does any of it really represent a departure from existing law?</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/a-brief-anecdote-on-testing-for-covid-19" target="_blank">A Brief Anecdote on Testing for COVID-19</a>. Find out where you can get tested for COVID-19.</p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/simple-negotiations-made-not-so-simple" target="_blank">Simple Negotiations Made Not-So-Simple.</a> Even something as simple as a plain old claim negotiation can still develop certain unexpected hiccups.</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"> </p> <p class="bodytext"><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>RISE AND SHINE: Employment-Based Health Benefits In A Post-COVID Future</strong><br />  </p> <p class="bodytext" style="text-align: justify;">By: Ron E. Peck, Esq. – September 2020 – <a href="https://www.sipconline.net/files/Rise_and_Shine_by_Ron_E__Peck.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="text-align: justify;">One would reasonably assume that, when discussing a pandemic and health care, the natural direction in which we would head next would be a discussion regarding the health impact – present and future – of COVID-19. The treatment options, the cost of said treatment, as well as short-term and long-term impact of the disease on patients. Yet, here I will not attempt to dissect the clinical issues presented by coronavirus, and the immediate, direct impact it will have on our health benefit plans, and self-funded plan sponsors. Instead, I will be discussing a threat to our industry not called COVID-19, but rather, a growing sociopolitical threat that has emerged in response to a larger economic victim of the virus.</p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2020" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext" style="text-align: justify;"><strong>SUBROGATION: The oldest and most effective form of cost containment</strong></p> <p class="bodytext" style="text-align: justify;">By: Maribel Echeverry McLaughlin, Esq. – August 2020 – <a href="https://www.sipconline.net/files/Subrogation-_The_oldest_and_most_effective_form_of_cost_containment_by_Maribel_Echeverry_McLaughlin%2C_Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="text-align: justify;">For many health plans, the first interaction with any type of cost containment method usually comes about when they begin to utilize subrogation as a way to keep plan costs low, and recover monies owed to them by third parties. It is one of the original, yet consistently effective, cost containment concepts that, as of recently, tends to get overlooked when discussing new and more innovative ways to enhance plan savings.</p> <p class="bodytext" style="text-align: justify;">The history of subrogation can be traced back to as far as the origins of the Court of Chancery in the Elizabethan period. The English Court of Chancery had jurisdiction over all matters in equity, such as trusts, land disputes, the estates of lunatics and guardianship of infants. In this period, subrogation was a common equitable remedy, where one party was permitted to assume a third party’s legal right to collect a debt.</p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2020" target="_blank">Click here to read the rest of this article</a><br />  </p> <p class="bodytext" style="text-align: justify;"><strong>COVID-19, Balance Billing, Out-Of-Network Claims, and Confusing Charges - An Ugly Combination</strong></p> <p class="bodytext" style="text-align: justify;">By: Jon Jablon Esq., and Tim Callender Esq. – July 2020 – <a href="https://www.sipconline.net/files/COVID-19%2C_Balance_Billing%2C_Out-of-Network_Claims%2C_and_Confusing_Charges_-_An_Ugly_Combination_by_John_Jablon_Esq__and_Tim_Callender_Esq.pdf" target="_blank">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="text-align: justify;">The COVID-19 crisis has sparked a discussion on an old, but repeatedly important and troublesome issue: balance billing and/or overbilling. During the early days of the COVID-19 crisis, news outlets were quick to report examples of health insurance coverage confusion, network issues, and billing issues, all related to a variety of COVID-19 claims.</p> <p class="bodytext" style="text-align: justify;">In April, the federal government chose to tackle this concern by placing prohibitions on how providers could bill COVID-19 patients who received services from providers receiving funds under the Public Health and Social Services Emergency Relief Fund. This attempt to control balance billing and excessive charging practices led to media confusion, with numerous media outlets reporting that the federal government had banned all balance billing and/or all surprise billing, which was not the case.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-4th-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext"> </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 2020 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 2020 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 style="text-align: justify;"><span class="bodytext"><strong>Learning Pods Program </strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South’s Brockton Clubhouse has created a Learning Pods Program designed to support K-8 Students as they adapt to distance learning. This full-day program hosted by The Boys & Girls Club of Metro South was designed to help students and their parents get back into the swing of things, given the change in how students are learning. As you know, The Phia Group is dedicated to ensuring children in the Boys & Girls Club of Metro South are always prepared for their school year. When we heard that they were in need of school supplies for 100 students, we jumped to the opportunity to help. We have compiled a list, loaded up the Amazon cart, and placed our order. The money that we used to purchase these suppliles comes from donations made by the Phia Family and we are proud to announce that we have raised the $2,500 needed to purchase all of the school supplies. We hope all of the children have an amazing school year and can’t wait to hear all about the progress being made with the Learning Pods Program!</p> <p class="bodytext" style="font-weight: normal"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/Learning%20Pods.jpg?ver=i3tZsppox0RXtAMquJVzjg%3d%3d" style="width: 279px; height: 312px;" /></p> <p><span class="bodytext"><strong>The Phia Group’s Diverse Library Exchange</strong></span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group and the Diversity Inclusion Committee are excited to announce the opening of Phia’s Diversity Exchange Library. Inspired by a recent article that featured Adam’s friends and family, the Phia Diversity Exchange Library is a designated space where employees can loan as well as pick up books that are written by authors, or feature characters, from diverse backgrounds.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Library includes both adult and children books with the goal of facilitating cross-cultural book sharing and dialogue so that employees, and their families, can learn more about other cultures and diverse communities. It is through knowledge and education that we can become more aware of our own place in this world and learn how to respect and embrace others from different backgrounds.</p> <p class="bodytext" style="font-weight: normal"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/Diverse%20Library.jpg?ver=96K3PI4LDPwA8IwWRsr25w%3d%3d" style="width: 434px; height: 292px;" /></p> <p class="bodytext" style="font-weight: normal"><br /> <a href="#top">Back to top ^</a></p> <p class="heading1"> </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Get to Know Our Employee of the Quarter:<br /> Aditya Sukumar </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 Aditya Sukumar, The Phia Group’s Q3 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;">Adi has been a valuable asset to the PDM and PMO teams. He dedication and commitment to client success is commendable. He has demonstrated his expertise in PDM and good communication skills during client demo’s and meetings. His goal oriented approach with focus on client success is very valued, especially his ability to carefully review and resolve client issues with a quick turnaround. He’s a wonderful team player, and doesn’t hesitate to take time out of his schedule to step in and help others when needed. He is truly a great asset to Phia.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q4 2020/aditya.jpg?ver=96K3PI4LDPwA8IwWRsr25w%3d%3d" style="width: 273px; height: 422px;" /></p> <p class="bodytext">Congratulations Aditya, 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><strong>Job Opportunities:</strong></p> <p class="bodytext">• Customer Care Representative</p> <p class="bodytext">• Accounting Administrator</p> <p class="bodytext">• Chief Financial Officer</p> <p class="bodytext">• Claim Analyst</p> <p class="bodytext">• Claim and Case Support Analyst</p> <p class="bodytext">• Case Investigator</p> <p class="bodytext">• Health Benefit Plan Administration Attorney</p> <p class="bodytext">• ETL Specialist</p> <p class="bodytext">• Executive 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">• Sabrina Centeio has been promoted from Claim Recovery Specialist IV to Sr. Claim Recovery Specialist</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• Dennis Ferzoko was hired as a Claim and Case Support Analyst</p> <p class="bodytext">• Kaitlyn Furtado was hired as a Case Investigator</p> <p class="bodytext">• Trina Garcia was hired as a PACE Specialist</p> <p class="bodytext">• Jenny Armstrong was hired as a Sr. Subro Atty</p> <p class="bodytext">• Brad Lee was hired as an IT Developer</p> <p class="bodytext">• Emily King was hired as a Customer Service Rep</p> <p class="bodytext">• Jillian Stone was hired as a Claim & Case Support Analyst</p> <p class="bodytext">• Andrea Goodman was hired as a Plan Drafter</p> <p class="bodytext">• Sneh Gaonshindhe was hired as a Sr. Software Engineer</p> <p class="bodytext">• Adam Doherty was hired as a Claim & Case Support Analyst</p> <p class="bodytext">• Anna Lopes was hired as a Claim & Case Support Analyst</p> <p class="bodytext">• Bradley Bedarian was hired as a Case Investigator</p> <p class="bodytext">• John Pagnotta was hired as a Case Investigator</p> <p class="bodytext">• Soumya Gampa was hired as a Sr. Software Engineer</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"></span></p> <p class="bodytext"><span class="heading1">Phia News:</span></p> <span class="boldtext">The Phia Group Reaffirms Commitment to Diversity & Inclusion </span> <p style="text-align: justify;">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 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 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 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> <ul class="bodytext" style="text-align: justify;"> </ul> <p class="bodytext" style="text-align: justify;"><strong>Welcome to Phia's New Home!</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group has officially moved! We are proud to announce that after 20 years in business, we have officially moved into an office that we have worked extremely hard for. Our growing staff needed more room and we wanted to make sure they felt right at home when they came to work. Check out our new office!</p> <p class="bodytext"><img alt="" height="354" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/newoffice.jpg?ver=4Z7GnXngh6hOa6iKdxAOgw%3d%3d" width="661" /><br /> <br /> <strong>Welcome to Phia’s New Home in Louisville, KY!</strong><br /> <br /> The Phia Group has officially outgrown its Kentucky office after less than one year of opening, and will in Septemeber be moving to a bigger, better location. Since operations began in Kentucky, we have hired over 20 individuals from the Louisville area. We are amazed by the rapid growth of The Phia Group’s sister office and can’t wait to add more Louisville locals to the Phia family!</p> <p class="bodytext"><img alt="" height="354" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/ky%20Office.jpg?ver=4Z7GnXngh6hOa6iKdxAOgw%3d%3d" width="659" /></p> <p class="bodytext"><strong>Welcome to Phia’s New Home in Louisville, KY!</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group has officially outgrown its Kentucky office after less than one year of opening, and will in Septemeber be moving to a bigger, better location. Since operations began in Kentucky, we have hired over 20 individuals from the Louisville area. We are amazed by the rapid growth of The Phia Group’s sister office and can’t wait to add more Louisville locals to the Phia family!</p> <p class="bodytext"><strong>Customer Success Team</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to announce the restructuring of it’s Customer Success Team. As many of you may know from experiences within your own organizations, every sector is experiencing a fundamental shift in customer expectations. It no longer is enough to just be the industry leader in results, one must be the industry leader in customer relations as well. Our Customer Success Team (“CST”) is lead by Rebekah McGuire-Dye. Mrs. McGuire-Dye has over 25 years of experience working in cost containment. Her experience lends her to be an exceptional advocate for The Phia Group’s clients. Mrs. McGuire-Dye will lead her team in providing not just reactive responses to our clients, but in a pro-active approach to ensure every client of The Phia Group is maximizing the value of our many services while always looking for new and innovative products to help our clients grow and lead in their respective areas.<br /> <br /> Here are a few items with which the CST can assist you with:<br /> <br /> • Identify concerns regarding any and all Phia Group services or results, confirm the absence of an issue or resolve the matter, and ensure customer satisfaction with the explanation or revision;<br /> <br /> • Identify any delays or roadblocks to remove them and ensure optimal performance;<br /> <br /> • Deliver all reports and resolve any issues associated with them;<br /> <br /> • Fully analyze, utilize, and interpret Value Reports and other reporting tools to identify both issues and opportunities;<br /> <br /> • Respond to routine file specific client questions (e.g., status on file #12345); and,<br /> <br /> • Provide subject matter expert (“SME”) assistance as needed.<br /> <br /> Although our CST team continues to grow, it is already one of the best staffed and most professional departments at The Phia Group. We encourage all clients to reach out directly if they have any questions at <a href="mailto:CustomerSuccessTeam@phiagroup.com" target="_blank">CustomerSuccessTeam@phiagroup.com</a>.</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> 1011The Stacks - 4th Quarter 2020https://www.phiagroup.com/Media/Posts/PostId/1010/the-phia-groups-4th-quarter-2020-newsletterNewslettersWed, 21 Oct 2020 17:48:41 GMT<p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:20px;"><span style="color:#0071ce;"><span style="line-height:115%"><span calibri="" style="font-family:"><b><span style="line-height:115%">Rise and Shine: Employment-Based Health Benefits in a Post-COVID Future</span></b></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;"><span calibri="" style="line-height: 115%; font-family: ">By: Ron E. Peck, Esq. </span></span></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;"></span></p> <p style="text-align: justify;">It is a summer day in August.  The year is 2020.  I dropped my son off at daycare this morning.  I feel guilt, fear and anxiety over having done so.  That is not how I felt upon doing so in August of 2019.  What has changed?  We are busy enduring COVID-19; a pandemic the likes of which the United States has not seen in one hundred years.<br /> <br /> COVID-19 has caused a ripple effect, felt by almost every facet of our modern society.  From retail and food services, to ride sharing and travel.  Tourism, education, and of course – health care.<br /> <br /> One would reasonably assume that, when discussing a pandemic and health care, the natural direction in which we would head next would be a discussion regarding the health impact – present and future – of COVID-19.  The treatment options, the cost of said treatment, as well as short-term and long-term impact of the disease on patients.  Yet, here I will not attempt to dissect the clinical issues presented by coronavirus, and the immediate, direct impact it will have on our health benefit plans, and self-funded plan sponsors.  Instead, I will be discussing a threat to our industry not called COVID-19, but rather, a growing sociopolitical threat that has emerged in response to a larger economic victim of the virus.<br /> <br /> As retail and restaurants have closed shop – for many, permanently; as businesses have had to suddenly adjust to a “work-from-home” environment – for many, without success; as an economy that was thriving has suddenly been thrust into a recession – so suddenly you would be forgiven for thinking you have whiplash … Employers, and thus employees, have been victims of a pandemic economy. <br /> <br /> People have been furloughed or laid off in record numbers.  Visit any nation, anywhere on the planet, and involuntarily losing one’s job is never deemed by the ex-employee to be a happy, welcome circumstance.  Universally, we work to provide for ourselves a sense of purpose, make a positive impact, and enjoy an income.  Thus, regardless of where you live, losing your job is usually not a cause for celebration.  In the United States, however, another reason for which people seek employment is to receive benefits.  Amongst those highly desired benefits, and perhaps primary amongst them, are health benefits.  Whether an employer pays premium to a carrier in exchange for traditional, “fully-funded” insurance… or… the employer sets aside contributions from itself and its employees, to “self-fund” its health plan… employees appreciate health benefits.  So much so, it only makes sense that employers realized they could craft, manage, and fund attractive health benefit plans, using them as an incentive – luring in job seekers and keeping existing employees.  Indeed, in a capitalistic economy like ours, employers are always hunting for the most effective ways to attract and keep the best talent.  In an economy that is functioning well, it only makes sense to allow employers to do so.<br /> <br /> What about an economy that is not functioning well?  If and when employers are not using health benefits to attract the best talent, because they cannot afford to pay for health benefits – let alone hire said talent in the first place… naturally, those people who were banking on employment as a source for benefits; people who only a few months prior were singing employment based benefits’ praises… will now question the wisdom of such an arrangement.  One study<sup>1</sup> suggests that more than five million Americans have lost their health benefits due to being laid off, as a result of COVID-19.<br /> <br /> Add this to a society that – at least in part – is already contemplating a “Medicare-for-All” option, and we have a perfect storm.  <br /> One person wrote, “Corporate America fights single payer universal health care afraid to lose power over workers. Insurance companies fight single-payer universal health care because they make money not providing health care. If small business didn’t have to pay for medical, they could raise wages, modernize, expand their businesses and grow our economy. Workers could leave toxic and unsafe working environments or raise their voices when feeling abused without fear of losing their benefits<sup>2</sup>” and they aren’t alone.  There exists a perception that employment-based health plans offer no benefit whatsoever over Medicare, and that – therefore – there is no reason to maintain it.<br /> <br /> Whenever we, as human beings, make a decision – we perform a cost/benefit analysis.  When I wake up in the morning, and decide to brush my teeth, I perform a cost/benefit analysis.  I weigh the time it takes to brush against the bad breath and tooth decay I’ll suffer if I fail to brush.  If and when we have an interest in another’s cost/benefit analysis, it behooves us to explain to them the benefits and costs involved in that decision.  Consider the following example…<br /> <br /> When my previous automobile hit 100,000 miles, I began contemplating my next automotive purchase.  I am constantly being exposed to manufacturer’s marketing – lauding their cars’ qualities.  Thus, when I was shopping around, I was more than armed with the costs and benefits of each option.<br /> <br /> Consider the average American voter.  Can you confidently say they are aware of the benefits of employment-based health plans?  I doubt it!  Can you confidently say they are aware of the costs of an alternative?  I doubt it!<br /> <br /> The bottom line is this – most people believe that providers of health care services charge one amount to all payers.  They believe that different health care providers in the same area charge about the same amount for the same services.  They believe that health insurance – whether it is fully-insured, self-funded, Medicare, or Medicaid – pays the bill in full, and if there is a discount, those savings are for the benefit of the payer, not the patient.  They believe there is no difference between a private plan and Medicare, aside from the means by which they pay for coverage – premiums or taxes.<br /> <br /> Rather than continuously allow our industry to be bashed by the media, to be misunderstood by the public, and thus fall short when forced to endure a cost/benefit analysis against Medicare-for-All … all with a backdrop of a pandemic economy … it behooves us to educate the public regarding the benefits of employment based health plans.<br /> <br /> Looking at my own employer, and our self-funded health plan; if Medicare-for-All or some other public option were made available at a lower cost to me than my current plan, I would not make the switch.  Why?  The answer, simply put, is that I understand the benefits of our plan.  I recognize that it is customized to match the needs of a population most like me in needs and wants.  I recognize that the costs I pay up front are used to enhance benefits I may need later.  I recognize that individuals who passionately care about my wellbeing are monitoring my plan and ONLY my plan, to ensure it functions well.<br /> <br /> COVID-19 and the unemployment it has triggered armed our adversaries with ammunition.  They point at the state of things and argue that health benefits are a human right – and as such – they cannot be tied to something as fickle as employment.  Yet, they fail to address that, whether through premiums or taxes, someone needs to pay for health care.  Should we all be covered by Medicare, those unemployed individuals will be called upon to pay their share, via taxes, using funds they don’t have.  As such, passing the buck is not a solution either.  The burden is on us to offer a better solution, and to suggest policies meant to contain the cost of the care itself. <br /> <br /> Above all else, our job is to remind people of the benefits of private health plans – benefits that Medicare can’t match.  We need to change the dialogue – shifting the focus away from unemployment as an excuse to abolish health plans, and instead shift the focus onto reducing the cost of care regardless of who is paying.</p> <p><sup>1</sup>  https://www.familiesusa.org/resources/the-covid-19-pandemic-and-resulting-economic-crash-have-caused-the-greatest-health-insurance-losses-in-american-history/<br /> <sup>2</sup>  https://www.concordmonitor.com/End-employer-based-health-care-35555925</p> <p> </p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="text-align: justify;"><span style="color:#0071ce;"><span style="font-size:20px;"><b><span style="line-height:115%"><span calibri="" style="font-family:">Subrogation: The Oldest and Most Effective Form of Cost Containment</span></span></b></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;">Maribel Echeverry McLaughlin, Esq. </span></strong></span></p> <p style="text-align: justify;">For many health plans, the first interaction with any type of cost containment method usually comes about when they begin to utilize subrogation as a way to keep plan costs low, and recover monies owed to them by third parties. It is one of the original, yet consistently effective, cost con-tainment concepts that, as of recently, tends to get overlooked when discussing new and more innovative ways to enhance plan savings.</p> <p style="text-align: justify;">The history of subrogation can be traced back to as far as the origins of the Court of Chancery in the Elizabethan period. The English Court of Chancery had jurisdiction over all matters in equity, such as trusts, land disputes, the estates of lunatics and guardianship of infants.  In this period, subrogation was a common equitable remedy, where one party was permitted to assume a third party’s legal right to collect a debt.  </p> <p style="text-align: justify;">In the present day, when plans pay for claims that are owed to them by third parties, they naturally expect to be reimbursed for those costs. However, during the Covid-19 crisis, many states were locked down, and people were forced to stay home; which meant less car accidents, less elective treatments due to statewide bans, and thus less money paid out by plans for medical claims.</p> <p style="text-align: justify;">According to information released by UC Davis, traffic accidents and crash-related injuries and deaths decreased by 50% during the first three weeks of California’s shelter-in-place order. The order began on March 20 and the university estimates that the decrease saved the state about $40 million each day. In other words, the state saved $1 billion in three weeks by having to respond to fewer car accidents.  The department found that the state’s reduction in accidents was paired with up to a 55% reduction in traffic and a 40-50% decrease in serious injuries for drivers, pedestrians, and cyclists.<sup>1</sup></p> <p style="text-align: justify;">While motor vehicle accidents have been less frequent, ironically the drivers that are on the road daily, have become increasingly more reckless. According to the National Safety Council’s President and CEO, Lorraine M. Martin, “disturbingly, we have open lanes of traffic and an apparent open season on reckless driving,” causing more fatal accidents in many states.* Fatalities caused by car accidents increased in Massachusetts and Minnesota<sup>2</sup>, with the latter seeing deadly accidents more than double typical rates. Other states like Nevada and Rhode Island experienced an increase in pedestrian accidents.<sup>3</sup></p> <p style="text-align: justify;">You would think that during a pandemic, plan spending would increase as the injuries in motor vehicle accidents get worse and the cost of a hospital admission for patients with COVID-19, the dis-ease caused by coronavirus, can top tens of thousands of dollars. Especially as there were over a hundred thousand hospitalizations just in the early months of the pandemic. Eventually, we can expect new additional costs to plans when an effective pharmaceutical treatment is identified, or hopefully a vaccine becomes widely available. However, social distancing measures, concerns over hospital capacity, and fears of contracting the virus are leading to other critical healthcare services being delayed or forgone.  For example, providers have delayed elective surgeries during the pandemic, thus having a downward effect on health costs, at least in the short term.<sup>4</sup>  Taken together, this data shows that there has been an abrupt and sizable decrease in healthcare utilization, at least in the early months of the pandemic. The exception has been telehealth, which has experienced an increase; however, the increase so far in telehealth was not enough to offset the decrease in in-person office visits. 4 In the first quarter of 2020 (January through March), spending on health services was relatively flat overall. Across all health care services, which excludes prescription drugs and social services, spending was down about -0.4% relative to the first quarter of 2019. Spending was up on nursing homes (5.9%), physician offices (3.9%), outpatient care centers (1.1%), but spending on medical labs (-2.7%) and hospitals (-4.1%) was down in the first quarter of 2020 com-pared to last year.<sup>4</sup> Federal spending data from the BEA are reported monthly on an annualized basis. If sustained for a year, the drop in personal consumption expenditures on health care services seen in April would total roughly $1 trillion dollars over a 12-month period.<sup>4</sup></p> <p style="text-align: justify;">Property and casualty insurers are also reporting a 40 to 50% drop in claims volume for personal automobile claims and a 30 to 40% reduction for commercial claims due to the Covid-19 pandemic.<sup>5</sup>  It is too soon to say whether the drop in frequency will fully offset the rebates that many auto-mobile insurers have been extending to consumers, which the Information Insurance Institute estimates will amount to $10.5 billion.</p> <p style="text-align: justify;">With all this information, it is easy to conclude that health plans are also saving money in not paying for motor vehicle accident related claims. According to the National Highway Traffic Safety Administration (NHTSA), U.S. motor vehicle crashes in 2010 cost almost $1 trillion in loss of productivity and loss of life.<sup>6</sup> The Centers for Disease Control and Prevention (CDC) said in 2010 that the cost of medical care and productivity losses associated with motor vehicle crash injuries was over $99 billion, or nearly $500, for each licensed driver in the U.S.<sup>7</sup> In 2015, the CDC report-ed that the average cost for a treatment for motor vehicle accident was $2,314. Which means, if a health plan has 100,000 employees, and roughly one in 150 lives will be involved in one motor vehicle accident per year, then a plan has a potential exposure of 600 lives with accident-related claims that year. If 600 lives have an average of $2,314 in costs, a plan could have had an expense of approximately $1.3 million in costs that year.  It is easy to conclude then, if accidents approximately decreased by 50%, then the plan’s expenses may have also decreased by 50%, thus saving a plan approximately an excess of $690,000, this year, alone. The Phia Group boasts their recoveries for established clients total an average of $30 recovered per employee per year.<sup>8</sup> That could trans-late, for a 100,000-employee plan, into a $3,000,000 recovery on a good year.</p> <p style="text-align: justify;">It is apparent, by way of current events in this country, that this new normal will be here for quite some time.  It is probable that when social distancing rules become more relaxed, people will feel more comfortable going back to provider’s offices and having elective surgeries, thus increasing plan expenses. But until the virus is under control, and an effective treatment is found, we can only assume that we will continue in this pattern of uncertainty.  Plans more likely than not, will see less expenditures this year in claims paid for members. This will allow for next year’s premiums to stay low and provide exceptional benefits to members at a low cost.</p> <p style="text-align: justify;">A plan could determine that not paying claims is less lucrative than getting claims reimbursed back to them. But the only way a plan would get any claims reimbursed to them, would be if they paid the claims in the first place.  Even though subrogation tends to be the main form of cost containment for plans, it is safe to say that the best form of cost containment is to not have to pay those claims at all.</p> <p><sup>1</sup>  Fell, A., Kushman, R., Oskin, B., Perez, T., & Bankston, E. (2020, June 09). California COVID-19 Traffic Report Finds Silver Lining. Retrieved July 10, 2020, from https://www.ucdavis.edu/news/california-covid-19-traffic-report-finds-silver-lining<br /> <sup>2</sup>  Wilson, K., Aued, B., Hertz, D., & Cuba, J. (2020, April 10). COVID-19 Cuts Car Crashes - But What About Crash Rates? Retrieved July 10, 2020, from https://usa.streetsblog.org/2020/04/09/covid-19-cuts-car-crashes-but-what-about-crash-rates/<br /> <sup>3</sup>  Have Car Accidents Decreased During the COVID-19 Crisis? (n.d.). Retrieved July 10, 2020, from https://www.hhrlaw.com/blog/2020/may/have-car-accidents-decreased-during-the-covid-19/</p> <p><sup>4</sup>  Twitter, C. (2020, May 29). How have healthcare utilization and spending changed so far during the coronavirus pandemic? Retrieved July 10, 2020, from https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-utilization-and-spending-changed-so-far-during-the-coronavirus-pandemic/<br /> <sup>5</sup>  *, N. (2020, April 15). Auto Claims Decline 40 to 50% as Consumers Stay Home, Snapsheet Says. Retrieved July 10, 2020, from https://www.claimsjournal.com/news/national/2020/04/15/296565.htm<br /> <sup>6</sup>  Vi.chilukuri.ctr@dot.gov. (2020, July 06). National Highway Traffic Safety Administration. Retrieved July 10, 2020, from http://www.nhtsa.dot.gov/<br /> <sup>7</sup>  Centers for Disease Control and Prevention. (n.d.). Retrieved July 10, 2020, from http://www.cdc.gov/<br /> <sup>8</sup>  Services. (n.d.). Retrieved July 10, 2020, from https://www.phiagroup.com/Services/Save-Claims-Recovery-Subrogation-Services</p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="margin-bottom:.0001pt; margin:0in 0in 8pt"><span style="color:#0071ce;"><span style="font-size:20px;"><strong><span style="line-height:normal"><span calibri="" style="font-family:">COVID-19, Balance Billing, Out-of-Network Claims, and Confusing Charges – An Ugly Combination</span></span></strong></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;">By Jon Jablon, Esq., and Tim Callender, Esq. </span></strong></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"></span></span></span></p> <p style="text-align: justify;">The COVID-19 crisis has sparked a discussion on an old, but repeatedly important and troublesome issue: balance billing and/or overbilling. During the early days of the COVID-19 crisis, news outlets were quick to report examples of health insurance coverage confusion, network issues, and billing issues, all related to a variety of COVID-19 claims.  </p> <p style="text-align: justify;">In April, the federal government chose to tackle this concern by placing prohibitions on how providers could bill COVID-19 patients who received services from providers receiving funds under the Public Health and Social Services Emergency Relief Fund. This attempt to control balance billing and excessive charging practices led to media confusion, with numerous media outlets reporting that the federal government had banned all balance billing and/or all surprise billing, which was not the case. The confusion on this basic attempt to stymie out of control billing, during a health crisis, highlights to need to discuss, yet again, the ever-pressing problem of balance billing, cost, network controls, and why excessive balance billing continues to happen.     </p> <p style="text-align: justify;">Practically speaking, when a member receives a balance-bill, the employer itself, the sponsored health plan, and the payer all go into “panic mode,” which is understandable. It is no secret that hospital chargemasters are essentially arbitrary. Leaving aside the fact that many plans have engaged a patient advocacy solution to assist with balance-billing, many health plans, TPAs, brokers, and patients want to know: Who’s to blame, and why is balance-billing allowed to happen? What is really going on when a provider balance-bills a patient? What can be done to avoid it?</p> <p style="text-align: justify;"><strong>Who’s To Blame?</strong></p> <p style="text-align: justify;">It’s easy and intuitive to blame medical providers for overbilling. The bill has the hospital’s name on it, and the bill is designed to compensate the hospital for use of its operating room, staff, and other resources. But blaming the provider is like blaming a person for taking advantage of a large loophole. It’s a dog-eat-dog world out there, and most of us take advantage of loopholes. Nothing illegal, hopefully, but if something is within our legal rights and it saves or makes us money, most people can reasonably be expected to operate within the parameters of that advantageous loophole.  </p> <p style="text-align: justify;">Instead, perhaps we should scrutinize the legal / regulatory authority. For years there have been certain legislative proposals in the works, both on the federal and state levels, that would effectively limit provider billing to a more reasonable amount, or at the very least provide a system of checks and balances. As it stands, though, alarmingly few laws like this exist today, and those that do tend to favor providers far more than any fairness they offer to health plans or patients. The reason? Everyone is stuck in the past. The old system, where insurers have unlimitedly-deep pockets, is not at all the case with self-funding, yet that still seems to be the mentality that legislatures and medical providers are using. Until there is a meaningful legislative change to add some sort of limitation on, or even a reasonable formula that must be followed by, provider billing, there won’t be any change to the paradigm where any price goes.</p> <p style="text-align: justify;"><strong>What Is Really Going On?</strong></p> <p style="text-align: justify;">Over years of dealing with overbilling and the problems it creates, it has become clear to many in the industry that hospitals do not really expect to get paid their gross charges. Hospitals do not collect, nor do they intend to collect on balance-bills. It seems that the collections threats are scare tactics used to gain higher payments from health plans, as many plans will do whatever it takes to protect the patient. With some plans, that tactic works well; other plans call a hospital’s bluff.</p> <p style="text-align: justify;">Think of it this way: when I walk into my local bike shop and ask for a tune-up, they quote me $179. Does it actually cost them the full $179 to provide the service? Probably not. Could they charge less? Sure. But the market bears it, and, more importantly, there’s no law prohibiting the shop from charging that fee.</p> <p style="text-align: justify;">Many suggest comparisons to other markets are inappropriate, since there’s a third-party payor (i.e. insurance) involved – but that does not fundamentally change the dynamic except to remove the relevance of the “the market bears it” factor. The medical services industry is not a “free market” since in most cases, expecting patients to actually shop around is extremely unrealistic; without the market-bearing aspect, we are left with only the reasoning of “there is no law against it.” For payors, that is not a good enough justification for such inflated, arbitrary billing.</p> <p style="text-align: justify;"><strong>What Can Be Done About It?</strong></p> <p style="text-align: justify;">How about patient advocacy? With respect to plans that systematically allow non-network claims at any amount less than full billed charges, most have adopted some form of patient advocacy or defense, to attempt to minimize the noise and impact of balance-billing, protect patients, and still ultimately save money on claims. That is what reference-based pricing vendors typically aim to accomplish and most do a pretty good job.</p> <p style="text-align: justify;">But, no matter the vendor, there are still some providers who simply will not go away without a big fight. The prevailing reference-based pricing mentality seems to be that no network is the best network, and for some plans that works very well. It depends on the employee population, employer’s risk tolerance, geographical location, and provider population density (and potentially other factors), and a health plan’s friendly neighborhood RBP vendor or broker are in the best positions to advise on that aspect – but at the end of the day, small, regional networks have tended to be a key to successful reference-based pricing for many health plans.</p> <p style="text-align: justify;"><strong>Direct Contracts & Narrow Networks</strong></p> <p style="text-align: justify;">“Narrow networks” constitute a middle ground between a direct contract with a provider and a traditional PPO model; although some large national networks now offer certain “narrow network” options, a health plan or TPA can create a de facto narrow network by simply contracting with a small curated group of providers. By picking and choosing providers, the payor is able to limit the size of the network (making the steerage created more valuable to each individual provider) and ensure that providers make certain concessions in exchange for the increased steerage.</p> <p style="text-align: justify;">“Custom” narrow networks can exponentially increase steerage for the chosen providers, but keep in mind that to many providers, the decision of whether to contract, or what rate to offer, depends on the volume of steerage – and volume is measured in number of lives, not in percent of lives. In other words, a health plan that contracts with two local physicians will in theory give each provider 50% of its total steerage, which is a very attractive percentage – but when the hospital asks how many lives make up that 50%, if the answer is 25 lives, the conversation is going to become much more difficult. If, however, the answer is 2,500 lives, you may have another story. That is one reason that TPAs often negotiate direct contracts across an entire block of business – however, that may leave the hurdle of having all groups potentially opted-in to the contract, possibly without wanting to be.</p> <p style="text-align: justify;"><strong>What Does The Future Hold?</strong></p> <p style="text-align: justify;">A couple of years ago, we at The Phia Group conducted a survey. One of the questions was “How do you view reference-based pricing?” The results were as follows:</p> <ul> <li style="text-align: justify;">76% of responders said, “Catalyst for change (part of a greater solution that will be a long term answer).”</li> <li style="text-align: justify;">14% of responders said “Stop-gap (a band aid that won’t resolve excessive healthcare costs long term).”</li> <li style="text-align: justify;">6% of responders said “Harmful (once enough people get balance billed, we’ll look bad and it will become prohibited by law).”</li> <li style="text-align: justify;">4% of responders said, “The whole shebang (the way to permanently solve healthcare price gouging).”</li> </ul> <p style="text-align: justify;">State surprise billing legislation definitely seems to be a step in the right direction toward curbing provider billing (although some states have shifted a higher burden onto the health plan rather than truly limiting billing). It is difficult to tell whether the rise of reference-based pricing has been a catalyst for that change, or simply the self-funded industry realizing, fifteen years ago, what legislatures have only just begun to realize in the last few years.</p> <p style="text-align: justify;"> </p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"></span></span></span></p> 1010New Opportunities to Save, Create Revenue & Avoid Scary Practiceshttps://www.phiagroup.com/Media/Posts/PostId/1008/new-opportunities-to-save-create-revenue-avoid-scary-practicesWebinarsMon, 19 Oct 2020 15:39:32 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/KPv7iN7bHs4" width="560"></iframe></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;">Join The Phia Team as they share some of the industry’s scariest blunders and gruesome practices. Turn down the lights and prepare to be horrified; but fear not... with this trick there are also treats. Not only will attendees learn from others' mistakes, but we will also pull from our bag of goodies new sources of revenue and savings for plans and administrators alike. If you miss this one, it will haunt you for the rest of your life.</span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><a href="https://youtu.be/KPv7iN7bHs4"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%"><span style="line-height:107%">Click Here to View Our Full Webinar on YouTube</span></span></span></span></a></p> <p style="text-align: justify;"><a href="/Portals/phiagroup/webinars/Oct2015/October%202020%20Webinar%20-%20FINAL.pdf?ver=gL9rIqCed5k56y1CASh4Jg%3d%3d"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%">Click Here to Download Webinar Slides Only</span></span></span></a></p> 1008Empowering Plans: P93 - Behind the Scenes – Town Halls, Nominees & Medicare-for-Allhttps://www.phiagroup.com/Media/Posts/PostId/1007/empowering-plans-p93-behind-the-scenes-towns-halls-nominees-medicare-for-allPodcastsMon, 19 Oct 2020 15:36:54 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/tC8PEzKW8EE" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"></span></span></p> <p style="margin:0in 0in 0.0001pt"><span style="font-size:16px;"><span style="color:#000000;"><span calibri="" style="font-family:">In this episode of the Empowering Plans podcast, Ron Peck and Brady Bizarro take you behind the scenes, avoiding the bright lights of presidential town halls and Supreme Court confirmation hearings. What is really going on? Is Medicare-for-All still a threat? Where is the Trump administration’s healthcare plan? How will a potential Justice Amy Cony Barrett rule on the Affordable Care Act case? Tune in to find out!</span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><a href="https://youtu.be/tC8PEzKW8EE"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;"> </span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/tC8PEzKW8EE"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></span></span></p> 1007Benefits on the Ballot – A Political Update for Health Benefits Professionalshttps://www.phiagroup.com/Media/Posts/PostId/1001/benefits-on-the-ballot-a-political-update-for-health-benefits-professionalsWebinarsTue, 22 Sep 2020 15:09:46 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/eOP_s3aVU1c" width="560"></iframe></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%"><span style="line-height:107%">Election season is underway.  The future of healthcare will be decided via the ballot box, court rooms, and congressional halls.  Pandemic or no pandemic, the gears of democracy are turning and what happens now will have long term effects for us all.  Join The Phia Group as they discuss the most important elections (including candidates’ positions on health), ongoing legal cases, and proposed laws.  They will dissect each and provide you with not only thoughts on how they may impact us, but how we can best prepare for likely outcomes. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><a href="https://youtu.be/eOP_s3aVU1c"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%"><span style="line-height:107%">Click Here to View Our Full Webinar on YouTube</span></span></span></span></a></p> <p style="text-align: justify;"><a href="/Portals/phiagroup/webinars/Sept 2017/September%202020_Webinar_Slides_Final.pdf?ver=4V092ANVInDQ4bGykGcOMg%3d%3d"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><span style="line-height:107%">Click Here to Download Webinar Slides Only</span></span></span></a></p> 1001The Phia Group, LLC Announces the promotion of Nick Fitzsimmons as Senior Director of Provider Relationshttps://www.phiagroup.com/Media/Posts/PostId/991/the-phia-group-llc-announces-the-promotion-of-nick-fitzsimmons-as-senior-director-of-provider-relationsPress ReleasesFri, 07 Aug 2020 13:15:57 GMT<p style="text-align:justify; margin:0in 0in 0.0001pt"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align:justify; margin:0in 0in 0.0001pt"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align:justify; margin:0in 0in 0.0001pt"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:">For Immediate Release<br /> <br /> August 7, 2020</span></span></span></span><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif"><br /> <br /> Canton, MA<b> -</b> The Phia Group LLC, the health benefit industry's leading cost-containment service provider, announces the promotion of Nick Fitzsimmons as Senior Director of Provider Relations.  "Nick has been partnered with The Phia Group for 2 years, helping us grow our Provider Relations department where, as part of that team, he distinguished himself as a key strategic contributor,” stated Adam Russo, CEO of The Phia Group. “Nick is a seasoned and experienced cost-containment guru and I look forward to his continued leadership in Provider Relations as we continue to grow and add to our suite of services.” </span></span></span><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif"><br /> <br /> Nick Fitzsimmons’ cost-containment journey began with Global Excel Management in 1996, managing a team of over 50 employees comprised of negotiators and sales representatives. He also led the network utilization, negotiation strategies, and later rose to the ranks of senior executive leadership.  “The Phia Group is a good fit for me as they are all about innovation, which is what I am looking for.”  stated Nick Fitzsimmons. “I want to be where the action is, and The Phia Group never sits still pursuing their deep commitment to lower the cost of healthcare.” </span></span></span><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="font-family:"Calibri",sans-serif"><br /> <br /> For more information regarding The Phia Group, please contact Vice President of Sales and Marketing, Tim Callender, by email at tcallender@phiagroup.com or by phone at 781-535-5631.</span></span><span style="font-family:"Calibri",sans-serif"><span style="font-family:"Calibri",sans-serif"><br /> <br /> About The Phia Group:</span><br /> <br /> The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive services, designed to control health care costs and protect plan assets.  By providing industry-leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></span><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:"></span></span></span></span></p> 991Empowering Plans: P88 - SCOTUS & HHS – ICYMIhttps://www.phiagroup.com/Media/Posts/PostId/990/empowering-plans-p88-scotus-hhs-icymiPodcastsMon, 03 Aug 2020 17:51:33 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/i71df5_Dess" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"> <span class="pre_wrap">In this episode of the Empowering Plans podcast, Jen and Nick discuss significant developments in nondiscrimination regulations, and the implications for those in the self-funding industry. They talk through the evolution of Section 1557 of the ACA, the new final rule issued by HHS, the Supreme Court’s recent decision on Title VII of the Civil Rights Act, and the looming legal challenges as the health care field attempts to reconcile what we’re hearing from the Supreme Court and HHS. They piece together what all this means for employer-sponsored plans, and offer some advice as to how employers and plans should respond.</span> </span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><a href="https://youtu.be/i71df5_Dess"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;"> </span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/i71df5_Dess"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></span></span></p> 990The Phia Group, LLC Announces Promotion of Jason Davis to Senior Vice-President of Provider Relationshttps://www.phiagroup.com/Media/Posts/PostId/989/the-phia-group-llc-announces-promotion-of-jason-davis-to-senior-vice-president-of-provider-relationsPress ReleasesMon, 03 Aug 2020 13:14:19 GMT<p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:">For Immediate Release</span></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:">August 3, 2020</span></span></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:">Canton, MA<b> -</b> The Phia Group LLC, the health benefit industry's leading cost-containment service provider, announces the promotion of Jason C. Davis to the role of Senior Vice-President of Provider Relations.  "Jason has been partnered with The Phia Group for nearly 7 years, and we have grown tremendously during this time; we now want to highlight and reward his contributions with a seat at the executive table” stated Adam Russo, CEO of The Phia Group. “Jason has proven himself to me and our clients as a person of intelligence and integrity, and I believe he is the right person to lead our Provider Relations department to the next level." </span></span></span></span><br />  </p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:"></span></span></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:">Prior to partnering with The Phia Group in 2014, Jason Davis was Vice-President US Markets for Global Excel Management, where for nearly 10 years he contributed at various levels of claim settlement, dispute resolution, R&D, product development, sales, and leadership.  “I believe in The Phia Group’s mission to lower healthcare costs for all, and so I am thrilled to be part of the Phia family and to build on our success,” added Jason Davis. </span></span></span></span><br />  </p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:"></span></span></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:">For more information regarding The Phia Group, please contact Vice President of Sales and Marketing, Tim Callender, by email at tcallender@phiagroup.com or by phone at 781-535-5631.</span></span></span></span></p> <p style="margin:0in; margin-bottom:.0001pt; text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span new="" roman="" style="font-family:" times=""><span style="font-size:10.5pt"><span arial="" style="font-family:"><br /> About The Phia Group:<br /> <br /> The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive services, designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.</span></span></span></span></p> 989The Phia Group's 3rd Quarter 2020 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/984/the-phia-groups-3rd-quarter-2020-newsletterNewslettersMon, 20 Jul 2020 14:19:21 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 2020/header2020.jpg?ver=tsaiCQ8yobpm91V_BFCutA%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/icons6.png?ver=aZbuq4-0K49erUS_imQTBg%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/topblock120_1.png?ver=aZbuq4-0K49erUS_imQTBg%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/topblock220_2.png?ver=aZbuq4-0K49erUS_imQTBg%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%"><br /> <br /> <br /> <img height="263" src="/Portals/phiagroup/Newsletter Q1 2018/adam.jpg?ver=JLWza13Y0n291uXrY5WQjQ%3d%3d" width="264" /></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:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">July in Boston is wonderful – great weather, great beaches, great barbeques – well ... maybe not this year. Seriously, though, in my opinion, there really isn’t a better time of year to be in New England. So one day ... soon ... maybe all of you can come visit.<br /> <br /> So much has happened at Phia since the last newsletter. We successfully moved into our new Canton, MA facility; we secured a larger space for our Louisville employees; we established our Customer Success Team (that will proactively reach out to you and your teams); we enhanced many of our client reporting tools, case descriptions and options: and</p> </td> </tr> </tbody> </table> <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;">last but not least, we have ensured that you all have the latest and most valuable information relating to COVID-19, how it impacts your businesses and client plans.</p> <p class="bodytext" style="text-align: justify;">With that in mind, let's continue the trend of entertainment and education, with yet another Phia Group Newsletter! I truly hope you will enjoy the valuable information this edition has in store for you, and as always, thank you for being part of The Phia Family. Enjoy!</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 Q1 2018/inthisissue.png?ver=n5HSLKiVNAfWV5tv5BtrZA%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group’s 2020 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p11">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="russo" name="russo"></a></p> <p class="heading1"><br /> <span style="font-size:18px;">Enhancement of the Quarter: Subrogation Value Reports</span></p> <p class="bodytext" style="text-align: justify;">To the Phia Group’s valued recovery clients: rejoice! We have supplemented our already-extensive reporting suite to provide you with a brand new report. The “Subrogation Value Report” is a new report that highlights recovery performance for a particular group, or across a TPA’s entire block of business – as well as compares those results to various benchmarks. The Subrogation Value Report provides the user with an easy-to-read summary of how much The Phia Group has recovered, on a quarterly or yearly basis (based on your preference), and it can also be run by The Phia Group’s <a href="mailto:customersuccessteam@phiagroup.com" target="_blank">Customer Success Team</a>, on-demand.<br /> <br /> This new report presents as a clean, clear PDF. Through the use of graphics and design, it provides an easy to digest yet comprehensive summary of the most valuable performance benchmarks, as well as compares those results to The Phia Group’s entire book of business, utilizing various useful metrics; an important retention and marketing tool for any user!<br /> <br /> The Subrogation Value Report will be automatically provided on a regular basis, as well as being available to all clients upon request, so be sure to contact The Phia Group’s Customer Success Team as needed – and as with all our reports, they will be accurate as of the minute they were run.</p> <p class="bodytext"> </p> <p class="bodytext"><img alt="" height="702" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/chart6.png?ver=rb5TD0u5A_wZsgpcGzGCsw%3d%3d" width="631" /></p> <p class="bodytext"> </p> <hr class="horiz" />_ <p> </p> <p class="bodytext"><span style="font-size:18px;"><strong>New Service Offered by Phia: Patient Defender</strong></span></p> <a id="p012" name="p012"></a> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to introduce its “Patient Defender” program. For a PEPM fee, every plan participant has access to legal representation against collections lawsuits or crippling balances being sent to collections before legal action ensues. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by aggressive tactics, Patient Defender will be there.<br /> <br /> To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a>.</p> <p> </p> <a id="p1" name="p1"></a> <p class="bodytext"><span style="font-size:18px;"><strong>Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)</strong></span></p> <p class="bodytext" style="text-align: justify;">Years ago, in response to growing industry concern regarding fiduciary duties and appeals, The Phia Group created its Plan Appointed Claim Evaluator (PACE) service. PACE is a service whereby The Phia Group takes on fiduciary duty for, and protects clients against fiduciary liability arising from, final-level internal appeals. It is designed to help health plans ensure adverse benefit determinations are correct and defensible, thereby insulating the plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult determinations, and free itself from worry that an unintentional yet arbitrary mistake could result in excessive damages.<br /> <br /> PACE includes:<br /> <br /> • Plan Document and stop-loss policy “Gap Reviews” to ensure compliance, eliminate coverage gaps, and ensure PACE readiness<br /> <br /> • Advanced-level webinars exclusively for PACE clients<br /> <br /> • Assessment of eligible, final internal appeals resulting in a written directive<br /> <br /> • Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (with The Phia Group covering all external review costs)<br /> <br /> The PACE Certification Program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.<br /> <br /> The PACE Certification program will educate you using 3 distinct chapters of information:<br /> <br /> <span style="color:#0071ce;"><b>Chapter One</b></span><br /> <br /> Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.<br /> <br /> <span style="color:#0071ce;"><b>Chapter Two</b></span><br /> <br /> Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.<br /> <br /> <span style="color:#0071ce;"><b>Chapter Three</b></span><br /> <br /> Explains what PACE is, what PACE does, and how it's obtained, implemented, and utilized.<br /> <br /> Please see the <a href="https://www.phiagroup.com/Portals/phiagroup/2020 Flyers/PACE Cert Flyer 2020-v2.pdf">PACE Certification flyer</a>, as well as <a href="https://www.youtube.com/watch?v=8xNqiSuyiP0" target="_blank">this video</a> for more information.<br /> <br /> Please contact Michael Vaz (<a href="mailto:mvaz@phiagroup.com" target="_blank">mvaz@phiagroup.com</a>) for more information.</p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Success Story of the Quarter: The Second-Level Appeal</span></strong></p> <p class="bodytext" style="text-align: justify;">A client of The Phia Group’s Plan Appointed Claim Evaluator (PACE) service recently received a large claim. The medical service from which the claim originated was performed in the emergency room of an out-of-network hospital, but the TPA’s initial medical review deemed it to be of a non-emergency nature; so the claim was processed the same as any normal non-network claim, rather than as a claim for emergency services. The provider was adamant that the services were emergency services, placed numerous calls to the TPA, and wrote an extremely long and detailed appeal.<br /> <br /> On appeal, the TPA diligently had the claim reviewed by a qualified medical reviewer, with the same results, so the appeal was denied. The provider continued its tirade against the TPA’s customer service staff, and eventually submitted a second-level appeal, which the TPA referred to The Phia Group for review pursuant to the PACE service agreement.<br /> <br /> The Phia Group obtained an independent medical review, which yielded the same results – that the claim was not emergent in nature. Phia rendered its determination, as a fiduciary, which the TPA relied upon in communicating the second-level appeal denial. As expected, the hospital renewed all its objections, but the administrative appeals were exhausted.<br /> <br /> This situation is still ongoing. Since the second-level appeal response was issued, the hospital has made numerous threats to sue the Plan, the TPA, and Phia; luckily, the Plan and TPA can rest easy knowing that the second-level appeal determination was made by The Phia Group, rather than by the Plan or TPA, so in the event of a lawsuit, Phia is responsible for any fiduciary damages assessed should the court deem the denial to be inappropriate.<br /> <br /> Regardless of the outcome, this is a perfect example of exactly how the PACE service works: the TPA and Plan can get back to their everyday business without worrying about liability from this and similar appeals.</p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Phia Case Study: The ASC OP</span></strong></p> <p class="bodytext" style="text-align: justify;">The beauty of this case study is in its simplicity.<br /> <br /> A client of The Phia Group’s overpayment recovery service had issued an overpayment to an ASC to the tune of over $12,000 due to incorrect application of the plan’s Usual and Customary limitations. Specifically, the Plan allowed the claim at 140% of Medicare, but the TPA had incorrectly processed the claim at 80% of billed charges. The TPA had sent half a dozen letters to the ASC to no avail; ultimately the TPA referred the case to The Phia Group, to see if we could get any movement.<br /> <br /> Upon receiving the file and discussing it with the TPA, we commenced recovery efforts, including sending an initial introductory and demand letter and following up with phone calls every few days. There was no response, so our legal team got involved; an attorney sent a very strongly-worded letter along with a vague warning that the Plan may be forced to take additional action if there was no response.<br /> <br /> Within a week of sending that letter, we received a call from the ASC’s owner, apologizing for the delay and letting us know the overpayment request would be reviewed in the coming days. One week later, to the day, the owner called again to let us know that the check was in the mail.<br /> <br /> The moral of this story? Sometimes all it takes is having that “Esq.,” on the end of a signature to make things happen – and sometimes having a reputation helps! In this case, The Phia Group’s legal team was able to recover $12,000 for the Plan.</p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Fiduciary Burden of the Quarter: SPD & PPO Contract Harmony</span></strong></p> <p class="bodytext" style="text-align: justify;">ERISA contains a broad framework of requirements regarding how health plans must notify claimants of a plan’s claim and appeal process and determinations. In the event of an Adverse Benefit Determination, a health plan must satisfy certain requirements. Three important requirements are (1) notifying the claimant of “[t]he specific reason or reasons for the adverse determination,” (2) including “[r]eference to the specific plan provisions on which the determination is based,” and also, (3) including “[a] description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary.” These are three requirements that are frequently overlooked.<br /> <br /> The following example is simplified from the original issue, but it is still noteworthy: The Phia Group recently worked with a TPA who denied a claim on behalf of its client health plan because the provider erroneously submitted the claim directly to the TPA, rather than to the network. The TPA included verbiage on the EOB to the effect of – to paraphrase – “please submit this claim directly to the network for repricing.” There can scarcely be any doubt about what that means. Especially for a medical provider who is contracted with the network, and who understands how the network works.<br /> <br /> Now, the interesting part of this anecdote is not really what happened, but instead the fact that even though the PPO contract specified that the claims should be submitted directly to the network – lending credence to the EOB’s remark code, the SPD itself did not contain that same requirement. Instead, the SPD specifically stated that claims must be submitted directly to the TPA. This creates a discrepancy between the PPO contract and the SPD in the most basic aspect of a claim: how to submit it! Recall that while benefit plans are contractually bound to abide by the terms of their network agreement, they – and beneficiaries of the Plan – are bound to obey the terms of the plan document. As a result, the EOB could arguably be deemed not to reflect the terms of the Plan, and the provider can thereby argue that the denial was not sufficient, (since the SPD technically does not support the denial, even though the provider is party to a network contract that says otherwise).<br /> <br /> So, while this EOB remark code does seem to have contained “[a] description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary,” it arguably cannot meet the other two requirements since, literally speaking, language in the SPD does not exist to that effect.<br /> <br /> This is an example of the common situation where two agreements conflict with one another, and the Plan Administrator has to make a choice of which one to follow. Making that choice is never ideal, so our advice is to say what you mean and mean what you say, in every agreement you have signed. Do not leave anything to chance or to anyone’s imagination!<br />  </p> <hr class="horiz" /> <p> </p> <p class="heading1"><a id="p5" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext">• Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Be_Ready_For_The_Drug_Pricing_Debate_To_Return_With_A_Bang_by_Nicolas_Bonds%2C_Esq.pdf" target="_blank">Be Ready For The Drug Pricing Debate To Return With A Bang – June 3</a>, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/06/03/voluntary-travel-covid-19-and-hazardous-activity-exclusions/" target="_blank">Voluntary travel, COVID-19 and hazardous activity exclusions</a> – June 03, 2020<br /> <br /> • Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Continuing Coverage During COVID-19.pdf" target="_blank">Continuing Coverage During COVID-19</a> – May 6, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/04/22/employer-compliance-beyond-cares-andffrca-dont-forget-the-basics/" target="_blank">Employer compliance beyond CARES and FFRCA: Don't forget the basics</a> – April 22, 2020<br /> <br /> • Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Are Your ICS Really EES_ A Look Who's Who on an Employee Benefit Plan by Kelly E_ Dempsey.pdf" target="_blank">Are Your ICS Really EES? A Look Who's Who on an Employee Benefit Plan</a> – April 7, 2020</p> <p class="bodytext">• BenefitsPro – <a href="https://www.benefitspro.com/2020/04/03/the-black-box-a-cautionary-anecdote/" target="_blank">The black box: A cautionary anecdote</a> – April 3, 2020<br /> <br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext">• <a href="https://www.phiagroup.com/Media/Posts/no-contract-no-problem" target="_blank">No Contract? No Problem!</a> Without a signed service agreement, some things can be left up in the air.<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/privacy-pitfalls-considerations-for-reopening-the-office" target="_blank">Privacy Pitfalls – Considerations for Reopening the Office.</a> Planning on reopening your office? Here’s what you need to know.<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/dpc-during-a-crisis" target="_blank">DPC During a Crisis.</a> The many benefits of Direct Primary Care.<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/did-hhs-just-ban-all-surprise-billing-during-the-covid-19-pandemic" target="_blank">Did HHS Just Ban All Surprise Billing During The COVID-19 Pandemic?</a> Apologies for the attention-grabbing headline, but no, as good as that would be for payers, it didn’t.<br /> <br /> • <a href="https://www.phiagroup.com/Media/Posts/covid-19-social-distancing-and-paid-sick-leave" target="_blank">COVID-19: Social Distancing and Paid Sick Leave.</a> The national shift to social distancing has effectively changed the way almost all of us go to work.</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>.</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="text-align: justify;">• On June 16, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/old-issues-new-environment-not-the-same-old-song" target="_blank">Old Issues, New Environment – Not The Same Old Song</a>,” where we discussed familiar issues such as balance billing, surprise billing, mental health parity, telemedicine, COB, and others, while framed in the context of these unique times.<br /> <br /> • On May 19, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/a-pandemic-economy-industry-risks-and-opportunities" target="_blank">A Pandemic Economy – Industry Risks and Opportunities</a>,” where we took a deeper dive on ways administrators are extending benefits and taking care of those in need.<br /> <br /> • On April 23, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/reasons-for-optimism" target="_blank">Reasons for Optimism</a>,” where we discussed the many GOOD and POSITIVE things that have both improved our industry since the end of 2019, and that are on the way.</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"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:</span></p> <p class="bodytext"><span class="heading1">Empowering Plans</span><br />  </p> <p class="bodytext" style="text-align: justify;">• On June 1, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p84-workers-comp-covid-19-preparing-for-an-influx" target="_blank">Workers' Comp. & COVID-19 - Preparing for an Influx</a>,” where our hosts, Jennifer McCormick and Brady Bizarro discuss the impact of COVID-19 on workers' compensation claims.<br /> <br /> • On May 6, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/wicked-awesome-wins-episode-1-a-million-dollar-start" target="_blank">A Million Dollar Start</a>,” where our hosts, Ron and Brady, interview, Attorney Robert Martinez, and explore a case in which he secured a massive balance bill write-off from a hospital using some creative tactics.<br /> <br /> • On April 27, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p83-video-conferencing-the-risk-to-phi" target="_blank">Video Conferencing & the Risk to PHI</a>,” where our hosts, Ron Peck and Brady Bizarro are joined by consulting attorney Nicholas Bonds to discuss the unique concerns facing covered entities and their business associates as more of us utilize video conferencing platforms while under quarantine.<br /> <br /> • On April 13, 2020, The Phia Group presented, “<a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p82-covid-19-studies-on-treatment-costs-industry-impact" target="_blank">COVID-19: Studies on Treatment Costs & Industry Impact</a>,” where our hosts, Jennifer McCormick and Brady Bizarro, discussed some of the latest studies on the potential cost of COVID-19 treatment for self-funded plans, the projected impact on employer-sponsored insurance, and how they think this pandemic could change the industry.</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=Kh7pZKnCThSnh6xAuiA8gQ%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="p8" name="p8"></a>The Phia Group’s 2020 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group's 2020 charity is the Boys & Girls Club of Metro South.</p> <p><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 351px; height: 172px;" /></p> <p class="bodytext" style="text-align: justify;">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="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.<br /> <br /> Since their founding, more than 20,000 Brockton 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"><strong><br /> <span style="font-size:18px;">Youth of the Year: Abiana Cruz</span></strong></p> <p class="bodytext" style="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.<br /> <br /> One lucky teen has officially been awarded a $5,000 scholarship and a new laptop, courtesy of The Phia Group. The Boys and Girls Clubs of Metro South has announced, Abiana Cruz, as the Boys & Girls Clubs of Metro South’s 2020 Youth of the Year.<br /> <br /> Cruz is a junior at Taunton High School and has been a member of the Taunton Clubhouse for 10 years. In addition to her many contributions to the Taunton Clubhouse as a member, Cruz works at the Club after school as an arts specialist, sharing her passion and creativity with younger Club members, and at Camp Riverside in the summer months as a camp counselor.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/YOTY%202020.jpg?ver=0a7Vgu5iyK4t6-kh9Hsc8Q%3d%3d" style="width: 502px; height: 375px;" /></p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Grab-and-Go Dinner Program</span></strong></p> <p class="bodytext" style="text-align: justify;">The Boys & Girls Club has been hit hard and the Phia family is here to help! The Boys & Girls Club is averaging 100 meals served per night with 85% of those meals being served in Brockton. They are also providing boxes with fresh produce and non-perishable food (pasta, canned goods, etc.) to an average of 25 Brockton families per week on Friday afternoons.<br /> <br /> Since the pandemic started in March, The Boys & Girls Club has been suffering financially. In total, the loss of programming revenue, public support, and special events fundraising between March 15th and June 30th is estimated at nearly $1M, or roughly 25% of their FY20 operating budget of $3,890,498.<br /> <br /> That figure continues to climb each time Clubhouse re-openings are further delayed. The Phia family came together and donated a total of $3,500.00 while our employees were working from home. We encouraged employees to utilize Venmo to make their donations, and they happily did so. We are so proud of the Phia family and happy to have the ability to assist families in need.<br /> <br /> If you would like to make a donation, please visit their website today and help a family in need. Here is their donation link: <a href="https://www.bgcmetrosouth.org/donate" target="_blank">https://www.bgcmetrosouth.org/donate</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="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">Be Ready For The Drug Pricing Debate To Return With A Bang</p> <p class="bodytext" style="font-weight: normal">By: Nicolas Bonds, Esq. – June 2020 - <a href="https://www.sipconline.net/files/Be_Ready_For_The_Drug_Pricing_Debate_To_Return_With_A_Bang_by_Nicolas_Bonds%2C_Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As 2020 dawned, one of the fiercest debates around containing healthcare costs pivoted on addressing the runaway prices of prescription drugs. In May of 2018, the Trump administration first floated their “<a href="https://www.hhs.gov/about/leadership/secretary/priorities/drug-prices/index.html" target="_blank">blueprint</a>” to lower drug prices, but hit a number of walls, legal and political.<br /> <br /> Meanwhile, Congress labored on a number of pieces of legislation to curtail drug prices, with House Democrats’ approach culminating in the <a href="https://www.congress.gov/bill/116th-congress/house-bill/3" target="_blank">Elijah Cummings Lower Drug Costs Now Act</a>. Named for the late Baltimore Democrat who pressed the Trump administration to do more to rein in drug costs, the bill was designed to empower the federal government to negotiate Medicare drug prices directly. The bill would have also placed a cap on the out-of-pocket prescription drug costs paid by those covered by Medicare Part D, while expanding dental, vision, and hearing coverage for Medicare recipients.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p><span class="bodytext"><br /> <strong>Continuing Coverage During COVID-19 </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Andrew Silverio, Esq. – May 2020 – <a href="https://www.sipconline.net/files/Continuing_Coverage_During_COVID-19_by_Andrew_Silverio.pdf" target="_blank">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">For the last month or so, like just about every industry, self-funded plan sponsors and those serving them have been frantically grappling with how to quickly and thoroughly address issues they’ve never had to encounter before. Entire segments of our economy have shut down essentially overnight, travel has screeched to a halt, and employers are dealing with questions of a type and scope they’ve never seen. Against this backdrop, individuals’ healthcare needs have never been more vital, while for many employers the path to ensuring they can continue to be covered has never been more wrought with pitfalls.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2020" target="_blank">Click here to read the rest of this article</a><br />  </p> <p><span class="bodytext"><strong>A Look Who's Who on an Employee Benefit Plan</strong></span></p> <p class="bodytext" style="font-weight: normal">By: Kelly Dempsey, Esq. – April 2020 – <a href="https://www.sipconline.net/files/Are Your ICS Really EES_ A Look Who's Who on an Employee Benefit Plan by Kelly E_ Dempsey.pdf" target="_blank">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The glory of self-funding is the flexibility an employer has to create a benefit plan that truly suits the individual employer. Employers with ERISA-governed self-funded plans have the opportunity to craft benefits and exclusions that align with the needs of their employee population, while implementing various cost containment solutions to assist the employer in offering a robust benefit plan, and, perhaps even more importantly, controlling the costs for the employees and the employer. But where does that flexibility stop?</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please 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="p11" name="p11"></a>Get to Know Our Employee of the Quarter: Regina Cattel </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.<br /> <br /> The Phia Explore team will only allow an Explore member to receive this award in the most exemplary of situations; and it is without question that we had one of those types of situations this quarter. As the pandemic advanced, and forced Phia to send most of us home to weather the storm, this employee made herself available to perform any and all duties necessary to maintain Phia’s essential operations that went above and beyond her day to day job duties. Whether it was taking on responsibilities such as managing and sorting the mail, scanning, assisting facilities with the office move, working late handling COVID task force preparations, while still managing to be available 24/7 for employee questions and concerns…you name it – this person has truly done it all. She has made The Phia Group a truly exceptional place to work, and strives to make us even better!<br /> <br /> Explore has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Regina Cattel, your Q2 Employee of the Quarter!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/regina.jpg?ver=0a7Vgu5iyK4t6-kh9Hsc8Q%3d%3d" style="width: 230px; height: 319px;" /></p> <p class="bodytext">Congratulations Regina, and thank you for your many current and future contributions.</p> <p><span class="boldtext"><br /> <span style="font-size:18px;">Job Opportunities:</span></span></p> <p>• Case Investigator<br /> <br /> • Health Plan Documentation Specialist/Plan Drafter<br /> <br /> • Claim and Case Support Analyst<br /> <br /> • Sr. Software Engineer<br /> <br /> • Health Benefit Plan Administration Attorney/Consulting Attorney</p> <ul class="bodytext"> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Promotions</span></strong></p> <p class="bodytext">• Alyssa Pisco has been promoted from Case Investigator to Claim Recovery Specialist III</p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">New Hires</span></strong><br /> <br /> • Nicole Capazzoli was hired as a Sr. Claim Recovery Specialist<br /> <br /> • Krishna Pathuri was hired as a Director, Business Analysis<br /> <br /> • Morganne Wagner was hired as a Project Manager<br /> <br /> • Irene Yalch was hired as an Office Administrator<br /> <br /> • Michael Young was hired as a Legal Intern<br /> <br /> • Michael Hutshell was hired as a Sr. Claim Recovery Specialist<br /> <br /> • Tara Otoka was hired as a Plan Drafter<br /> <br /> • Susan Bivens was hired as a Data Architect<br /> <br /> • Cindy Merrell was hired as a Subrogation Attorney<br /> <br /> • Katelyn Jalkka was hired as an Accounting Intern<br /> <br /> • Caelin McDonald was hired as a Sales Coordinator<br /> <br /> • Pruett Cunningham was hired as an Executive Assistant</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>Phia News</span></p> <p class="bodytext"><span style="font-size:18px;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong></span></p> <p class="bodytext" style="text-align: justify;">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.<br /> <br /> 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.<br /> <br /> 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.<br /> <br /> 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 id="pcert" name="pcert"></a></p> <a id="p12" name="012"></a> <p class="bodytext"><span style="font-size:18px;"><strong>Welcome to Phia’s New Home!</strong></span></p> <p class="bodytext" style="text-align: justify;">The Phia Group has officially moved! We are proud to announce that after 20 years in business, we have officially moved into an office that we have worked extremely hard for. Our growing staff needed more room and we wanted to make sure they felt right at home when they came to work. Check out our new office!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/newoffice.jpg?ver=4Z7GnXngh6hOa6iKdxAOgw%3d%3d" style="width: 527px; height: 354px;" /></p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Welcome to Phia’s New Home in Louisville, KY!</span></strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group has officially outgrown its Kentucky office after less than one year of opening, and will in Septemeber be moving to a bigger, better location. Since operations began in Kentucky, we have hired over 20 individuals from the Louisville area. We are amazed by the rapid growth of The Phia Group’s sister office and can’t wait to add more Louisville locals to the Phia family!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q3 2020/ky%20Office.jpg?ver=4Z7GnXngh6hOa6iKdxAOgw%3d%3d" style="width: 527px; height: 354px;" /></p> <p class="bodytext"><strong><br /> <span style="font-size:18px;">Customer Success Team</span></strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to announce the restructuring of it’s Customer Success Team. As many of you may know from experiences within your own organizations, every sector is experiencing a fundamental shift in customer expectations. It no longer is enough to just be the industry leader in results, one must be the industry leader in customer relations as well. Our Customer Success Team (“CST”) is lead by Rebekah McGuire-Dye. Mrs. McGuire-Dye has over 25 years of experience working in cost containment. Her experience lends her to be an exceptional advocate for The Phia Group’s clients. Mrs. McGuire-Dye will lead her team in providing not just reactive responses to our clients, but in a pro-active approach to ensure every client of The Phia Group is maximizing the value of our many services while always looking for new and innovative products to help our clients grow and lead in their respective areas.<br /> <br /> Here are a few items with which the CST can assist you with:<br /> <br /> • Identify concerns regarding any and all Phia Group services or results, confirm the absence of an issue or resolve the matter, and ensure customer satisfaction with the explanation or revision;<br /> <br /> • Identify any delays or roadblocks to remove them and ensure optimal performance;<br /> <br /> • Deliver all reports and resolve any issues associated with them;<br /> <br /> • Fully analyze, utilize, and interpret Value Reports and other reporting tools to identify both issues and opportunities;<br /> <br /> • Respond to routine file specific client questions (e.g., status on file #12345); and,<br /> <br /> • Provide subject matter expert (“SME”) assistance as needed.<br /> <br /> Although our CST team continues to grow, it is already one of the best staffed and most professional departments at The Phia Group. We encourage all clients to reach out directly if they have any questions at <a href="mailto:CustomerSuccessTeam@phiagroup.com" target="_blank">CustomerSuccessTeam@phiagroup.com</a>.</p> <p> </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 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> 984The Stacks - 3rd Quarter 2020https://www.phiagroup.com/Media/Posts/PostId/983/the-stacks-3rd-quarter-2020NewslettersMon, 20 Jul 2020 13:39:05 GMT<p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:20px;"><span style="color:#0071ce;"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"><b><span style="line-height:115%">Be Ready For The Drug Pricing Debate To Return With A Bang</span></b></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;"><span style="line-height: 115%; font-family: "Calibri", sans-serif;">By: Nick Bonds, Esq. </span> </span></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;"></span></p> <p style="text-align: justify;">As 2020 dawned, one of the fiercest debates around containing healthcare costs pivoted on addressing the runaway prices of prescription drugs. In May of 2018, the Trump administration first floated their “blueprint” to lower drug prices, but hit a number of walls, legal and political.</p> <p style="text-align: justify;">Meanwhile, Congress labored on a number of pieces of legislation to curtail drug prices, with House Democrats’ approach culminating in the Elijah Cummings Lower Drug Costs Now Act. Named for the late Baltimore Democrat who pressed the Trump administration to do more to rein in drug costs, the bill was designed to empower the federal government to negotiate Medicare drug prices directly. The bill would have also placed a cap on the out-of-pocket prescription drug costs paid by those covered by Medicare Part D, while expanding dental, vision, and hearing coverage for Medicare recipients.</p> <p style="text-align: justify;">Though far from perfect, the legislation was ambitious policy and it received broad support from Democrats. Meanwhile, Republicans in the House and Senate released their own drug pricing plans, both echoing the Democrats’ approach of tuning up Medicare Part D. The House Republicans’ policy package, the Lower Costs, More Cures Act, included a suite of transparency measures and caps on insulin costs. Senate Republicans’ Prescription Drug Pricing Reduction Act imposed penalties for price increases above inflation for Medicare Part B and Part D drugs, and capped expenses for seniors, among other things. While there was no consensus on the precise approach, there was virtually universal acceptance that the American people wanted to see movement on drug pricing reform.</p> <p style="text-align: justify;">Even so, partisan gridlock kept any of those bills from becoming law. The dust up did, however, lead President Trump to put even greater pressure on HHS Secretary Alex Azar to get the ball rolling on their plan to encourage state importation of a significant number of cheaper Canadian prescription drugs – one of the many steps laid out in the aforementioned blueprint to reduce drug prices. The President then doubled down on his renewed push for drug pricing legislation at the most recent State of the Union, using his address to make the issue one of the central planks in his 2020 election platform.</p> <p style="text-align: justify;">Drug pricing discussions have taken a back seat to the more pressing pandemic. The federal government has understandably been more focused on dealing with the dual health and economic crises of unprecedented scale. To that end, the Families First Coronavirus Response Act (“FFCRA”) and Coronavirus Aid, Recovery, and Economic Stimulus (“CARES”) Act were passed rapidly and with wide-ranging bi-partisan support. Together, these laws took steps to ensure Americans receive testing and treatment for Covid-19, but the financial toll of contracting the virus will still be a devastating blow to most individuals.</p> <p style="text-align: justify;">The world may have a year or longer to wait for a vaccine to prevent Covid-19, and nascent treatments for the virus have yet to be perfected. While some therapies are showing promise (even some involving llamas), no treatment has received quite so much of the limelight as remdesivir. An experimental drug developed by Gilead Sciences, remdesivir has received the blessing of White House coronavirus task force member Dr. Anthony Fauci, and been granted an emergency use authorization (“EUA”) by the Food and Drug Administration.  </p> <p style="text-align: justify;">Effectively, this EUA means that under the FFCRA and CARES Act, health plans will be required to cover this therapy, but an unanswered question lingers: How much does remdesivir cost? Gilead Sciences has yet to set the price for its drug, though the company has donated 1.5 million doses. The drug maker faces a difficult decision, needing to balance the development costs and potential profits of remdesivir against the desperate public need for viable treatments. Estimates of the drug’s prospective price vary wildly. The Institute for Clinical and Economic Review (“ICER”), a Boston-based nonprofit that performs cost analyses on medical treatments, released a recent report estimating that a “cost recovery” pricing model may run as low as $10 for a ten-day course of treatment. Alternatively, under a more traditional “cost-effectiveness” pricing model, ICER estimates place the cost of that same course of treatment closer to $4,500.</p> <p style="text-align: justify;">To complicate matters, Gilead Sciences may actually have a viable patent on remdesivir, so until other therapies are developed the company may have a government-backed monopoly on the treatment of Covid-19. The development of the drug, however, may well have been at least partially subsidized by federal money. Gilead previously faced a similar situation with their HIV treatment Truvada – which led the government to sue for a license to the drug.</p> <p style="text-align: justify;">Gilead Sciences will have to balance public opinion, social responsibility, their own finances, and the potential government response as they consider how to price remdesivir. As will any other drug maker who develops a treatment for Covid-19. Whatever price point Gilead settles on, the fallout from their decision will certainly linger. A drug this high profile, coming along amid a global emergency, cannot help but reignite the drug price debate. It may be a slow burn – that debate may need to be tabled until the pandemic is under control, maybe even beyond the 2020 election – but the fuse is most certainly lit.</p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="text-align: justify;"><span style="color:#0071ce;"><span style="font-size:20px;"><b><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif">Continuing Coverage During COVID-19</span></span></b></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;">By: Andrew Silverio, Esq.</span></strong></span></p> <p style="text-align:justify; margin:0in 0in 8pt">For <span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">the last month or so, like just about every industry, self-funded plan sponsors and those serving them have been frantically grappling with how to quickly and thoroughly address issues they’ve never had to encounter before.  Entire segments of our economy have shut down essentially overnight, travel has screeched to a halt, and employers are dealing with questions of a type and scope they’ve never seen.  Against this backdrop, individuals’ healthcare needs have never been more vital, while for many employers the path to ensuring they can continue to be covered has never been more wrought with pitfalls. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">As self-funding consultants, we’ve already fielded just about any question one could imagine relating to the COVID-19 pandemic.  It is encouraging though, from a human perspective, that the most common questions we’re seeing don’t relate to how to comply with new federal laws, or even how to contain costs in a time when most employers are being forced to tighten their belts dramatically.  Rather, the most common and urgent inquiries we receive are all variations on the same basic issue – how can we ensure our employees can remain covered?</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">This seemingly simple question often gets extremely complicated though, as plan sponsors are dealing with business decisions they never envisioned.  What if you have to close down completely for a month?  Two months?  What if you have to cut everyone’s hours to be able to ensure everyone continues receiving a paycheck?  What if employees are placed on leaves of absence or furloughed?  Will stop-loss cover continuations of coverage?  It’s very unlikely that even a well-drafted plan document is already set up to address situations like this. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The first and most important item to check off the list is to ensure that the plan document allows for continuation of coverage in whatever situation you’re dealing with.  Just how to label that situation has become a point of confusion in itself, however.  Employers are getting hung up on terminology – do we call it a layoff or a furlough? Can we call it a leave of absence?  Does this impact actively at work status?  Our general guidance has been to forget about terminology – it doesn’t matter.  If your plan clearly describes the events that would otherwise cause a loss of eligibility and clearly establishes that eligibility is intended to continue regardless, it doesn’t matter if the break in service is called a layoff, a furlough, a leave of absence, a pastrami sandwich, etc. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Another significant source of anxiety for plan sponsors is how stop-loss carriers will treat plan changes in connection with COVID-19.  Many carriers have issued releases that seem very reassuring – saying in broad terms that plans need not worry, and that stop-loss will honor COVID-19 updates and amendments won’t be required of applicable stop-loss policies.  We would caution against taking these representations <i>too</i> broadly, however.  A reasonable interpretation of most of these releases is that carriers will honor any plan changes to the extend necessary for plans to comply with the law (namely the Families First Coronavirus Response Ace and the CARES Act).  However, most plans are contemplating changes beyond what’s required by law.  For example, to date there is no federal requirement to extend coverage which would otherwise be terminated after layoff or due to a reduction in hours – the only required extension of coverage under these laws would fall under a new category of FMLA leave.  There’s also no federal mandate to waive cost sharing for most COVID-19 treatment, as opposed to diagnostic testing (a step many plan sponsors are taking to mirror trends in the fully-insured world).  The prudent approach is to expect collaboration, but not rely on it, and take all the proactive steps that may be necessary to protect the plan and employer. </span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"></span></p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="margin-bottom:.0001pt; margin:0in 0in 8pt"><span style="color:#0071ce;"><span style="font-size:20px;"><strong><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Are Your ICs Really EEs? A Look Who’s Who on an Employee Benefit Plan </span></span></strong></span></span></p> <p style="text-align: justify;"><span style="font-size:18px;"><strong><span style="color:#000000;">By: Kelly Dempsey, Esq.</span></strong></span></p> <p style="margin-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">The glory of self-funding is the flexibility an employer has to create a benefit plan that truly suits the individual employer. Employers with ERISA-governed self-funded plans have the opportunity to craft benefits and exclusions that align with the needs of their employee population, while implementing various cost containment solutions to assist the employer in offering a robust benefit plan, and, perhaps even more importantly, controlling the costs for the employees and the employer. But where does that flexibility <i>stop</i>? </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Flexibility can begin to taper off when it comes to determining which individuals are eligible for employer-sponsored coverage. In short, the relevant regulations mandate that only employees of the employer sponsoring the health plan should be eligible to participate. So the logical next question is: who qualifies as an employee? </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">In general, individuals that are issued a 1099 instead of a W-2 are independent contractors (“ICs”) and are accordingly not employees (“EEs”), and thus should not be offered employee benefits; to that end, the Internal Revenue Service (“IRS”) provides various resources to assist employers in appropriately classifying workers. The IRS looks at three areas of the relationship: (1) the behavioral control the employer has on the individual, (2) the level of financial control, and (3) the type or nature of the relationship. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Interestingly, the IRS specifically lists “benefits” under the “type of relationship” category as a consideration for classifying a worker. While the considerations are a sliding scale rather than a hard-and-fast rule (as in, simply offering benefits does not necessarily make the individual an employee), it is certainly a factor. There is also a 20-factor (yes – <i>20</i>) test found in Revenue Ruling 87-41 (1987-1 C.B. 296), but the IRS is aware that certain factors may not apply to every situation.  Ultimately, misclassifying individuals may jeopardize the IC’s “IC” status, which leads to various complications for the employer, the IC, and the health plan. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">As states continue to develop employment-related laws to address various aspects that either directly relate to or at least tangentially effect employee benefits, one such development is of specific interest. New Jersey in particular has issued several new laws that took effect immediately in late 2019, related to independent contractor status and worker misclassifications. The New Jersey Department of Labor and Workforce Development now has the authority to issue monetary penalties for misclassification. If a labor contractor is involved, the employer and the labor contractor have <i>joint</i> liability for any violations and penalties. In April 2020, New Jersey employers will also be required to post a notice regarding worker misclassification. The poster will include information about the prohibition on misclassification of workers, information on the differences between ICs and EEs, the benefits and protections employees are entitled to under state law, the remedies available to misclassified workers, and contact information for complaints or notification of alleged violations. These laws are the result of Governor Murphy issue Executive Order No. 25 in May of 2018 that established the Task Force on Employee Misclassification, making it a top priority to put guidelines in place to diminish work misclassification, which is believed to be widespread problem. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">If the State of New Jersey determines that individuals are being identified as ICs when they really are EEs (and vice versa), the State may issue specific penalties and even stop-work orders, in addition to other remedies or penalties found in other applicable law. There are two penalties that can be imposed. The first is an administrative penalty for misclassifying an employee. For the first violation, the administrative penalty is $250 per misclassified employee. Subsequent violations may increase the penalty up to a maximum of $1,000 per misclassified employee. The second penalty is structured a bit differently and the monetary amount 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 IC cannot be held accountable for the prior employer’s mistake. The State may dictate that the penalty is paid directly to the misclassified workers, or the employer may be required to pay into a trust account for any applicable workers. Employers are to be provided with notice and given the opportunity to appeal by requesting a hearing with the Commissioner of Labor and Workforce Development. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">As with most laws, there is a good faith factor worked into the analysis. Ultimately the State must look to a variety of factors when applying penalties, including any previous violations by the employer, the seriousness of the violation, the employer size, and the good faith of the employer.   </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">If you’re still reading, you’re probably thinking: why does this matter to me? Over the last few years there has been an uptick in the number of self-funded plans that appear to want to include ICs as eligible, so if you’re a claims administrator, a consultant, or a broker, one of the plans you work with is likely impacted. Aside from specific state law penalties, there are a variety of considerations. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Plan language is a major consideration (as it so often is). This may seem like the easiest piece of the puzzle, but as we dig in a bit, it becomes clear that it’s not so simple. Clear eligibility language is crucial to ensure compliance with ERISA Summary Plan Description requirements, so the first step is to modify the eligibility provisions of the document, including how a covered person or participant is defined. Again, determining when to offer coverage is usually simple, but the length of coverage and termination of coverage get a bit trickier. How long will the IC be eligible? Are ICS only covered when working on a project? Would the IC be terminated immediately when a project is over? Would an IC be interested in such coverage if only offered for a limited period of time?</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Benefits are usually offered when there is a permanency of the relationship between the employer and individual; generally, true employment relationships do not have defined end dates, while IC relationships usually have a more definite timeframe. That defined timeframe can make crafting the plan language offering coverage to ICs into a tedious process, and could be difficult for a TPA to administer!</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Employers also need to consider whether they are inadvertently creating a MEWA – a multiple employer welfare arrangement. The offer of coverage to non-employees (i.e., the ICs) likely creates a MEWA. Generally speaking, a MEWA is created when one benefit plan is offered to two or more unrelated entities. Because each IC is a separate entity, it could create a de facto MEWA by including even <i>one</i> IC in the plan benefits. As the MEWA and Association Health Plan (“AHP”) space is another area of developing law, the company would need to properly form the MEWA or AHP first before modifying plan eligibility provisions, and an employer that forms a MEWA loses many of the coveted protections afforded by ERISA.</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">If the employer still wants to continue down this path, the next consideration is tax consequences for both the employer and the IC. By classifying an individual as an IC, an employer avoids paying employment taxes; however, the IC is likely to be taxed on the benefits provided by the employer, since pre-tax protections generally do not apply. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">Certain employers may be eligible for the IRS’ Voluntary Classification Settlement Program (“VCSP”), which allows employers to reclassify workers and receive some relief from federal employment taxes that the employer was not paying. Employers can also seek a proactive determination from the IRS regarding the proper classification of workers (although it’s not easy to estimate how long that might take to receive). Last, but not least, there are resources for individuals to calculate unreported taxes and report an apparent misclassification to the IRS. </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">In addition to the above, stop loss is also a consideration; in order to ensure that these individuals’ claims will be covered under the stop loss policy, it need to be underwritten accordingly and the policy must be written to include coverage for ICs. It generally goes without saying, but the stop loss carrier will need to sign off on the plan language modifications as well (generally before the changes go into place). </span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">With that said, will other states follow New Jersey’s lead? The answer to that question is unclear; however, since the passage of the Affordable Care Act in 2010, the United States Department of Labor is continuing to audit self-funded ERISA-governed plans on a regular basis, looking at a variety of things. Some audits are truly randomized, while others begin due to a complaint from a plan beneficiary. Employers should take a proactive approach to review their benefit offerings and assess whether the health plan’s actual eligibility exactly matches what is stated in the Plan Document, Summary Plan Description, and employee handbook, and update the documents accordingly (or correct any EE or IC statuses accordingly).</span></span></span></p> <p style="margin-bottom:.0001pt; 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-bottom:.0001pt; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif">In summary, it’s natural for an employer to want to offer benefits, including a robust health plan, to the individuals working for the benefit of the employer; however, if those individuals are not actual employees, things can go sideways quickly. Employers should proceed with caution when deciding to offer employer benefits to independent contractors. In this ever-changing industry, states are continuing to develop new rules for employers that bleed into the employee benefit space and can impact their self-funded health plan offerings. These new state laws, combined with existing federal guidelines, can be difficult to navigate, but with some careful planning, employers are given the tools they need to figure it all out!</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"></span></p> 983Empowering Plans: P86 - COVID, Floyd, and the Fight for Social Justicehttps://www.phiagroup.com/Media/Posts/PostId/982/empowering-plans-p86-covid-floyd-and-the-fight-for-social-justicePodcastsFri, 17 Jul 2020 20:17:31 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/zd_ldD2HH-g" width="560"></iframe></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">In this special episode, Ron and Brady address recent events that has altered the world as we knew it in a matter of months, and in one notable case, in one day. The emergence of Covid-19, the resulting mandatory restrictions to daily life, and televised tragic death of Mr. George Floyd, an unarmed African American man, at the hands of law enforcement has altered our collective understanding of security and racial equality in the U.S. In a moment of time that has been compared to the Civil Rights Movement, our very own Philip Qualo, Chairperson of the Phia Diversity Inclusion Committee, joins us to provide his perspective on these issues and the importance for Americans to unite in the face of tragedy. For industry leaders who may be uncertain on how to support their workforce in this “cancel culture” era, we also share some of our own internal approaches we have adopted that have not only been well received but actually celebrated by our staff and the industry as a whole.  As racial disparities continue to persist in access to meaningful healthcare, resulting in grossly disproportionate outcomes for people of color, the escalating cost of healthcare in an increasingly diverse workforce, social justice and racial equality are conversations that can no longer be ignored or kept silent.  </span></span> </p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><a href="https://www.youtube.com/watch?v=zd_ldD2HH-g&feature=youtu.be"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;"> </span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=zd_ldD2HH-g&feature=youtu.be"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></span></span></p> 982Wicked Awesome Wins: Episode 1 – A Million Dollar Starthttps://www.phiagroup.com/Media/Posts/PostId/964/wicked-awesome-wins-episode-1-a-million-dollar-startPodcastsWed, 06 May 2020 16:15:32 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/to1gHi3I3ok" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"></span></span></p> <p style="margin: 0in 0in 0.0001pt; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">Today, we launch a new series harkening to our Boston roots - “Wicked Awesome Wins.” Here, we will showcase our staff and some of their most successful and noteworthy wins on behalf of our clients. Join Ron and Brady as they interview Attorney Robert Martinez and explore a case in which he secured a massive balance bill write-off from a hospital using some creative tactics.</span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:14px;"><a href="https://youtu.be/to1gHi3I3ok"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;"> </span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/to1gHi3I3ok"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></span></span></p> 964The Phia Group's 2nd Quarter 2020 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/957/the-phia-groups-2nd-quarter-2020-newsletterNewslettersTue, 21 Apr 2020 13:11:57 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 2020/header2020.jpg?ver=yH3GPWbzyelbdI2ETY5ayQ%3d%3d" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/icons2-2020.png?ver=GcqUS7ubwbQrntShjsI6ow%3d%3d" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo"><img src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/topblock120.png?ver=zanceZcWPXhth2MLYGeyuw%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/topblock220.png?ver=16iHqygLlgTa9FaqMb02bw%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%"><br /> <img height="304" src="https://www.phiagroup.com/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" width="264" /></td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">The world has changed for all of us, and we are all presently facing challenges and obstacles that none of us could have previously imagined. That being said, I’m not going to sit here in my basement office and cry a river. Instead, I see all of the amazing things that have happened over the past month. I see my kids as I teach them math, reading, and how to create anything that comes to their minds; (we are actually building a pretty awesome fort in the backyard). I see my Phia Group team members and their children during our weekly video calls, and my determination to ensure that we suffer no layoffs is renewed. I see the opportunities ahead of us, as a company, an industry, and as a nation.</p> </td> </tr> </tbody> </table> <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;">I see what we can do as colleagues and as friends to emerge even stronger, blazing a path to an improved future. This experience will forever change us, but I choose to see how that change can be for the better. I do know that my Phia family has shown exceptional resilience and grown stronger through this ordeal - our employees believe in each other and our collective future is bright. I hope that our webinars, podcasts and articles have helped you and your clients do the same in these bizarre times. We are here for you. Be well, and stay in touch.</p> </td> </tr> <tr> <td colspan="2" valign="top"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/fort.jpg?ver=iZflDpwaxZcqEkSIyguskg%3d%3d" style="width: 560px; height: 450px; float: left;" /> <p> </p> <iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Kqw8pXjIDm4" width="560"></iframe><br />  </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="#p1">Service Focus of the Quarter: Phia Unwrapped</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group’s 2020 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p11">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"><br /> Enhancement of the Quarter: Subrogation Value Reports<a id="russo" name="russo"></a></p> <p class="bodytext" style="text-align: justify;">To the Phia Group’s valued recovery clients: rejoice! We have supplemented our already-extensive reporting suite to provide you with a brand new report. The Value Report is a new activity report that highlights recovery benchmarks for a particular group, or across your entire block. This report will provide the user with an easy-to-read summary of how much money The Phia Group has recovered for the client health plans, on a quarterly or yearly basis. The Value Report also contains metrics comparing this performance to The Phia Group’s entire book of business.</p> <p class="bodytext" style="text-align: justify;">This new report presents as a clean, readable PDF; it can be run on-demand and is designed to give a comprehensive summary of the most valuable performance metrics, which can be an important retention and marketing tool for any user!</p> <p class="bodytext" style="text-align: justify;">The Value Report will be added to our client-ready Tableau reporting suite, so recovery clients can run them as needed – and as with all our reports, they will be accurate as of the minute they were run.</p> <p class="bodytext"> </p> <hr class="horiz" /> <p> </p> <p class="bodytext"><strong>Phia’s Latest Hire – Rebekah McGuire Dye, J.D.</strong></p> <a id="p012" name="p012"></a> <p class="bodytext" style="text-align: justify;">Rebekah McGuire Dye was recently hired as the new Vice President of Client Solutions and Account Management with the Phia Group. Ms. Dye is leading the Phia Group’s client care service to the highest level of concierge client service ever established in the cost containment industry.</p> <p class="bodytext" style="text-align: justify;">As a partner to clients’ senior leadership, Ms. Dye and her accomplished team provide an authentic level of customer caring to ensure every aspect of the Phia – client relationship is positive, productive and genuine.</p> <p class="bodytext" style="text-align: justify;">Ms. Dye comes from a 25-year career with the largest cost containment provider in the industry. During her tenured career she has served over 150 health benefit providers in roles ranging from front line file handler to Group Vice President overseeing all Commercial subrogation operations for over 20 million benefit recipient lives. Her lengthy cost containment career, while focused on the Health Care line of business, also includes expertise in both Disability and Property & Casualty subrogation matters.</p> <p class="bodytext" style="text-align: justify;">Ms. Dye is an active member of both IDS and NASP. You can find several published articles by Ms. Dye in the NASP Subrogator magazine and she is a frequent subject matter expert speaker on recovery matters.</p> <p class="bodytext" style="text-align: justify;">While not pursuing cost containment endeavors, she is an avid reader, nature lover and family-centered person residing in rural Kentucky. Her favorite stewardship is serving as an elected member of the Nelson County Kentucky school board. Her passion for education and children make her an invaluable member of the Board.<br />  </p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/rebekah.png?ver=Ivg9S1q0Rnd2gdkZuSDfTw%3d%3d" style="width: 406px; height: 406px;" /></p> <a name="p1"></a><br />   <p class="bodytext"><strong>Service Focus of the Quarter: Phia Unwrapped</strong></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 <a href="https://phiagroup.com/Services/Save-Phia-Unwrapped">Phia Unwrapped</a>, 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 percent of actual savings, leading to fair rates and no excessive 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;">Contact our Vice President of Sales and Marketing, attorney Tim Callender, to learn more about Phia Unwrapped. Tim can be reached by phone at 781-535-5631 or by email at <a href="mailto:TCallender@phiagroup.com">TCallender@phiagroup.com</a>.<br />  </p> <p class="bodytext"><strong>New Service Offered by Phia: Patient Defender</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to introduce its <a href="https://phiagroup.com/Services/Protect-Patient-Defender-Balance-Billing">“Patient Defender”</a> program. For a small PEPM fee, every plan participant has access to legal representation against lawsuits targeting patients, or crippling balances being sent to collections, when efforts to amicably resolve these disputes fail, Patient Defender is the ultimate weapon in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by these increasingly aggressive tactics, Patient Defender will be there.</p> <p class="bodytext" style="text-align: justify;">Patient Defender finally plugs the gap that has existed across the industry in relation to reference-based pricing programs and balance billing concerns. With Patient Defender, a small PEPM rate ensures that a trusted law firm is placed on retainer, ready and willing to assist the patient when balance-billing occurs. Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.</p> <p class="bodytext" style="text-align: justify;">To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or <a href="mailto:tcallender@phiagroup.com" target="_blank">tcallender@phiagroup.com</a>.<br /> <a id="p12" name="012"></a><br /> <br /> <strong>Success Story of the Quarter: Managing COVID-19</strong></p> <p class="bodytext" style="text-align: justify;">We have all heard enough about COVID-19 to last a lifetime, but in this difficult time, this quarter’s success story is designed to thank you for your contribution to stopping the spread of the virus.</p> <p class="bodytext" style="text-align: justify;">We have been asked – or ordered – by our various governments to practice social distancing, or even true quarantining. This is neither easy nor convenient; the economy is suffering and many are getting laid off from their jobs, but humans are facing a dangerous threat against which we must unite.</p> <p class="bodytext" style="text-align: justify;">This success story is ongoing. The Phia Group has committed to enabling all employees to work remotely to avoid the need to congregate in an office, to ensure that our valued clients and the industry can keep functioning as normally as possible, and we thank you for whatever actions you have taken to help stop the spread of the COVID-19 virus.</p> <p class="bodytext" style="text-align: justify;">We wish you all good health.<br />  </p> <p class="bodytext"><strong>Phia Case Study: Outpatient Detox Negotiation</strong></p> <p class="bodytext" style="text-align: justify;">A health plan utilized the Phia Unwrapped service, allowing out-of-network claims at the rate of 150% of Medicare. This plan did not use a large national network, but instead used a narrow, regional network (which was less expensive and yielded better discounts, since each provider was afforded greater steerage).</p> <p class="bodytext" style="text-align: justify;">One particular out-of-network substance abuse provider billed $2,900 per day for outpatient detox, which is many times what Medicare would allow. The plan’s TPA had tried to secure a direct contract multiple times, but each time the provider stalled the conversation, and once the statutory timeframe to pay was about to toll, the provider denied the attempts to contract and forced the plan to pay the claim or watch its member be balance-billed.</p> <p class="bodytext" style="text-align: justify;">When the matter was escalated to The Phia Group, the Provider Relations team leveraged certain data as well as innovative arguments and tactics to yield a result where the provider agreed to a flat fee of 175% of Medicare per day.</p> <p class="bodytext" style="text-align: justify;">In just the first few weeks since this negotiation was finalized, the plan has already saved over $22,000.</p> <p class="bodytext"><strong><br /> Fiduciary Burden of the Quarter: The Black Box</strong></p> <p class="bodytext" style="text-align: justify;">Whether it’s Usual and Customary, Maximum Allowable Charge, billed charges (GASP – why?!) or a network rate, or something else entirely, health plans obviously need to pay some amount for claims. That much is obvious. What is not so obvious, however, is how some plans and administrators come up with these amounts. We have seen many instances of the “black box” approach, where a number goes in one side and another number comes out the other, with no indication of how that repricing was performed; what’s worse is when neither the SPD nor the EOB provides any indication of what the repricing is based on.</p> <p class="bodytext" style="text-align: justify;">New York, for one, has historically taken issue with this approach. ERISA favors extreme transparency, as do state laws. ERISA provides a self-funded health plan with an extremely wide latitude to structure benefits however it chooses, as long as the plan explains what it’s going to do.</p> <p class="bodytext"><strong><br /> New Service Offered by Phia: Patient Defender</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to introduce its “Patient Defender” program. For a PEPM fee, every plan participant has access to legal representation against collections lawsuits or crippling balances being sent to collections before legal action ensues. Patient Defender is a key tool in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by aggressive tactics, Patient Defender will be there.</p> <p class="bodytext" style="text-align: justify;">To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a>.</p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><a id="p4a" name="p4a"></a></p> <p class="heading1">Phia Fit to Print:</p> <p class="bodytext">• BenefitsPro – <a href="https://www.benefitspro.com/2020/03/17/expanded-paid-sick-leave-requirements-under-the-families-first-coronavirus-response-act/">Expanded paid sick leave requirements under the Families First Coronavirus Response Act</a> – March 17, 2020<br /> <br /> • Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/Utah Goes To Mexico-A First For The Drug Importation by Brady Bizarro.pdf" target="_blank">Utah Goes To Mexico - A First For The Drug Importation</a> – March 3, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/02/25/the-cost-of-care-contradiction/" target="_blank">The 'cost of care' contradiction</a> – February 25, 2020<br /> <br /> • Self-Insurers Publishing Corp. – <a href="https://www.sipconline.net/files/A Case Study In Savings- by Philip Qualo%2C J_D.pdf" target="_blank">A Case Study In Savings: How The Phia Group is Offering Employees Free Healthcare</a> – February 6, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/02/04/changing-perceptions-of-health-benefits-one-pregnancy-at-a-time/?slreturn=20200106141738" target="_blank">Changing perceptions of health benefits, one pregnancy at a time</a> – February 4, 2020<br /> <br /> • BenefitsPro – <a href="https://www.benefitspro.com/2020/01/14/californias-new-fsa-notice-requirement-not-so-clear/?utm_medium=BenefitsPro&utm_source=SocialFlow&fbclid=IwAR3Giuy0Hk8dngB-a4wgumaXlnjN-X3V-ApLpS2n6rt7ZnbB8IQKpPh2Ieo" target="_blank">California’s new FSA notice requirement not so clear</a> – January 14, 2020<br /> <br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /><a id="p5" name="p5"></a> <p class="heading1">From the Blogosphere:</p> <p class="bodytext">• <a href="https://www.phiagroup.com/Media/Posts/PostId/938/employers-beware-handling-employee-absences-resulting-from-coronavirus-quarantine" target="_blank">EMPLOYERS BEWARE: Handling Employee Absences Resulting from Coronavirus Quarantine</a>. Facts you should know about this pandemic.</p> <p class="bodytext">• <a href="https://www.phiagroup.com/Media/Posts/PostId/937/new-insight-on-provider-surprise-billing" target="_blank">New Insight on Provider Surprise Billing.</a> These state-based laws have limited applicability.</p> <p class="bodytext">• <a href="https://www.phiagroup.com/Media/Posts/i-got-a-fever-and-the-only-prescription-is-more-transparency" target="_blank">I Got a Fever, and the Only Prescription is More Transparency.</a> Another transparency-minded federal rule is getting some push back.</p> <p class="bodytext">• <a href="https://www.phiagroup.com/Media/Posts/PostId/943/incur-aging-a-review-of-the-term-incurred" target="_blank">“Incur”-aging a Review of the Term “Incurred.”</a> Make sure you know the meaning of this word when it comes to your plan documents and stop-loss policies!</p> <p class="bodytext">• <a href="https://www.phiagroup.com/Media/Posts/PostId/925/what-happens-to-a-health-plan-during-a-merger-or-acquisition" target="_blank">What Happens to a Health Plan during a Merger or Acquisition?</a> There are typically three types of transactions when it comes to mergers and acquisitions.</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>.</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a></span></p> <p class="bodytext"><span class="heading1">Webinars</span></p> <p class="bodytext" style="text-align: justify;">• On March 30, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/covid-19-the-cares-act-workplace-safety-faqs" target="_blank">“COVID-19: The CARES Act & Workplace Safety FAQs,”</a> where we discussed the impact of this historic federal legislation on our industry and answer your questions about workplace safety.</p> <p class="bodytext" style="text-align: justify;">• On March 23, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/949/special-edition-the-phia-group-and-covid-19-faqs-answered" target="_blank">“Special Edition - The Phia Group and COVID-19 FAQs Answered,”</a> where we addressed the COVID-19 pandemic and the industry's most frequently asked questions.</p> <p class="bodytext" style="text-align: justify;">• On March 10, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/941/the-top-10-of-2020-cost-containment-measures-to-implement-right-now" target="_blank">“The Top 10 of 2020: Cost Containment Measures to Implement Right Now,”</a> where we discussed the cost-containment measures they encounter most frequently, and tell some success stories, some horror stories, and how you can make the best decisions for your clients’ bank accounts.</p> <p class="bodytext" style="text-align: justify;">• On February 12, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/936/double-dose-revisiting-rx-drugs-and-answering-your-questions" target="_blank">“Double Dose: Revisiting Rx Drugs and Answering Your Questions,”</a> where we took a deeper dive on the topic of Rx drugs, tackle the difficult questions asked in last month’s webinar, and help plans protect themselves while staying ahead of the curve.</p> <p class="bodytext" style="text-align: justify;">• On January 21, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/930/a-dose-of-savings-addressing-drugs-pbms-and-the-controversies-surrounding-them" target="_blank">“A Dose of Savings – Addressing Drugs, PBMs, and the Controversies Surrounding Them,”</a> where we discussed the Rx trends to watch for, the biggest threats to health plans, cost-containment strategies to implement, political efforts underway, and an injection of information you can’t do without.</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> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /><span class="heading1"><a id="p7" name="p7"></a></span> <p class="bodytext"><span class="heading1">Podcasts:</span></p> <p class="bodytext" style="text-align: justify;"><span class="heading1">Empowering Plans</span><br /> <br /> • On March 31, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p81-covid-19-provider-state-impact" target="_blank">“COVID-19: Provider & State Impact,”</a> where our hosts, Kelly Dempsey and Brady Bizarro discuss the unique responses we have seen from individual states and providers while evaluating their impact on the self-funded industry.</p> <p class="bodytext" style="text-align: justify;">• On March 19, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/946/empowering-plans-p80-covid-19-latest-updates-legislation" target="_blank">“COVID-19: Latest Updates & Legislation,”</a> where our hosts, Ron Peck and Brady Bizarro discuss the latest developments related to COVID-19, the impact on the self-funded industry, and review the contours of the Families First Coronavirus Response Act, which guarantees free coronavirus testing for all Americans as well as an expansion of paid sick days for a subset of workers.</p> <p class="bodytext" style="text-align: justify;">• On March 11, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/942/empowering-plans-p79-covid-19-preparedness-what-self-funded-plans-should-be-doing-right-now" target="_blank">“COVID-19 Preparedness: What Self-Funded Plans Should Be Doing Right Now,”</a> where our hosts, Brady Bizarro and Jennifer McCormick discuss the recent outbreak of COVID-19 (coronavirus), and provide insight into how you should be preparing, what concerns you should have about your benefits documents, and how to navigate applicable law.</p> <p class="bodytext" style="text-align: justify;">• On March 6, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/940/empowering-plans-p78-debating-the-debates" target="_blank">“Debating the Debates,”</a> where our hosts, Ron Peck and Brady Bizarro assess candidates’ (and EX-candidate’s) proposals, and what it all means for our industry.</p> <p class="bodytext" style="text-align: justify;">• On January 31, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/934/empowering-plans-p77-care-where-care-everywhere" target="_blank">“Care Where? Care Everywhere!,”</a> where our hosts, Adam Russo and Ron Peck interview industry legend, Ernie Clevenger, regarding CareHere, LLC, the future of consumer-centric medicine, technology – and most importantly – the MyHealthGuide newsletter!</p> <p class="bodytext" style="text-align: justify;">• On January 24, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/932/empowering-plans-p76-taking-the-stage-in-2020" target="_blank">“Taking the Stage in 2020,” </a>where our hosts, Ron Peck and Brady Bizarro discuss the first Democratic debate of 2020 and the latest ruling from a federal appeals court on Obamacare.</p> <p class="bodytext" style="text-align: justify;">• On January 3, 2020, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/923/empowering-plans-p75-free-health-benefits-at-phia" target="_blank">“Free Health Benefits at Phia,”</a> where our hosts, Adam Russo and Ron Peck discuss the different tactics used to offer Phia's employees FREE health benefits!</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"> </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="p8" name="p8"></a></span></p> <p class="bodytext"><span class="heading1">The Phia Group’s 2020 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group's 2020 charity is the Boys & Girls Club of Metro South.</p> <p><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 662px; height: 325px;" /></p> <p class="bodytext" style="text-align: justify;">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="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. Since their founding, more than 20,000 Brockton 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"><strong>Youth of the Year</strong></p> <p class="bodytext" style="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="text-align: justify;">One of these lucky kids will be awarded a $5,000 scholarship and a new laptop, courtesy of The Phia Group. Good luck to all of these amazing students and we wish you the very best in your future endeavors!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/youthofyear2.png?ver=poIODntg6C41ZkCANeZvxQ%3d%3d" style="width: 502px; height: 328px;" /></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">Utah Goes To Mexico - A First For The Drug Importation</p> <p class="bodytext" style="font-weight: normal">By: Brady Bizarro, Esq. – March 2020- <a href="https://www.sipconline.net/files/Utah Goes To Mexico-A First For The Drug Importation by Brady Bizarro.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Much ink has been spilled about prescription drug importation as a strategy for combating America’s exorbitant drug prices. Despite this practice being technically illegal, many self-funded plans have engaged in it for years without facing any repercussions. With Congress and the Trump administration still unable to agree on a drug pricing reform bill, these programs will almost certainly become more widespread. As they proliferate, they are likely to attract more scrutiny from the Food and Drug Administration (“FDA”), which, although it has rarely enforced the law in this area, has recently taken action against vendors engaged in drug importation. One large insurer, the state of Utah, has become the first to deliberately adopt a type of drug importation program which is much less likely to attract the attention of the FDA and might serve as a roadmap for other self-funded plans in search of relief.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/947/the-stacks-2nd-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p><span class="bodytext"><br /> <strong>A Case Study In Savings: How The Phia Group is Offering Employees Free Healthcare </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Philip Qualo, J.D. – February 2020 – <a href="https://www.sipconline.net/files/A Case Study In Savings- by Philip Qualo%2C J_D.pdf" target="_blank">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Founder and Chief Executive Officer (CEO) of The Phia Group, LLC, Adam V. Russo, Esq., made an announcement at our most recent Christmas party that caused a reaction that could be heard all throughout the New England region. An overwhelming explosion of applauses, screams, and in some cases, tears and sobs, shook the entire venue as the CEO described a major milestone that made Phia history. What was this groundbreaking announcement? The Phia Group has joined the ranks of only a handful of employers in the United States that offers free healthcare… yes… FREE… healthcare coverage to their employees! Despite astronomical increases in healthcare and prescription drug costs throughout the nation, and soaring insurance premiums, Phia now offers free healthcare coverage to all employees who have been enrolled in the group health plan for a period of time. We did this without raising out-of-pocket costs or employee contributions!</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/947/the-stacks-2nd-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please 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="p11" name="p11"></a></span></p> <p class="bodytext"><span class="heading1">Get to Know Our Employee of the Quarter:<br /> Cindy Monfils</span></p> <p class="bodytext" style="text-align: justify;">In addition to her daily tasks, Cindy has been coming into the office to handle all faxes & outgoing mail to ensure the company is functioning as normal. In addition to helping with the annual Phia Forum, she helps to manage all aspects of The Phia Group’s office. Cindy comes in on weekends and helps with other tasks such as painting and putting together chairs. Cindy goes out of her way to make Phia a great place to work. She is a phenomenal asset to the company, and The Phia Group’s transition into working remotely would not have gone so seamlessly if it weren’t for her.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/cindy2.png?ver=oOnbP_ZwVN_QsQdrygEb0Q%3d%3d" style="width: 230px; height: 319px;" /></p> <p class="bodytext">Congratulations Cindy, 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">Phia News</span></p> <p class="bodytext"><strong>Celebrating 20 Years of Empowering Plans!</strong></p> <p class="bodytext" style="text-align: justify;">On February 10, 2020, The Phia Group celebrated 20 years of being in business! The Phia Group was founded in Adam Russo’s basement in February of 2000. Since that time the company has grown beyond any dream that Adam could have imagined. It is hard to believe how fast 20 years have passed, but we are looking forward to many more years of success!</p> <p class="bodytext"> </p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/20%20Years.png?ver=IZEalY7fRkvB25ToLBslUA%3d%3d" style="width: 400px; height: 472px;" /></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext"><br /> PACE® Certification Is Making Waves</span> <p class="bodytext">The PACE Certification program will educate you using 3 distinct chapters of information:</p> <p class="bodytext" style="text-align: justify;"><span style="color:#0071ce;"><strong>Chapter One</strong></span><br /> Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.</p> <p class="bodytext" style="text-align: justify;"><span style="color:#0071ce;"><strong>Chapter Two</strong></span><br /> Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.<br /> <br /> <span style="color:#0071ce;"><strong>Chapter Three</strong></span><br /> Explains what PACE is, what PACE does, and how it's obtained, implemented, and utilized.</p> <p class="bodytext" style="text-align: justify;">The PACE Certification Program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.</p> <p class="bodytext" style="text-align: justify;">Additionally, the PACE Certification program provides education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.</p> <p class="bodytext" style="text-align: justify;">Please see the <a href="https://www.phiagroup.com/Portals/phiagroup/2020 Flyers/PACE Cert Flyer 2020-v2.pdf" target="_blank">PACE Certification flyer,</a> as well as this video for more information.</p> <p class="bodytext"><br /> Please contact Michael Vaz (<a href="mailto:mvaz@phiagroup.com" target="_blank">mvaz@phiagroup.com</a>) for more information.</p>   <hr class="horiz" /> <p><span class="boldtext">Job Opportunities:</span></p> <p>• Plan Drafter</p> <p>• Case Investigator</p> <p>• Claim Recovery Specialist III</p> <p>• Consulting Attorney</p> <p>• Claim and Case Support Analyst</p> <ul class="bodytext"> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a><strong></strong></p> <p class="bodytext"><strong></strong></p> <p class="bodytext" style="text-align: justify;"><strong><br /> Promotions</strong><br /> <br /> • Zachariah John has been promoted from Manager, Applications Development to Sr. Manager, Applications Development</p> <p class="bodytext" style="text-align: justify;">• Igor Senic has been promoted from Accounting Administrator to Senior Accounting Administrator • Ulyana Bevilacqua has been promoted from Supervisor, PGC to Manager, Drafting Services</p> <p class="bodytext" style="text-align: justify;">• Andrew Fine has been promoted from Intake Specialist to Team Lead, Intake</p> <p class="bodytext" style="text-align: justify;">• Cara Carll has been promoted from Manager of Claim Evaluation to Manager of Claim & Case Support</p> <p class="bodytext" style="text-align: justify;">• Lisa Decristoforo has been promoted from Team Lead of Case Evaluation to Team Lead of Case Evaluation and Customer Service</p> <p class="bodytext" style="text-align: justify;">• Ashley Hoey has been promoted from Team Lead of Customer Service & Claim Analysis to Team Lead of Claim Analysis and Claim & Case Support</p> <p class="bodytext" style="text-align: justify;">• Kelly Dempsey has been promoted from <span style="font-size:12px;"><span calibri="">Director, Consulting and ICE Services</span> to <span calibri="">Vice President, Consulting</span></span></p> <p class="bodytext" style="text-align: justify;">• Kelsey Dillon has been promoted from Claim and Case Support Analyst to Senior Claim & Case Support Analyst</p> <p class="bodytext" style="text-align: justify;">• <span style="font-size:11pt"><span calibri="" style="font-family:">Ulyana Bevilacqua</span></span> has been promoted from <span style="font-size:11pt"><span calibri="" style="font-family:">Supervisor, Drafting Services</span></span> to <span style="font-size:11pt"><span calibri="" style="font-family:">Manager, Drafting Services</span></span></p> <p class="bodytext" style="text-align: justify;">• <span style="font-size:11pt"><span calibri="" style="font-family:">Lauren Radley</span></span> has been promoted from <span style="font-size:11pt"><span calibri="" style="font-family:">Manager, Drafting Services</span></span> to <span style="font-size:11pt"><span calibri="" style="font-family:">Director, Drafting Services</span></span></p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> • Rebekah McGuire-Dye was hired as the VP, Client Solutions and Account Management</p> <p class="bodytext">• Josh Jones was hired as a Claim Recovery Specialist IV - BI</p> <p class="bodytext">• Timothy Pope was hired as a Provider Relations Attorney</p> <p class="bodytext">• Jessica Riley was hired as a Sr. Administrative Assistant</p> <p class="bodytext">• Hollan Holm was hired as an Attorney I</p> <p class="bodytext">• Laura Pickett was hired as a Sr. Claims Recovery Specialist</p> <p class="bodytext">• Julia Goyette was hired as a Legal Intern</p> <p class="bodytext">• Nick Frederick was hired as a Claim Recovery Specialist IV - BI</p> <p class="bodytext">• Daniel Scalzi was hired as a Case Investigator I</p> <p class="bodytext">• Brad Tramontozzi was hired as a Manager of Talent Acquisition</p> <p class="bodytext">• Kori Watkins was hired as a VP, Project Management Offices (PMO)</p> <p class="bodytext">• Mitch Hilbert was hired as a Claims Specialist, Provider Relations</p> <p class="bodytext">• Larry Moffett was hired as a Claims Specialist, Provider Relations</p> <p class="bodytext">• Jessica Dunn was hired as a Plan Drafter</p> <p class="bodytext"><strong><br /> Superbowl Festivities</strong></p> <p class="bodytext" style="text-align: justify;">The Phia family held its famous Superbowl Sunday pride party the week before Superbowl Sunday, and we had a great turnout this year! With all of the great gear, our Phia family wore this year, we got a great picture that you can check out below. Congratulations to the Kansas City Chiefs on their big win!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/superbowl2.png?ver=3EACvbcWP6Ok7dpcZja77A%3d%3d" style="width: 527px; height: 354px;" /></p> <p class="bodytext"><strong><br /> Candy Heart Contest</strong></p> <p class="bodytext" style="text-align: justify;">We set up a little contest at the front desk for Valentine's Day and asked everyone to guess how many candy hearts were in the jar! The winner was Samantha Cox with a guess of 258 candy hearts. There were a total of 267 candy hearts in the jar. It’s hard to believe that all of those pieces of candy fit into that tiny jar!<br />  </p> <img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q2 2020/candyheart.png?ver=MKaNG6SvzZLpTaCZ-ZlbNg%3d%3d" style="width: 521px; height: 441px;" /> <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=eqc29gwmZYirVPghPxnKkA%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> 957The Stacks – 2nd Quarter 2020https://www.phiagroup.com/Media/Posts/PostId/947/the-stacks-2nd-quarter-2020NewslettersThu, 19 Mar 2020 18:18:43 GMT<p style="text-align: justify;"><span style="font-size:130%;"><span style="color:#0071CE;"><strong>A Case Study In Savings: How The Phia Group is Offering Employees Free Healthcare</strong></span></span></p> <p style="text-align: justify;"><span style="font-size:130%;"><strong><span style="color:#000000;"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">By: Philip Qualo, J.D. </span> </span></strong></span></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><span style="color:#000000;">The Founder and Chief Executive Officer (CEO) of The Phia Group, LLC, Adam V. Russo, Esq., made an announcement at our most recent Christmas party that caused a reaction that could be heard all throughout the New England region. An overwhelming explosion of applauses, screams, and in some cases, tears and sobs, shook the entire venue as the CEO described a major milestone that made Phia history. What was this groundbreaking announcement? The Phia Group has joined the ranks of only a handful of employers in the United States that offers free healthcare&hellip; yes&hellip; FREE&hellip; healthcare coverage to their employees! Despite astronomical increases in healthcare and prescription drug costs throughout the nation, and soaring insurance premiums, Phia now offers free healthcare coverage to all employees who have been enrolled in the group health plan for a period time. We did this <em>without</em> raising out-of-pocket costs or employee contributions!</span></p> <p style="text-align: justify;"><span style="color:#000000;">Six months before this announcement, when the CEO first considered offering free healthcare, I was tasked with identifying other employers that offer free healthcare, and more importantly, how they did it. Although identifying employers that offered some variation of free healthcare was an easy task, since there are approximately only ten or eleven employers currently doing this, what we could not find was information on <em>how </em>they did it. Consistent with our stated mission to reduce the cost of healthcare through innovative technologies, legal expertise, and focused, flexible customer service, we have decided to break away with this tradition of mystery and intrigue and share with the world how we accomplished this milestone. This is how we did it&hellip;</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>To Insure &hellip; or Self-Insure?</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Our journey started many years ago when we decided to self-insure our employer-sponsored group health plan. We realized early on that choosing the right type of health insurance would be an essential part of the growth and long-term success of our company. The Phia Group started with a handful of employees twenty years ago, and now, we have several offices throughout the country. But when Phia was still a seedling, we knew that the key to our success hinged on not only attracting top talent to our workforce, but more importantly, retaining them. As healthcare is one of the top factors employees consider when they assess their employment satisfaction, we knew the key would be to offer a robust health plan that would appeal to a wide demographic of diverse individuals. With healthcare costs skyrocketing, however, we weren&rsquo;t sure how to accomplish this without annihilating our budget.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Ultimately, we decided to take the risk and self-insure our group health plan. We realized that by self-insuring our own group health plan, we could avoid the off-the-shelf price tag sticker shock of a fully-insured plan, and have the flexibility to customize our benefits to meet the specific needs of our growing employee population. Unlike traditional health insurance plans which require employers to pre-pay for potential claims through monthly premiums, self-insuring our health plan provided us with a wide range of saving opportunities as we were only required to pay claims as services were rendered. By choosing a benchmark that met the needs of our workforce, we were able to cut out the wasteful benefits we do not need to keep our costs low. The savings allowed us to add more desirable benefits to our health plans that kept our employees not only healthy, but more importantly, happy. Healthy and happy employees are more likely to be more productive and stay with their employer even in the most competitive of job markets.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Maximize Savings </strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">So we decided to self-insure &hellip; what next? Since our goal was to enhance our savings potential, with the hope of one-day passing along the savings to our workforce, our next step was to develop the most effective and clear plan language that would minimize our risk and liability while keeping our expenditures low. We wanted to accomplish this, however, without stripping our plan of the benefits are employees have grown to enjoy. To meet this goal, we developed our own plan design and incorporated the most innovative cost-containment techniques, working within the boundaries of our network agreement, and integrated them into our group health plan in easy to understand language aimed at educating our participants to ensure they utilize the high quality lower cost healthcare options. For example, our plan rewards employees for making cost-effective decisions by waiving co-pays when utilizing the reasonably priced yet effective facilities, generic prescription drugs and other low cost alternatives. Finally, to avoid the financial pitfalls of excess or erroneous payments, we created and adopted some of the strongest subrogation plan language in the country that further empowered our plan to identify more claim recovery opportunities as well as maximize our those recoveries. </span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Empower the Plan &hellip; Empower the Employees</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Another benefit of self-insuring that played a role in our ability keep our costs low was access to our claims data. In the fully-insured world, carriers traditionally raise rates annually with little to no explanation. Since carriers are not required to provide employers with claims data, fully-insured employers are basically left powerless to develop strategies to keeping their premiums low. Information is power. Because we self-insure, we enjoy complete access to our claims data and rely on this vital information to identify wastes, high expenditures, and develop innovative and unique ways to save costs on an annual basis. However, we were still not satisfied.</span></p> <p style="text-align: justify;"><span style="color:#000000;">As an industry expert in the self-insured arena, we knew there was more we could do as a plan sponsor to maximize our savings even more, but we knew we could not do this alone. We realized that without the support of our employees, our efforts to enhance our group health plan savings could only go so far. Without employees, a group health plan is nothing but a Plan Document/Summary Plan Description. So how do we get employees interested in, and more importantly, excited about keeping plan expenses low by opting for high quality low cost options? We wanted to be able to maximize options for our employees without dictating their healthcare needs or placing restrictions on our health plan.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The lightbulb went on &ndash; rather than dictate or limit healthcare options &ndash; we decided to <em>incentivize </em>our employees towards high quality low cost care options. We developed a broad range of employer cost-containment incentives aimed at educating our employees about their healthcare options with an irresistible incentive &ndash; a percentage of the savings! For example, by simply consulting with our Human Resources department before selecting a provider for certain procedures, a participant is eligible to receive a percentage of the savings that may result from the consultation. We also created a plan option with a Direct Primary Care (DPC) feature that is paid for company and completely free to our employees &ndash; no copays and no out-of-pocket when utilizing our DPC &ndash; ever! As an employer invested in our workforce, we always strived to keep our employee contributions low. However, by incentivizing employees to make cost-effective decisions about their healthcare needs and keeping their contributions low, employees not only became interested in keeping our health plan costs low &hellip; they became obsessed! In their mind, they were in it for the incentives &ndash; extra cash for picking the best care at the lowest cost? Why not?</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Passing It On </strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">What our employees did not realize until our most recent Christmas party, however, is that by utilizing our cost-containment incentives we covertly evolved into a work culture with a shared commitment &ndash; keeping our health plan costs low. To our employees, our incentives were just opportunities to get some extra funds or save some money while still accessing the best healthcare. With a strong group health plan, and plan participant&rsquo;s eager to reap the rewards of our cost-containment incentives, our dream became a reality. Our group health plan savings had maximized to a point that we are now able to offer our employees a benefit that few companies provide &hellip; free healthcare coverage.</span></p> <p style="text-align: justify;"><span style="color:#000000;">____________________________________________________________________________________________________</span></p> <p style="text-align: justify;"><span style="color:#0071CE;"><span style="font-size:130%;"><strong>Utah Goes to Mexico &ndash; A First for Drug Importation</strong></span></span></p> <p style="text-align: justify;"><strong><span style="color:#000000;"><span style="font-size:larger;">By: Brady Bizarro, Esq.</span></span></strong></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><span style="color:#000000;">Much ink has been spilled about prescription drug importation as a strategy for combating America&rsquo;s exorbitant drug prices. Despite this practice being technically illegal, many self-funded plans have engaged in it for years without facing any repercussions. With Congress and the Trump administration still unable to agree on a drug pricing reform bill, these programs will almost certainly become more widespread. As they proliferate, they are likely to attract more scrutiny from the Food and Drug Administration (&ldquo;FDA&rdquo;), which, although it has rarely enforced the law in this area, has recently taken action against vendors engaged in drug importation. One large insurer, the state of Utah, has become the first to deliberately adopt a type of drug importation program which is much less likely to attract the attention of the FDA and might serve as a roadmap for other self-funded plans in search of relief.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>The Legality</em></span></p> <p style="text-align: justify;"><span style="color:#000000;">There are two traditional types of drug importation: mail order and pharmacy tourism. By and large, most self-funded plans engage in mail order drug importation: that is, they partner (directly or indirectly) with a vendor that assists plan participants in obtaining a drug from outside of the country by U.S. mail. All forms of drug importation are illegal under federal law. The Food, Drug, and Cosmetic Act (&ldquo;FDCA&rdquo;), codified as 21 U.S.C. &sect;&sect; 301 <em>et seq</em>., broadly prohibits the importation of prescription drugs. The statute specifically prohibits the importation or introduction of any &ldquo;new drug&rdquo; into interstate commerce which has not been approved by the FDA, any prescription drug not labeled as required by federal law, or any prescription drug dispensed without a valid prescription written by a licensed American practitioner. <em>See</em> 21 U.S.C. &sect; 355; 21 U.S.C. &sect; 352, 353; 21 U.S.C. &sect; 353(b).</span></p> <p style="text-align: justify;"><span style="color:#000000;">Federal law considers a drug to be misbranded if, at any time prior to dispensing, the label of the drug fails to include the symbol &ldquo;Rx only.&rdquo; <em>See</em> 21 U.S.C. &sect; 353(b)(4)(A). Drugs that are dispensed by international pharmacies do not bear this label. For example, Canadian pharmacies label their drugs with the tag &ldquo;Pr,&rdquo; as opposed to &ldquo;Rx only,&rdquo; and federal law does not consider these labels to be functionally equivalent. Therefore, even drugs that are manufactured abroad with the same chemical composition as their U.S. counterparts are considered illegal to import because of these strict labeling requirements.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>Selective Enforcement</em></span></p> <p style="text-align: justify;"><span style="color:#000000;">Although the practice is technically illegal, it appears that enforcement is selective, particularly when small amounts of prescription drugs imported for personal use are involved, either via U.S. mail or in baggage. According to the FDA&rsquo;s own website, it does not typically object to the personal importation of unapproved drugs when all of the following conditions are met: the drug is for use for a serious condition for which effective treatment is not available in the United States; there is no commercialization or promotion of the drug to U.S. residents; the drug does not represent an unreasonable risk; the individual importing the drug verifies in writing that it is for his or her own use and provides contact information for the treating physician or shows that the product is for the continuation of treatment begun in a foreign country; and, generally, no more than a three-month supply of the drug is imported. </span><em><span style="color:#000000;">See</span> </em><a href="http://www.fda.gov/AboutFDA/Transparency/Basics/ucm194904.htm">http://www.fda.gov/AboutFDA/Transparency/Basics/ucm194904.htm</a>.</p> <p style="text-align: justify;"><span style="color:#000000;">While individual consumers may reasonably rely on the FDA&rsquo;s selective enforcement in this context, a company maintaining a business model or a self-funded plan utilizing a drug importation program might not. When the FDA has acted, it has been against companies engaged in or assisting with the importation of drugs through the U.S. mail. For example, on February 26, 2019, the FDA issued a &ldquo;Warning Letter&rdquo; to CanaRx, a vendor which administers a popular drug importation program to self-funded employers and their covered participants. <em>See</em></span> <a href="https://www.fda.gov/ICECI/EnforcementActions/WarningLetters/ucm632061.htm">https://www.fda.gov/ICECI/EnforcementActions/WarningLetters/ucm632061.htm</a>.</p> <p style="text-align: justify;"><span style="color:#000000;">Though this mail order program, the vendor essentially acts as an agent connecting patients to foreign pharmacies in &ldquo;Tier 1&rdquo; countries - those which meet certain standards in drug regulation - which ship the foreign version of a prescription drug directly to the patient. The patient&rsquo;s health plan is then invoiced for the cost. The FDA&rsquo;s warning letter asserts that this mail order program violates numerous provisions of federal law. While CanaRx responded to the warning letter defending the legality of its program, the position taken by the FDA with respect to mail order drug importation is consistent with similar enforcement actions the FDA has taken in the past.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>Utah&rsquo;s Pharmacy Tourism Program</em></span></p> <p style="text-align: justify;"><span style="color:#000000;">In contrast with using mail order drug importation programs, the state of Utah has become the first large health insurer to utilize a pharmacy tourism drug importation program. Implemented in 2019, the program has already saved the state nearly $250,000, according to the plan&rsquo;s managing director. Due to the program&rsquo;s avoidance of the U.S. mail system, carefully crafted policies and procedures, and narrow criteria for eligibility, it appears far less likely to attract the attention of the FDA than typical mail order programs.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Utah&rsquo;s Public Employee Health Plan is self-funded and self-administered, covering roughly 160,000 individuals. The state had been considering various options to deal with skyrocketing drug costs. It decided against using a mail order program and instead opted for a pharmacy tourism model. In 2019, it implemented a voluntary Pharmacy Tourism Program which is offered to patients taking one or more of thirteen specialty drugs, dealing mostly with rheumatoid arthritis, multiple sclerosis, and other serious, chronic conditions. The program currently covers approximately 400 people.</span></p> <p style="text-align: justify;"><span style="color:#000000;">As part of the program, the plan pays its plan participants to fly to either San Diego, California or Vancouver, Canada. If they are headed to Mexico, the plan pays to drive them to a specified hospital in Tijuana to pick up a 90-day supply of medicine. A representative from a specialty pharmacy escorts the plan participant across the border and stays with the individual at all times. If necessary, the plan also covers lodging costs. Plan participants still pay their usual copayments and are incentivized to participate in the program through a $500 cash incentive. The plan works with a designated hospital to coordinate travel and arrange for the purchase of the drugs. Throughout this process, the plan tracks the medications from the manufacturer to the pharmacy to the patient, increasing the likelihood that the integrity of the chain of custody is maintained.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In reviewing the FDA&rsquo;s previous enforcement actions, it is clear that the integrity of the chain of custody is one important factor in determining whether the agency will scrutinize any particular drug importation program. The agency seems more concerned about programs that involve introducing foreign drugs into the U.S. mail system than it is about individuals acquiring foreign drugs at the point of sale and carrying them across the border. With mail order programs, such as the one introduced by the state of Maine a few years back, there could be many entities mailing foreign drugs to individuals in the U.S. It would be very difficult for the FDA to track those entities and to ensure the integrity of the chain of command.</span></p> <p style="text-align: justify;"><span style="color:#000000;">By contrast, with Utah&rsquo;s program, an individual is completing the transaction in person at a designated facility and is accompanied by a representative from a specialty pharmacy. There is no middleman involved in transporting the foreign drug from the pharmacy to the individual, which significantly lessens the commercialization of the process. Also, scale matters in this context and for pharmacy tourism programs, utilization is lower than it would be for mail order programs (so far only ten plan participants have traveled to Mexico under Utah&rsquo;s program).</span></p> <p style="text-align: justify;"><span style="color:#000000;">As explained, all drug importation programs are technically illegal in the United States. There are no guaranteed approaches to avoiding FDA enforcement of federal law. Still, the FDA applies enforcement discretion and very seldom seizes incoming drugs or prosecutes individuals when the importation is conducted under the right circumstances. Politicians in Utah estimate that its pharmacy tourism program could save the state&rsquo;s self-funded plan north of $1 million if more eligible individuals sign up. So long as bipartisan legislative reform remains just out of reach, self-funded plans will continue to pursue alternative approaches as cost-saving measures. If nothing else, these approaches are a constant reminder of a broken system in desperate need of repair.</span></p> 947The Top 10 of 2020: Cost Containment Measures to Implement Right Nowhttps://www.phiagroup.com/Media/Posts/PostId/941/the-top-10-of-2020-cost-containment-measures-to-implement-right-nowWebinarsTue, 10 Mar 2020 16:28:26 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/mUNTPvpkZ8k" width="560"></iframe></p> <p style="text-align: justify;">Self-funding can be great if you know how to use it – but it can also be disastrous if done wrong. Health plans trust their TPAs and brokers to make the right decisions for them, and cost-containment is always the right decision. From choosing a stop-loss carrier all the way to handling appeals, the self-funding market is full of options and customizations, and some are (much) better than others.</p> <p style="text-align: justify;">Join The Phia Group’s legal team as they discuss the cost-containment measures they encounter most frequently, and tell some success stories, some horror stories, and how you can make the best decisions for your clients’ bank accounts.</p> <p style="text-align: justify;"><a href="https://youtu.be/mUNTPvpkZ8k">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 941Empowering Plans: P78 – Debating the Debateshttps://www.phiagroup.com/Media/Posts/PostId/940/empowering-plans-p78-debating-the-debatesPodcastsFri, 06 Mar 2020 14:41:37 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/J9oPgOM0H5s" width="560"></iframe></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><span style="color:#000000;">In this episode, Ron Peck and Brady Bizarro assess candidates&rsquo; (and EX-candidate&rsquo;s) proposals, and what it all means for our industry. </span></p> <p style="text-align: justify;"><a href="https://youtu.be/J9oPgOM0H5s"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/J9oPgOM0H5s"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 940Double Dose: Revisiting Rx Drugs and Answering Your Questionshttps://www.phiagroup.com/Media/Posts/PostId/936/double-dose-revisiting-rx-drugs-and-answering-your-questionsWebinarsWed, 12 Feb 2020 14:55:22 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/96TO8ckEqys" width="560"></iframe></p> <p style="text-align: justify;">Last month, we discussed some disturbing trends surrounding prescription drugs, and what they mean for self-funding. The overwhelming feedback we received after last month’s webinar was that you, our viewers, want more information on this particular topic – so we’re back with a sequel!</p> <p style="text-align: justify;">Join The Phia Group’s legal team as they take a deeper dive on the topic of Rx drugs, tackle the difficult questions asked in last month’s webinar, and help plans protect themselves while staying ahead of the curve.</p> <p style="text-align: justify;"><a href="https://youtu.be/96TO8ckEqys">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 936Empowering Plans: P77 – Care Where? Care Everywhere!https://www.phiagroup.com/Media/Posts/PostId/934/empowering-plans-p77-care-where-care-everywherePodcastsFri, 31 Jan 2020 14:52:34 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/9VciEF-tLI4" width="560"></iframe></p> <p>In this episode, Adam and Ron interview industry legend, Ernie Clevenger, regarding CareHere, LLC, the future of consumer-centric medicine, technology &ndash; and most importantly &ndash; the MyHealthGuide newsletter!</p> <p style="text-align: justify;"><a href="https://youtu.be/9VciEF-tLI4"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/9VciEF-tLI4"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 934Empowering Plans: P76 – Taking the Stage in 2020https://www.phiagroup.com/Media/Posts/PostId/932/empowering-plans-p76-taking-the-stage-in-2020PodcastsFri, 24 Jan 2020 16:25:03 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/2XG0XOFitL8" width="560"></iframe></p> <p><strong>In this episode, Ron Peck and Brady Bizarro discuss the first Democratic debate of 2020 and the latest ruling from a federal appeals court on Obamacare. Time could be running out, both for the ACA and for the candidates for president. You do not want to miss our take on these issues and more!</strong></p> <p style="text-align: justify;"><a href="https://youtu.be/2XG0XOFitL8"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/2XG0XOFitL8"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 932A Dose of Savings – Addressing Drugs, PBMs, and the Controversies Surrounding Themhttps://www.phiagroup.com/Media/Posts/PostId/930/a-dose-of-savings-addressing-drugs-pbms-and-the-controversies-surrounding-themWebinarsTue, 21 Jan 2020 17:00:40 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/KxmBIuWm-lM" width="560"></iframe></p> <p style="text-align: justify;">Whether you are a fan of politics, profits, or identifying savings, you are likely keeping a close eye on pharmaceuticals. From life-preserving medications that have been around for decades (and whose price increases continue to outpace the national GDP) to specialty drugs that are inches away from FDA approval (and bankrupting most benefit plans), the cost tied to drugs is a hot topic. While congressional efforts to curb rising costs have stalled, pharmaceutical companies, pharmacy benefit managers (PBMs), and politicians continue to look for someone else to blame. Join The Phia Group as they discuss the Rx trends to watch for, the biggest threats to health plans, cost-containment strategies to implement, political efforts underway, and an injection of information you can’t do without.</p> <p style="text-align: justify;"><a href="https://youtu.be/KxmBIuWm-lM">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 930The Phia Group's 1st Quarter 2020 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/928/the-phia-groups-1st-quarter-2020-newsletterNewslettersThu, 16 Jan 2020 17:10:57 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%20Q1%202020/header2020.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/icons5.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#russo"><img src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/topblock120.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/topblock220.png" 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="281" src="/Portals/phiagroup/Newsletter%20Q1%202018/adam.jpg" width="290" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><br /> <span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> &nbsp; <p class="bodytext" style="text-align: justify;">Happy New Year everyone! 2020 marks the 20th anniversary of The Phia Group and it made me realize just how much we have accomplished and how far we have come. I am not going to sit here and tell you that this was the dream - to have a leading cost containment firm in the self-funding industry with over 200 employees. I just wanted to create something, anything that would change the status quo. I had no concept of the size of Phia, the revenues, the expertise, the reputation, the services, or the technology we have created.</p> </td> </tr> </tbody> </table> <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;">I just had a passion to offer more than what was being offered at that time. I was 26, living in my mother&rsquo;s basement, and basically had nothing to lose. We never got a loan, never had investors, never hired top talent - we couldn&rsquo;t afford anyone! &nbsp;What we had was a determination to have fun, disrupt and innovate.&nbsp;What we created after 20 years still boggles my mind. &nbsp;I want all of you to know how much I appreciate the friendships, the loyalty and the collaboration we have built together. I will never forget where I came from or how I got here - thank you. Happy reading and I hope you all have an amazing 2020. &nbsp;I know we will.&nbsp;</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%20Q1%202018/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p20">Service Focus of the Quarter: Plan Appointed Claim Evaluator&reg; (PACE)</a><br /> <a href="#p3">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2020 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employees of the Quarter &amp; Year</a><br /> <a href="#pnews">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p>&nbsp;</p> <p class="heading1" style="text-align: justify;"><a name="russo"></a>We Are Proud to Announce: Free Health Benefits for Phia Employees &amp; Their Families</p> <p style="text-align: justify;">The Phia Group, LLC is pleased to announce that with the ringing in of the new year, it will be offering FREE HEALTH BENEFITS to employees and their families.&nbsp; Specifically, plan participants that have been enrolled in the plan for five or more years will be enrolled in January of 2020 and have zero contribution or premium; 100% of the cost of their and their families&rsquo; membership is paid for by The Phia Group. Further, no plan participant&rsquo;s contribution rate will increase in 2020.</p> <p style="text-align: justify;">This remarkable achievement is made possible thanks to the application and utilization of cost containment measures developed and provided by The Phia Group to the self-funded health benefits community, and proactive efforts on the part of its own plan membership to be educated, and cost-conscious &ldquo;consumers&rdquo; of healthcare.</p> <p style="text-align: justify;">Adam V. Russo, remarked &ndash; in response to those that believe cost-shifting the burden of rising healthcare costs onto employees is inevitable &ndash; that, with the right tactics in place, health benefits can be affordable and employees do not need to bear the burden of an inefficient health plan.&nbsp; &ldquo;If our approach to health benefits didn&rsquo;t work,&rdquo; Adam continued,&ldquo;&hellip; could we afford to maintain our contribution levels, year after year?&nbsp; Could we continue to offer benefits with no co-pays or deductible?&nbsp; The answer is no.&rdquo;</p> <p style="text-align: justify;">Ron E. Peck, explained, &ldquo;Our mission is to ensure health benefits are robust and affordable for hard-working Americans.&nbsp; Very few people work as hard as our own employees, so providing them with the best, most affordable benefits is us living our mission.&rdquo;</p> <p style="text-align: justify;">&ldquo;We are very proud to be able to offer our employees and their families the types of benefits they&rsquo;d only see at a very small number of businesses, nationwide;&rdquo; Adam concluded.</p> <p class="heading1"><a id="p20" name="p20"></a></p> <p class="heading1">&nbsp;</p> <p class="heading1">Service Focus of the Quarter: Plan Appointed Claim Evaluator&reg; (PACE)</p> <p class="bodytext" style="text-align: justify;">Some years ago, in response to growing industry concerns over fiduciary duties and appeals, The Phia Group created its Plan Appointed Claim Evaluator (PACE) service. PACE is a risk-sharing service for final-level internal appeals. It is designed to help ensure Plans and their TPAs made correct determinations in response to appeals, thereby insulating the health plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations.</p> <p class="bodytext" style="text-align: justify;">PACE includes:</p> <p class="bodytext" style="text-align: justify;">&bull; Plan Document and stop-loss policy &ldquo;Gap Reviews&rdquo; ensure compliance, eliminate coverage gaps, and ensure PACE readiness;</p> <p class="bodytext" style="text-align: justify;">&bull; Advanced-level webinars exclusively for PACE clients;</p> <p class="bodytext" style="text-align: justify;">&bull; Assessment of eligible final internal appeals resulting in a written directive; and,</p> <p class="bodytext" style="text-align: justify;">&bull; 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 now offer complimentary PACE Certification &ndash; with which your organization can enhance your PACE business, improve your internal appeals processes, ensure regulatory compliance, and improve your operation as a whole.</p> <p class="bodytext" style="text-align: justify;">Chapter One of PACE Certification explores the ins and outs of self-funding; Chapter Two takes a deeper dive into the laws and regulations applicable to self-funded health plans; Chapter Three explains what PACE is, how it works, and how it can best be utilized.</p> <p class="bodytext" style="text-align: justify;">To learn more, contact Michael Vaz at <a href="mailto:mvaz@phiagroup.com" target="_blank">mvaz@phiagroup.com</a> or 781-884-4971.</p> <p class="bodytext">&nbsp;</p> <a id="p3" name="p3"></a> <p class="heading1">Phia Case Study: Claim Negotiation &amp; Signoff (CNS)&nbsp;</p> <p class="bodytext" style="text-align: justify;">The Phia Group was asked to negotiate a high-dollar claim on behalf of a self-funded health plan sponsored by a non-profit religious order. The charges totaled just over $100,000.00, and repricing yielded a Medicare rate of only $7,500.00 (a mark-up of over 1300% over Medicare). To compound the situation, the plan document had not been updated since the early 1990s, and had very weak language governing payment for out-of-network claims.</p> <p class="bodytext" style="text-align: justify;">One of The Phia Group&rsquo;s negotiators noted that the hospital bore the same name of the religious order of which the patient was an ordained member. After some investigation, Phia learned that this religious order was the very same that founded the hospital nearly a century ago.</p> <p class="bodytext" style="text-align: justify;">In the initial outreach to the provider, we explained the claim&rsquo;s metrics and equivalent Medicare rate; it was our hope that even without strong plan language or unloading our newfound argument regarding the member&rsquo;s relationship to the hospital, the hospital would recognize the importance of settlement. Unfortunately, the provider was largely unresponsive to our efforts. After over a month of constant persistence in the form of calls, e-mails, and faxes, we finally received an offer from the provider to accept 35% off of billed charges. While not the smallest discount, that payment still would have constituted almost 900% of the applicable Medicare rate, and our client was not inclined to accept the offer.</p> <p class="bodytext" style="text-align: justify;">In crafting a response, we got a little creative, and quoted some language directly from the &ldquo;history&rdquo; section of the hospital&rsquo;s website. This patient, we noted, is a member of the religious order that founded this hospital back in 1922, and which transformed it into a hospital for children in 1936. That the hospital was now seeking almost 900% of the applicable Medicare rate from one of its founders seemed unreasonable and disingenuous. We also quoted a study that found that the average charge for an out-of-network claim in the state was 176% of Medicare; through this figure, we were able to base our client&rsquo;s counteroffer in a concrete metric, even though the plan&rsquo;s cost-containment language left much to be desired.</p> <p class="bodytext" style="text-align: justify;">Ultimately, the provider agreed to accept our offer of 176% of the Medicare rate, and close its file. By going the extra mile, The Phia Group was able to save its client over $88,000; since the Plan Document didn&rsquo;t have strong cost-containment language, the Plan would have legally been on the hook for the vast majority of it, had this settlement not been achieved.</p> <hr class="horiz" />  <p>&nbsp;</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: New Denial Reasons on Appeal</strong></p> <a id="p12" name="p12"></a> <p class="bodytext" style="text-align: justify;">It&rsquo;s not uncommon for health plans to realize, while adjudicating a claimant&rsquo;s appeal, that the initial denial reason was incorrect or incomplete. That&rsquo;s one major function of appeals &ndash; to let a claimant identify that the denial reason is inapplicable. For instance, if the initial Adverse Benefit Determination denies a claim on the basis that the service is experimental, the claimant may appeal and present evidence that the claim is not in fact experimental. The fiduciary, when reviewing the appeal, may realize &ldquo;whoops &ndash; this claim should have been denied for lack of medical necessity, but we used an experimental code by mistake!&rdquo;</p> <p class="bodytext" style="text-align: justify;">The result is generally that the fiduciary will still deny the appeal, but write that the claim is denied for medical necessity, rather than being experimental. The appeal is a request for additional benefits, but if additional benefits are not payable for some other reason that was not written in the initial denial, then the appeal should still be denied. Health plans often do not consider this to be a &ldquo;separate&rdquo; or &ldquo;new&rdquo; denial &ndash; but legally, it is.</p> <p class="bodytext" style="text-align: justify;">Considering appeals to have been exhausted despite having provided a new denial reason effectively leaves the claimant with no opportunity to appeal that new denial for medical necessity. Courts have iterated that this is contrary to the intent and requirements of ERISA, which are designed to ensure that claimants are afforded the opportunity to appeal an adverse benefit determination. An appeal denial with a reason not previously given for that particular claim&rsquo;s denial is therefore considered to be an initial adverse benefit determination all over again, even if given as part of a second-level appeal.</p> <p class="bodytext" style="text-align: justify;">In short, any time a new denial reason is given for an existing claim, the claimant has the right to appeal that denial reason.</p> <p class="bodytext" style="text-align: justify;">This could in theory create an absurd situation where the plan must accept many different appeals for the same claim &ndash; but to avoid that, we would suggest that the plan list all its denial reasons in the initial denial, when possible. That way, the plan can ensure that it does not need to respond to multiple unnecessary appeals, and also that a claimant is not strung along with the undue burden to appeal multiple times to try to get a straight answer out of her health plan.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Success Story of the Quarter: Balance-Billing at its Best!</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group was presented with a balance-billing claim from a client of Payer Compass&rsquo; INNOVATE360 service, for which The Phia Group provides back-end balance-billing support. This particular claim was billed at $1.57 million; the health plan allowed 150% of Medicare, which was about $289,000. The balance, billed in full to the patient, was nearly $1.3 million.</p> <p class="bodytext" style="text-align: justify;">The TPA had been told prior to The Phia Group&rsquo;s involvement that the maximum &ldquo;discount&rdquo; the provider would allow was 15%. Understandably, this payor would not accept that, and instead engaged The Phia Group to try to resolve this claim to alleviate the balance-billing. The payor was potentially willing to pay additional money to settle the claim, but certainly not the amount the provider was demanding.</p> <p class="bodytext" style="text-align: justify;">The Phia Group engaged the provider, and right off the bat, attorney Rob Martinez unloaded all the arguments he had in his arsenal. They included arguments based on the ID card, the plan document, the hospital&rsquo;s financial assistance policy, detrimental reliance, and more &ndash; and on a more personal note, the fact that this hospital was sending bills to its supposedly valued patient for $1.3 million.</p> <p class="bodytext" style="text-align: justify;">Amazingly, the hospital conceded that Rob&rsquo;s arguments were sufficient to extinguish the balance. The account was awarded a zero balance, and poof &ndash; just like that &ndash; Rob &ldquo;the Magician&rdquo; Martinez made a $1.3 million balance-bill disappear.</p> <a name="p1"></a> <p class="bodytext"><strong>New Service Offered by Phia: Patient Defender</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to introduce its &ldquo;Patient Defender&rdquo; program. For a small PEPM fee, every plan participant has access to legal representation against lawsuits targeting patients, or crippling balances being sent to collections, when efforts to amicably resolve these disputes fail, Patient Defender is the ultimate weapon in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan &ndash; from reference-based pricing plans to traditional network plans; if and when a patient is threatened by these increasingly aggressive tactics, Patient Defender will be there.</p> <p class="bodytext" style="text-align: justify;">Patient Defender finally plugs the gap that has existed across the industry in relation to reference-based pricing programs and balance billing concerns. With Patient Defender, a small PEPM rate ensures that a trusted law firm is placed on retainer, ready and willing to assist the patient when balance-billing occurs. Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.</p> <p class="bodytext" style="text-align: justify;">To learn more about Patient Defender or any of The Phia Group&rsquo;s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or <a href="mailto:tcallender@phiagroup.com" target="_blank">tcallender@phiagroup.com</a>.</p> <p>&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p5" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext" style="text-align: justify;">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/12/04/cobra-can-be-complicated-what-to-watch-for/" target="_blank">COBRA can be complicated: What to watch for</a> &ndash; December 4, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/ACA Enrollment By The Numbers! Administration's Attempts To Stall The ACA At Work_ by Christopher Aguiar%2C Esq.pdf" target="_blank">ACA Enrollment By The Numbers! Administration&#39;s Attempts To Stall The ACA At Work?</a> &ndash; December 1, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/11/22/trending-therapy-options-gene-and-stem-cell-therapy-for-self-funded-plans/?utm_source=SocialFlow&amp;utm_medium=BenefitsPro&amp;fbclid=IwAR21FWzL799AGtVAZG2SAMhzRAQFvt9QFbPyPha5rVQHTOfl0Mq4pUyFt04" target="_blank">Trending therapy options: Gene and stem cell therapy for self-funded plans</a> &ndash; November 22, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/ACA Round-Up For 2020- Items Affecting Employer-Sponsored Group Health Plans by Corrie Cripps.pdf" target="_blank">ACA Round-Up for 2020: Items Affecting Employer-Sponsored Group Health Plans</a> &ndash; November 5, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/The Tower of Babel-Talking Heads Talking Past Each Other by Ron E_ Peck.pdf" target="_blank">The Tower of Babel-Talking Heads Talking Past Each Other</a> &ndash; October 4, 2019</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/913/washingtons-surprise-billing-law-goes-into-effect-january-2020" target="_blank">Washington&rsquo;s &ldquo;Surprise&rdquo; Billing Law Goes Into Effect &ndash; January 2020</a>. One less surprise you&rsquo;ll have to worry about.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/911/new-transparency-rules-released-but-will-they-last" target="_blank">New Transparency Rules Released, But Will They Last?</a> A proposed rule to bring transparency to hospitals near you.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/908/theories-v-practicality-the-simplest-answer-is-often-the-best" target="_blank">Theories v. Practicality: The Simplest Answer is Often the Best!</a> The easiest path to third party recovery.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/903/happy-almost-new-plan-year" target="_blank">Happy (Almost) New Plan Year!</a> Preparing your plan documents for 2020!</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/896/battle-lines-drawn-over-medicare-for-all-in-the-latest-democratic-debate" target="_blank">Battle Lines Drawn over Medicare for All in the Latest Democratic Debate.</a> Is there truly a cure for our healthcare system?</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"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;">&nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On December 17, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/916/a-perfect-vision-for-2020" target="_blank">&ldquo;A Perfect Vision for 2020,&rdquo;</a> where we review the issues, topics, and innovations of 2019 that we believe will impact 2020, as well as the strategies you need to implement now to conquer the coming year.</p> <p class="bodytext" style="text-align: justify;">&bull; On November 13, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/905/plan-language-rx-and-lawsuits-to-watch-and-file-innovation-for-a-changing-industry" target="_blank">&ldquo;Plan Language, Rx, and Lawsuits to Watch (and File): Innovation for a Changing Industry,&rdquo;</a> where we discuss innovative programs to manage vendor fees, balance-bill litigation, Rx manufacturer assistance, and other ideas being proposed by players in the industry.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 17, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/897/2020-forecast-storm-clouds-clear-skies-and-the-issues-that-will-dominate-next-year" target="_blank">&ldquo;2020 Forecast - Storm Clouds, Clear Skies, and the Issues that will Dominate Next Year,&rdquo;</a> where we discuss the issues that impacted 2019, and are poised to dominate 2020, including (but not limited to) Mental Health Parity, Paid Leave, Health Insurance Taxes, Drug Prices, Regulations, and Coupons.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:</span></p> <p class="bodytext"><span class="heading1">Empowering Plans</span></p> <p class="bodytext" style="text-align: justify;">&bull; On December 19, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/918/empowering-plans-p74-medicare-podcast-for-all" target="_blank">&ldquo;Medicare Podcast for All&rdquo;</a> where our hosts, Ron Peck and Brady Bizarro, pick apart Elizabeth Warren&rsquo;s Medicare-for-All proposal, and the concept as a whole; the good, the bad, and the really bad.</p> <p class="bodytext" style="text-align: justify;">&bull; On December 11, 2019, The Phia Group presented,<a href="https://www.phiagroup.com/Media/Posts/PostId/915/empowering-plans-p73-preparing-your-plan-document-for-2020" target="_blank"> &ldquo;Preparing Your Plan Document for 2020,&rdquo;</a> where The Phia Group&rsquo;s Executive Vice President and General Counsel, Ron E. Peck, and Senior Vice President of Consulting, Jen McCormick, sit down to discuss the top-rated topic chosen by Phia&rsquo;s webinar listeners. Make sure you tune in to find out what Ron and Jen have to say about plan documents and learn the do&rsquo;s and don&rsquo;ts when it comes to reviewing and updating your plan document in 2020!</p> <p class="bodytext" style="text-align: justify;">&bull; On November 21, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/909/empowering-plans-p72-the-young-the-restless" target="_blank">&ldquo;The Young &amp; The Restless,&rdquo;</a> where our hosts, Adam Russo and Brady Bizarro sit down with Craig Clemente, Chief Operations Officer at Specialty Care Management and outgoing Chairman of the SIIA Future Leaders Committee, to discuss the future of the committee and the many ways they intend on engaging the younger generation.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1">Face of Phia</span></p> <p class="bodytext" style="text-align: justify;">&bull; On November 15, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/906/faces-of-phia-episode-19-shauna-makes-a-comeback" target="_blank">&ldquo;Shauna Makes a Comeback,&rdquo;</a> where our hosts, Adam Russo and Ron Peck, sits down with Shauna Mackey, The Phia Group&rsquo;s Associate General Counsel. Tune in to learn more about Shauna and her experience with both public and private healthcare throughout her pregnancy and delivery.</p> <p class="bodytext" style="text-align: justify;">&bull; On November 4, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/901/faces-of-phia-episode-18-battling-balance-billing" target="_blank">&ldquo;Battling Balance-Billing,&rdquo;</a> where our hosts, Adam and Ron, interview Lyneka Hubbert, a Medical Claim Negotiator here at The Phia Group.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 16, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/893/faces-of-phia-episode-17-reminiscing-on-memories-with-mrs-marsh" target="_blank">&ldquo;Reminiscing on Memories with Mrs. Marsh,&rdquo;</a> where our hosts, Adam and Ron, interview Jen Marsh, our Client Satisfaction &amp; Quality Control Manager.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1">Tales From the Plan</span></p> <p class="bodytext" style="text-align: justify;">&bull; On October 24, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/898/tales-from-the-plan-episode-5-translating-phias-benefit-plan" target="_blank">&ldquo;Translating Phia&rsquo;s Benefit Plan,&rdquo;</a> where our hosts, Adam Russo and Ron Peck, interview The Phia Group&rsquo;s Human Resources Manager, Linda Pestana. Learn how Linda was able to navigate our health plan and negotiate with a provider to make her son&rsquo;s hearing aids affordable.</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="heading1">&nbsp;</p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" height="157" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/apple.png" title="" width="504" /></a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2020 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2020 charity is the Boys &amp; Girls Club of Metro South.</p> <p><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/boysgirls.png" style="width: 351px; height: 172px;" title="" /></p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton 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>&nbsp;</p> <p class="bodytext"><strong>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 130 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> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/angeltree.png" style="width: 502px; height: 328px;" title="" /></p> <p>&nbsp;</p> <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 &amp; Girls Club of Metro South. Adam Russo and his helpers passed out hundreds of gifts to over 130 children. We hope these children enjoy their new toys as much as they enjoyed spending time with Santa!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/santa.png" style="width: 498px; height: 354px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>2019 Kennedy Service Award</strong></p> <p class="bodytext" style="text-align: justify;">Adam and Kelly Russo were honored with the 2019 Kennedy Service Award last week at the 2019 Great Futures Gala hosted by The Boys &amp; Girls Clubs of Metro South. Check out the link below to see highlights from this unforgettable night! To learn more about this award, <a href="https://www.bgcmetrosouth.org/greatfuturesgala" target="_blank">please visit</a></p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/kennedy.png" style="width: 462px; height: 583px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Thanksgiving Dinner Delivery</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Family was out and about the week of Thanksgiving, delivering Thanksgiving dinners to the families of The Boys and Girls Club of Metro South! Additionally, our Phia Family in Idaho was 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> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/thanksgiving2019.png" style="width: 464px; height: 285px;" title="" /></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">ACA Enrollment By The Numbers! Administration&#39;s Attempts To Stall The ACA At Work?</p> <p class="bodytext" style="font-weight: normal">By: Chris Aguiar, Esq. &ndash; December 2019 &ndash; <a href="https://www.sipconline.net/files/ACA Round-Up For 2020- Items Affecting Employer-Sponsored Group Health Plans by Corrie Cripps.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">With headlines focused on collusion, corruption, impeachment, and a wall being erected in Colorado, much of the political discourse in 2019 has avoided Healthcare Reform. In contrast, 2017 and 2018 featured many headlines with the current Administration doing everything within Its power to make good on a touchstone of Its 2016 campaign platform; President Trump and the Republican Party pushed for repeal and replacement of Barak Obama&rsquo;s crowning achievement, the Affordable Care Act. When they were unable to garner the votes, the President utilized powers outside the control of Congress to weaken key parts of the Law designed to ensure the viability of the Insurance Marketplace, as well as keeping the American public in the dark regarding enrollment by virtually defunding marketing efforts. Many feared these tactics would encourage disengagement of the young and healthy, demographics crucial to maintaining a balanced risk pool covered by the Marketplace. Did it work?</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/927/the-stacks-1st-quarter-2020" target="_blank">Click here to read the rest of this article</a> &nbsp;</p> <p><br /> <span class="bodytext"><strong>ACA Round-Up for 2020: Items Affecting Employer-Sponsored Group Health Plans </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Corrie Cripps &ndash; November 2019 &ndash; <a href="https://www.sipconline.net/files/ACA Round-Up For 2020- Items Affecting Employer-Sponsored Group Health Plans by Corrie Cripps.pdf" target="_blank">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">During this open enrollment season, plan sponsors of group health plans should be aware of any Affordable Care Act (ACA) changes that may affect the design and administration of their plans.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The case Texas v. United States is the ongoing litigation challenging the constitutionality of the ACA. A decision on this case is expected at any time from the Fifth Circuit Court of Appeals (&ldquo;Fifth Circuit&rdquo;). Any decision appears likely to be appealed to the Supreme Court. Whether or not the Supreme Court will take the case depends on how the Fifth Circuit rules. If the Supreme Court does not take the case, the Fifth Circuit&rsquo;s decision will remain the law; however, the agencies will most likely need to issue regulatory guidance on how they interpret the decision.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/927/the-stacks-1st-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p>&nbsp;</p> <p class="bodytext"><strong>The Tower of Babel-Talking Heads Talking Past Each Other</strong></p> <p class="bodytext">By: Ron E. Peck, Esq. &ndash; October 2019 &ndash; <a href="https://www.sipconline.net/files/The Tower of Babel-Talking Heads Talking Past Each Other by Ron E_ Peck.pdf" target="_blank">Self-Insurers Publishing Corp. </a></p> <p class="bodytext" style="text-align: justify;">As the 2020 Presidential Election draws closer, the topic of healthcare continues to dominate the airwaves. Be it media or debate, this is one of the (if not the) issue about which everyone is talking; but pay close attention and you&rsquo;ll notice they aren&rsquo;t all speaking the same language.</p> <p class="bodytext" style="text-align: justify;">One word everyone can agree upon is &ldquo;affordability.&rdquo; The issue, however, is that depending upon whom you ask, what it is that ought to be &ldquo;affordable&rdquo; differs. Some people throw the term &ldquo;access&rdquo; around, while others seek affordable &ldquo;care,&rdquo; whilst still others focus (candidly) on affordable insurance.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/927/the-stacks-1st-quarter-2020" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a></p> <p class="heading1">Phia&rsquo;s 2019 Speaking Engagements:</p> <p class="bodytext">&bull; 1/9/2019 &ndash; FMMA Conference &ndash; Austin, TX</p> <p class="bodytext">&bull; 2/27/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Denver, CO</p> <p class="bodytext">&bull; 3/8/2019 &ndash; UnitedAg Conference &ndash; Anaheim, CA</p> <p class="bodytext">&bull; 3/19/2019 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charlotte, NC</p> <p class="bodytext">&bull; 3/21/2019 &ndash; CGI Business Solutions Seminar &ndash; Woburn, MA</p> <p class="bodytext">&bull; 3/26/2019 &ndash; HFTPA Broker Meeting &ndash; Tyler, TX</p> <p class="bodytext">&bull; 4/3/2019 &ndash; BenefitsPRO Broker Expo &ndash; Miami, FL</p> <p class="bodytext">&bull; 4/5/2019 &ndash; Pareto Conference &ndash; Nashville, TN</p> <p class="bodytext">&bull; 4/7/2019 &ndash; Captive Symposium &ndash; Cayman Islands</p> <p class="bodytext">&bull; 4/8/2019 &ndash; National Beer Wholesalers Association Legislative Conference &ndash; Washington DC</p> <p class="bodytext">&bull; 4/12/2019 &ndash; FMMA 2019 Annual Conference &ndash; Dallas, TX</p> <p class="bodytext">&bull; 4/23/2019 &ndash; Johns Hopkins Industry Education Series &ndash; Baltimore, MD</p> <p class="bodytext">&bull; 4/24/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 4/25/2019 &ndash; BevCap&rsquo;s Best Practices Workshop &ndash; Orlando, FL</p> <p class="bodytext">&bull; 4/26/2019 &ndash; Society of Professional Benefit Administrators Annual Conference &ndash; Washington, D.C.</p> <p class="bodytext">&bull; 5/2/2019 &ndash; MassAHU Benefest 2019 Conference &ndash; Westborough, MA</p> <p class="bodytext">&bull; 5/14/2019 &ndash; Cypress Unversity &ndash; Las Vegas, NV</p> <p class="bodytext">&bull; 5/30/2019 &ndash; Contrarian Captive &ndash; Austin, TX</p> <p class="bodytext">&bull; 6/11/2019 &ndash; Leavitt Conference &ndash; Big Sky, MT</p> <p class="bodytext">&bull; 7/16/2019 &ndash; HCAA TPA Summit &ndash; Dallas, TX</p> <p class="bodytext">&bull; 7/31/2019 &ndash; 2019 MVP Academy &ndash; Wellesley, MA</p> <p class="bodytext">&bull; 8/20/2019 &ndash; Pritchard &amp; Jerden Employee Benefits Forum &ndash; Brookhaven, GA</p> <p class="bodytext">&bull; 9/17/2019 &ndash; WebTPA Annual Confernece &ndash; Dallas, TX</p> <p class="bodytext">&bull; 9/19/2019 &ndash; Employee Benefits Planning Association Conerence &ndash; Seattle, WA</p> <p class="bodytext">&bull; 9/30/2019 &ndash; SIIA National Educational Conference &amp; Expo &ndash; San Francisco, CA</p> <p class="bodytext">&bull; 10/27/2019 &ndash; 2019 Annual NASP Conference &ndash; Washington DC</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1">Phia&rsquo;s 2020 Speaking Engagements:</span></p> <p class="bodytext">&bull; 1/30/2020 &ndash; SunLife MVP Academy &ndash; San Diego, CA</p> <p class="bodytext">&bull; 1/31/2020 &ndash; 2020 Kairos Risk Management Summit &ndash; Phoenix, AZ</p> <p class="bodytext">&bull; 2/13/2020 &ndash; Artex Risk Solutions Conference &ndash; Orlando, FL</p> <p class="bodytext">&bull; 2/18/2020 &ndash; HMIG Producer Advisory Counsil &ndash; Amelia Island, FL</p> <p class="bodytext">&bull; 3/9/2020 &ndash; CICA Captive Conference &ndash; Palm Springs, CA</p> <p class="bodytext">&bull; 3/12/2020 &ndash; SunLife MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 3/26/2020 &ndash; TABA Spring Conference &ndash; Woodlands, TX</p> <p class="bodytext">&bull; 4/26/2020 &ndash; Berkley Captive Symposium &ndash; Caymen Islands</p> <p class="bodytext">&bull; 6/10/2020 &ndash; Leavitt Conference &ndash; Big Sky, MT</p> <p class="bodytext">&bull; 6/18/2020 &ndash; SunLife MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 7/14/2020 &ndash; HCAA TPA Summit &ndash; St. Louis, MO</p> <p>&nbsp;</p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employees of the Quarter:<br /> Igor Senic &amp; Desireé Erskine</span></p> <p class="bodytext" style="text-align: justify;"><strong>Desireé</strong> is always going above &amp; beyond to help everyone in the company. From trying to fix the fax machines &amp; printers, sending out all of the mail when we are short-staffed at the front desk, to setting up a computer at a coworker&rsquo;s home &amp; driving them to and from work. She does all of these extra things while being the main component of the OP department. Desireé is an extremely hard worker who has passion and truly cares about this company.</p> <p class="bodytext" style="text-align: justify;"><strong>Igor</strong> has worked so diligently over the past year in Accounting and it is well deserved. He has come up with multiple enhancements to improve and benefit the Accounting department.</p> <p class="bodytext" style="text-align: justify;">A few examples:</p> <p class="bodytext" style="text-align: justify;">(1) He has stepped up and has become someone on the team that the others can come to for assistance, ask questions, and resolve issues. (2) He set up training for the new Kentucky claims recovery specialists to make sure they are more comfortable with the Accounting payment process, along with trainings for the other accounting team members. (3) His knowledge of OP has helped make the OP payment processing more efficient &amp; he was part of updating the OP payment process from processing payments individually to being able to process multiple payments at one time.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/2020employee.png" style="width: 479px; height: 319px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;">Congratulations Desireé (pictured above) and Igor, and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1">Get to Know Our Employees of the Year:<br /> Megan Colter &amp; Joanna Wilmot</span></p> <p class="bodytext" style="text-align: justify;"><strong>Megan</strong> joined our team as a Consultant in 2018. Since that time Megan&rsquo;s duties have expanded to include final reviews of plan document checklists, assessments and SBC services. Megan has also been very helpful in training and mentoring new employees. Megan always makes sure the client&rsquo;s expectations and deadlines are met. She has been staying late and/or working from home and her effort is appreciated. Megan is a pleasure to work with and we are happy she is part of our team!</p> <p class="bodytext" style="text-align: justify;"><strong>Joanna</strong> is an exceptional example of a model employee. Her kindness, loyalty, enthusiasm, and dedication are only a few of the reasons why she deserves an employee of the year title. She is never short of energy which she selflessly offers to the team, her work product, and our clients.</p> <p class="bodytext" style="text-align: justify;">She is dedicated and hardworking. Over the course of this year she reviewed, audited and revised each process to maximize efficiency and productivity. Specifically, our clients continue to ask for customized approaches, reports, and notifications. Most recently a TPA client requested a tailored notification process for when a mutual client was being onboarded by a partner vendor. Joanna not only went out of her way to build a notification process for this TPA but she also immediately implemented this process for all clients. This is an example of the personal touch and consistency she exemplifies every day. Building a sense of community is important to Joanna as well. For Thanksgiving she organized a team-building and community give back opportunity for PACE. This shows she not only cares about her team, but about her community and the team&rsquo;s contribution to the community.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/employeeyear2020.png" style="width: 486px; height: 417px;" title="" /></p> <p class="bodytext">Congratulations Joanna &amp; Megan, 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">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Phia News</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>PACE&reg; Certification Is Making Waves</strong></p> <p class="bodytext">The PACE Certification program will educate you using 3 distinct chapters of information:</p> <p class="bodytext"><strong>Chapter One</strong></p> <p class="bodytext" style="text-align: justify;">Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.</p> <p class="bodytext"><strong>Chapter Two</strong></p> <p class="bodytext" style="text-align: justify;">Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.</p> <p class="bodytext"><strong>Chapter Three</strong></p> <p class="bodytext" style="text-align: justify;">Explains what PACE is, what PACE does, and how it&#39;s obtained, implemented, and utilized. The PACE Certification program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.</p> <p class="bodytext" style="text-align: justify;">Additionally, the PACE Certification program provides education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.</p> <p class="bodytext" style="text-align: justify;">Please see the <a href="https://www.phiagroup.com/Portals/phiagroup/2019 Flyers/PACE Cert Flyer.pdf" target="_blank">PACE Certification flyer</a>, as well as <a href="https://www.youtube.com/watch?v=8xNqiSuyiP0" target="_blank">this video</a> for more information.</p> <p class="bodytext" style="text-align: justify;">Please contact Michael Vaz (<a href="mailto:mvaz@phiagroup.com" target="_blank">mvaz@phiagroup.com</a>) for more information.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Ugly Sweater Contest</strong></p> <p class="bodytext" style="text-align: justify;">The Phia family held its famous ugly sweater contest the week before Christmas, and we had a great turnout this year! With all of the great sweaters, it was a close race for finding the person with the ugliest sweater, but once we tallied up all of the votes, we found a winner. Congratulations to Rob Jolly, who is pictured below in the brown bear getup!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/uglysweater.png" style="width: 445px; height: 272px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Halloween at Phia</strong></p> <p class="bodytext" style="text-align: justify;">Phia had its annual Halloween costume competition in late October. There were a lot of great costumes on display, but we could only choose one winner. Congrats to Ben Mooney, the homeless man with a passion for healthcare!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/halloween2020.png" style="width: 459px; height: 296px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Candy Corn Contest</strong></p> <p class="bodytext" style="text-align: justify;">We set up a little contest at the front desk and asked everyone to guess how many candy corn! The winner was Andrew Fine, and the total count was 408. Andrew guessed that there were 402 pieces of candy corn. It&rsquo;s hard to believe that all of those pieces of candy fit into that tiny jar!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter%20Q1%202020/candycorn.png" style="width: 450px; height: 472px;" title="" /></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p><span class="boldtext">Job Opportunities:</span></p> <p>&bull; PACE Specialist</p> <p>&bull; Administrative Assistant</p> <p>&bull; Staff Attorney &ndash; PGC</p> <p>&bull; Health Plan Documentation Specialist</p> <p>&bull; Claims Specialist, Provider Relations</p> <p>&bull; Manager, Talent Acquisition</p> <p>&bull; Case Investigator I</p> <p>&bull; Data / ETL Analyst</p> <p>&bull; Provider Relations Client Concierge</p> <p>&bull; Vice President of Client Solutions and Account Management</p> <p>&bull; Human Resources Compliance Specialist</p> <ul class="bodytext"> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a><br /> &nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Promotions</strong><br /> <br /> &bull; Bethany LaChance has been promoted from Case Investigator to Claim Recovery Specialist III</p> <p class="bodytext" style="text-align: justify;">&bull; Dylan Fry has been promoted from Case Investigator to Senior Claim Recovery Specialist</p> <p class="bodytext" style="text-align: justify;">&bull; Allison Britton has been promoted from Case Investigator to Legal Assistant</p> <p class="bodytext" style="text-align: justify;">&bull; Brenna Jackson has been promoted from Legal Assistant to Senior Claim Recovery Specialist</p> <p class="bodytext" style="text-align: justify;">&bull; Jiyra Martinez has been promoted from Customer Service Representative to Senior Claim Recovery Specialist</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> &bull; Diane Mcauley was hired as an Executive Assistant</p> <p class="bodytext">&bull; Arianna Hibbard was hired as an Executive Assistant</p> <p class="bodytext">&bull; Robert Jolly was hired as a Claim And Case Support Analyst</p> <p class="bodytext">&bull; Jessica Grande was hired as an Intake Specialist</p> <p class="bodytext">&bull; Alyssa Campbell was hired as a Case Investigator</p> <p class="bodytext">&bull; Elizabeth Painten was hired as a Human Resources Assistant</p> <p class="bodytext">&bull; Corey Crigger was hired as a Provider Relations Attorney</p> <p class="bodytext">&bull; Joshua Farley was hired as a Provider Relations Attorney</p> <p class="bodytext">&bull; Cole Wagner was hired as an Accounting Assistant</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter%20Q1%202018/footerlogo.png" 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> 928The Stacks – 1st Quarter 2020https://www.phiagroup.com/Media/Posts/PostId/927/the-stacks-1st-quarter-2020NewslettersTue, 14 Jan 2020 18:48:36 GMT<p><strong><span style="font-size:130%;"><span style="color:#0071CE;">ACA Enrollment By The Numbers! Administration&rsquo;s attempts to stall the ACA At Work?</span></span></strong></p> <p><strong><span style="font-size:130%;"><span style="color:#0071CE;">By: Christopher Aguiar, Esq. </span></span></strong></p> <p style="text-align: justify;">With headlines focused on collusion, corruption, impeachment, and a wall being erected in Colorado, much of the political discourse in 2019 has avoided Healthcare Reform. In contrast, 2017 and 2018 featured many headlines with the current Administration doing everything within Its power to make good on a touchstone of Its 2016 campaign platform; President Trump and the Republican Party pushed for repeal and replacement of Barak Obama&rsquo;s crowning achievement, the Affordable Care Act. When they were unable to garner the votes, the President utilized powers outside the control of Congress to weaken key parts of the Law designed to ensure the viability of the Insurance Marketplace, as well as keeping the American public in the dark regarding enrollment by virtually defunding marketing efforts. Many feared these tactics would encourage disengagement of the young and healthy, demographics crucial to maintaining a balanced risk pool covered by the Marketplace. Did it work?</p> <p style="text-align: justify;">It all came to a head when, in rather theatrical fashion, the late Senator John McCain stood on the Senate floor and casted his vote with a momentous <em>thumbs down</em>, as though he was a dictator in Ancient Rome deciding the fate of a gladiator on the heels of a losing battle. This iconic moment marked the end of a legislative war of words, highlighted to that point by Twitter attacks from the President, himself, where the Republican Party was unable to garner the 50 votes necessary under the Budget Reconciliation Act to pass the Better Care Reconciliation Act. What followed was a tactical maneuvering by President Trump to undermine of key features of the ACA through his control of federal agencies and national purse strings.</p> <p style="text-align: justify;">First came a backhanded legislative maneuver wherein the Administration built Reform provisions into a tax bill. In December of 2017, President Trump signed the Tax Cuts and Jobs Act (&ldquo;TCJA&rdquo;). Among many other provisions, the Bill effectively directed the Internal Revenue Service to cease enforcing the Individual Mandate. In so doing, the Government would no longer penalize Americans who chose not to purchase health insurance. So, even though the Affordable Care Act was still the Law of the Land, one of the key provisions intended to protect the health of the risk pool by ensuring it was balanced and included not only the old and sick but also the young and healthy, now had no teeth. Many posited this lack of enforcement could hamstring the Law by encouraging the very malady it was designed to avoid, adverse selection. Without the tax to be levied upon non-compliant Americans, another important challenge to the Law was also set in motion, Its constitutionality.</p> <p style="text-align: justify;">When now Chief Justice Roberts upheld the constitutionality of the Affordable Care Act in an historic 2012 Supreme Court decision, it was upon enforcement of this provision that he relied. Specifically, Roberts held in <em>National Federation of Independent Business v. Sebelius</em>, 567 U.S. 519 (<strong>2012</strong>) that the Law was constitutional because the Federal Government was empowered to generate revenue. This <em>penalty</em>, as it was initially labeled, to be levied against Americans who chose not to purchase health insurance, then, was actually a tax, a permissible exercise of the Government&rsquo;s power of taxation. So, too, was the Affordable Care Act considered constitutional. With the Administration&rsquo;s removal of enforcement of this tax, without repealing the Law or provision itself, the constitutionality of the Affordable Care Act is again called into question because where no revenue is generated, the Individual Mandate is now arguably invalid. Such is the question to be answered by The Supreme Court when it issues a ruling <em>Texas v. US</em>, 809 F. 3d 134 (2015). Though oral arguments took place in July of 2019, no ruling has been issued.</p> <p style="text-align: justify;">The final act taken by the Administration was an exercise of the Executive Branch&rsquo;s control of money. Specifically, it is within the power of the president to control how certain federal funds are spent, a power which allowed President Trump to slash the Affordable Care Act&rsquo;s marketing budget by 90%. The fear? With significantly less advertising of open enrollment, would American&rsquo;s be aware of the Open Enrollment period and how they could go about purchasing coverage on the Exchange?</p> <p style="text-align: justify;">Though not significant, the efforts may have had some impact on the enrollment which occurred from November 1 through December 15, 2018. According to Kaiser Family Foundation as well as the Centers for Medicare &amp; Medicaid Services (&ldquo;CMS&rdquo;), enrollment through Healthcare.gov was down 4% in 2018 as compared to 2017. Overall, enrollment was down 3% in 2018 as compared to 2017. Those numbers seem insignificant when you consider the significant budgetary limitations that were placed on advertising, but perhaps the more telling and concerning data lies in the decline of new enrollees and percentage of those who qualified for subsidies. With respect to enrollees, 39% of enrollees were new in 2016. That number in 2017 had fallen to 31%, and even further in 2018 to 24%.</p> <p style="text-align: justify;">Perhaps the most concerning data point, however, is the percentage of new enrollees who qualify for premium subsides/tax credits. Those who qualify for these subsidies do so because they are individuals or families with low to moderate income levels. In 2017, 83% of new enrollees qualified for these subsidies. In 2018, that number grew to 87%. This indicates that lower income individuals and families are flocking to the health insurance exchanges at significantly higher rates than their wealthier (and perhaps, healthier) counterparts. Historically, data suggests that lower income individuals also tend to be less healthy. Accordingly, it appears the fear of adverse selection may indeed be manifesting itself as the young and healthy seem to be avoiding entering the Marketplace, either due to obtaining benefits through employee sponsored plans, or their willingness to gamble on their youth to save a buck.</p> <p style="text-align: justify;">It is difficult to ascertain with certainty whether the policy decisions made by the current Administration truly have a causal link to the drop indicated above, or if the connection is simply correlative. The numbers themselves speak to a very ominous reality. The number of new enrollees is declining each year. Additionally, the Marketplace appears to be obtaining a higher rate of enrollees annually in the low to moderate income demographic. Finally, 1/3 of new enrollees, annually, appear to be over the age of 55 and 64% are over the age of 35. As we head into 2020 and what should be another year of significant reform rhetoric, a Supreme Court decision that could leave the Country without a healthcare system on the books, and Healthcare once again top of mind in a presidential election cycle, the Administration will continue to attempt to repeal the Affordable Care Act, or endeavor to limit its efficacy. If adverse selection is in fact coming to fruition as the data seems to support, the Affordable Care Act may be headed for its demise either organically or though direct legislative attacks. It will certainly not be aided by an administration that will actively undermine the parts of a healthcare system that were intended to ensure its success; a flawed system that often leaves Americans footing a significant bill. Even with these attempts, the Republican Party has failed to clearly put forth a viable replacement. Be it with the ACA in some form, a Republican alternative, or the &ldquo;Medicare for All&rdquo; approach being touted by the large contingent Democratic candidates, Healthcare discussion is here to stay.</p> <p style="text-align: justify;">____________________________________________________________________________________________________</p> <p><span style="color:#0071CE;"><span style="font-size:130%;"><strong>ACA Round-Up for 2020: Items Affecting Employer-Sponsored Group Health Plans</strong></span></span></p> <p><strong><span style="font-size:130%;"><span style="color:#0071CE;">By: Corrie Cripps</span></span></strong></p> <p style="text-align: justify;">During this open enrollment season, plan sponsors of group health plans should be aware of any Affordable Care Act (ACA) changes that may affect the design and administration of their plans.</p> <p style="text-align: justify;">The case <em>Texas v. United States<sup>1</sup></em> is the ongoing litigation challenging the constitutionality of the ACA. A decision on this case is expected at any time from the Fifth Circuit Court of Appeals (&ldquo;Fifth Circuit&rdquo;). Any decision appears likely to be appealed to the Supreme Court. Whether or not the Supreme Court will take the case depends on how the Fifth Circuit rules. If the Supreme Court does not take the case, the Fifth Circuit&rsquo;s decision will remain the law; however, the agencies will most likely need to issue regulatory guidance on how they interpret the decision.</p> <p style="text-align: justify;">As of the date of this article, the Trump administration is continuing to enforce the ACA. As such, plans will need to ensure they are maintaining compliance with the ACA provisions. The following is a summary of the recent regulatory actions that will affect self-insured plans in 2020.</p> <p style="text-align: justify;"><strong><u>ACA Contraceptive Mandate</u></strong></p> <p style="text-align: justify;"><em>Update on the Obama-Era Rules</em></p> <p style="text-align: justify;">On June 5, 2019, U.S. District Judge Reed O&rsquo;Conner of the Northern District of Texas issued a nationwide injunction<sup>2</sup> against the Affordable Care Act&rsquo;s (ACA&rsquo;s) contraceptive mandate and its accommodation process, stating the mandate can no longer be enforced against employers who object to contraceptive coverage as it violates the Religious Freedom Restoration Act (RFRA). The injunction applies to all employers and individuals who object to contraceptive coverage based on sincerely held religious beliefs.</p> <p style="text-align: justify;">The case, <em>DeOtte v. Azar</em><sup>3</sup>, was filed in October 2018 on the grounds that the plaintiffs (two Christian couples and one business whose owner is a Christian [Braidwood Management Inc.]) are forced to choose between purchasing health insurance that includes contraceptive coverage or not having insurance. The basis of the claim is having to choose between covering contraceptives under its group health plan, complying with the accommodation process of the contraceptive mandate, or paying a penalty for noncompliance. The court ruled that requiring employers with religious objections to use the contraceptive mandate&rsquo;s accommodation violates RFRA, as does requiring individuals to obtain coverage with contraceptives.</p> <p style="text-align: justify;">This decision will apply to all employers that object to the contraceptive mandate, based on sincerely held religious beliefs, regardless of size or status as a nonprofit or for-profit entity. Since these employers are now exempt from the accommodation process, employees under these employer group health plans will no longer have coverage for some or all contraceptive services.</p> <p style="text-align: justify;">As for individuals, this decision allows individuals who object to some or all contraceptive services based on sincerely held religious beliefs to &ldquo;&hellip;purchase or obtain health insurance that excludes coverage or payments for some or all contraceptive services from a health insurance issuer, or from a plan sponsor of a group plan, who is willing to offer a separate benefit package option, or a separate policy, certificate, or contract of insurance that excludes coverage or payments for some or all contraceptive services.&rdquo; Based on this injunction, it is not clear if self-funded plans will need to offer a separate plan that does not include contraceptive coverage for employees who are religious objectors.</p> <p style="text-align: justify;">There is a safe harbor for officials who enforce the contraceptive mandate. Under the safe harbor, the federal government can ask whether an employer or individual that fails to comply with the contraceptive mandate is a sincere religious objector and file notice in court &ldquo;&hellip;if the defendants reasonably and in good faith doubt the sincerity of that employer or individual&rsquo;s asserted religious objections&rdquo;. Federal regulators can also enforce the mandate against those who are found by a court to not be sincere religious objectors.</p> <p style="text-align: justify;"><em>Update on the Trump Administration Rules</em></p> <p style="text-align: justify;">There are at least three lawsuits&mdash;brought in California, Massachusetts, and Pennsylvania&mdash;challenging the Trump administration&rsquo;s final rules on religious and moral objections to the contraceptive mandate.<sup>4,5</sup> Those rules were set to go into effect in January 2019 until they were enjoined by federal district court judges in Pennsylvania and California.</p> <p style="text-align: justify;">The rulings in Pennsylvania and California do not permanently block the new rules on the contraceptive coverage exemptions; however, the rulings stop the rules from going into effect while legal challenges are pursued.</p> <p style="text-align: justify;">Those employers who are potentially eligible for the expanded exemptions of the Trump administration&rsquo;s final rules and wish to utilize an exemption in the future will need to closely monitor the latest developments.</p> <p style="text-align: justify;"><strong><u>Out-of-Pocket Limits for Non-Grandfathered Plans</u></strong></p> <p style="text-align: justify;"><em>2020 Out-of-Pocket Maximums</em></p> <p style="text-align: justify;"><em><u>For non-HDHPs</u>:</em></p> <p style="text-align: justify;">The Health and Human Services Department issued a Final Rule on its Notice of Benefit and Payment Parameters for 2020 (2020 NBPP Final Rule).<sup>6</sup> The ACA 2020 maximum annual limitation on cost-sharing is $8,150 for individual coverage and $16,300 cumulative for family coverage. (Note that the ACA&rsquo;s embedded self-only limitation is $8,150 for family plans).</p> <p style="text-align: justify;"><em><u>For HSA-compatible HDHPs</u>:</em></p> <p style="text-align: justify;">In Revenue Procedure 2019-25, the Internal Revenue Service (IRS) provided the inflation-adjusted Health Savings Account (HSA) contribution limits effective for calendar year 2020, along with minimum deductible and maximum out-of-pocket expenses for the high-deductible health plans (HDHPs) that HSAs are coupled with.<sup>7</sup> For HDHP self-only coverage, the minimum deductible amount cannot be less than $1,400. The 2020 maximum out-of-pocket expense amount for self-only coverage is $6,900. For 2020 family coverage, the minimum deductible amount is $2,800 and the out-of-expense maximum is $13,800. (Note that the ACA&rsquo;s embedded self-only limitation is $8,150 for family plans).</p> <p style="text-align: justify;"><em>Drug Manufacturer Coupons</em></p> <p style="text-align: justify;">Per the 2020 NBPP Final Rule, health plans are not required to count drug manufacturer coupons toward the annual limit on cost-sharing when a medically appropriate generic equivalent is available.</p> <p style="text-align: justify;">On August 26, 2019, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, &ldquo;the Departments&rdquo;) issued a joint FAQ regarding limitations on cost-sharing under the ACA.<sup>8</sup> Specifically, the FAQ addresses whether non-grandfathered group health plans must count drug manufacturers&rsquo; coupons toward the annual cost-sharing/out-of-pocket limits under the ACA.</p> <p style="text-align: justify;">Per this new FAQ, it came to the attention of the Departments that the drug manufacturer coupon&nbsp; provision of the 2020 NBPP Final Rule could create a conflict with the IRS regulations pertaining to HDHPs. Specifically, Q&amp;A 9 of IRS Notice 2004-50 provides that the provision of drug discounts will not disqualify an individual from being eligible (for the HDHP) if the individual is responsible for paying the costs of the drugs (considering the discount) until the deductible is met.<sup>9</sup> This Q&amp;A requires the HDHP to <em>disregard</em> the drug assistance when determining whether the minimum deductible for an HDHP had been satisfied by only allowing amounts <em>actually paid</em> by the individual to be taken into account for that purposes.</p> <p style="text-align: justify;">The 2020 NBPP Final Rule, layered with the existing IRS Q&amp;A, creates conflicting policy.&nbsp;As a result, the Departments, as stated in this August 2019 FAQ, realize this &ldquo;ambiguity&rdquo; and intend to undertake future rulemaking for 2021. In addition, until 2021, the Departments will not initiate an enforcement action if a group excludes the value of drug assistance from the annual limitation on cost sharing, <em>including in circumstances in which there is no medically appropriate generic available.</em></p> <p style="text-align: justify;">Plans, however, when implementing or utilizing such a provision should be cognizant that this does not conflict with the existing Q&amp;A for HDHPs.</p> <p style="text-align: justify;">Prior to adopting such a provision, the plan, employer, and all related entities should ensure they understand the impact for the participants and the plan.</p> <p style="text-align: justify;"><strong><u>New (or Modified) Preventive Care Recommendations for Non-Grandfathered Health Plans</u></strong></p> <p style="text-align: justify;">The Affordable Care Act&rsquo;s (ACA) preventive services mandate for non-grandfathered plans requires certain preventive services be covered in-network without cost-sharing for plan participants. The ACA uses the following when determining the preventive services that must be covered:</p> <ol style="margin-left: 40px;"> <li style="text-align: justify;" value="NaN">Evidence-based items or services rated A or B in the United States Preventive Services Task Force (USPSTF) recommendations.</li> <li style="text-align: justify;" value="NaN">Recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention (CDC).</li> <li style="text-align: justify;" value="NaN">Comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA).</li> <li style="text-align: justify;" value="NaN">Comprehensive guidelines for women supported by the Health Resources and Services Administration (HRSA).</li> </ol> <p style="text-align: justify;">The final preventive services regulations, issued in July 2015, contain guidelines for when plans must incorporate any modified recommendations.<sup>10</sup></p> <p style="text-align: justify;">The following are new or modified preventive care recommendations that become effective in 2020:</p> <p style="text-align: justify; margin-left: 40px;"><strong>1. Skin Cancer Prevention (Date Issued: March 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)</strong></p> <p style="margin-left: 0.5in; text-align: justify;">The USPSTF updated its 2012 recommendation on skin cancer prevention. In this updated recommendation, the USPSTF expanded the age range for behavioral counseling interventions to include persons aged 6 months to 24 years with fair skin types (the previous recommendation applied to persons aged 10 to 24 years, based on the evidence available at that time).<sup>11</sup></p> <p style="text-align: justify; margin-left: 40px;"><strong>2. Screening for Osteoporosis to Prevent Fractures (Date Issued: June 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)</strong></p> <p style="margin-left: 0.5in; text-align: justify;">The USPSTF recommends osteoporosis screening for postmenopausal women younger than 65 years at increased risk of osteoporosis (created from prior osteoporosis screening mandates, this requirement clarifies the population for screening, introduces reference to menopause, and references clinical risk assessment for determining increased risk).<sup>12</sup></p> <p style="text-align: justify; margin-left: 40px;"><strong>3. Spinal muscular atrophy screening for newborns (Date Issued: July 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)</strong>&nbsp;</p> <p style="margin-left: 0.5in; text-align: justify;">The Uniform Panel of the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (an HRSA task force) added newborn screening for certain kinds of spinal muscular atrophy.<sup>13</sup></p> <p style="text-align: justify; margin-left: 40px;"><strong>4. Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults (Date Issued: September 2018;</strong> <strong>Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)</strong></p> <p style="margin-left: 0.5in; text-align: justify;">The USPSTF updated its previous 2012 recommendation statement on screening for obesity in adults. While it is still a &ldquo;B&rdquo; recommendation, the USPSTF expanded the description of behavioral counseling interventions. As with the 2012 recommendation, the 2018 recommendation is that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher (calculated as weight in kilograms divided by height in meters squared) to intensive, multicomponent behavioral interventions.<sup>14</sup> The only update to the recommendation is the expansion of the type of behavioral counseling interventions.</p> <p style="text-align: justify; margin-left: 40px;"><strong>5. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults (Date Issued: October 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)</strong></p> <p style="margin-left: 0.5in; text-align: justify;">This USPSTF recommendation incorporates new evidence since 2013 and provides additional information about the types of ongoing support services that appear to be associated with positive outcomes.<sup>15</sup></p> <p style="text-align: justify;"><strong><u>ACA Reporting</u></strong></p> <p style="text-align: justify;">Both the Employer Shared Responsibility Mandate (&ldquo;Employer Mandate&rdquo;) and the Individual Shared Responsibility Mandate (&ldquo;Individual Mandate&rdquo;) of the ACA continue to apply. As such, Applicable Large Employers (ALEs) will need to ensure they file the applicable forms for Internal Revenue Code (IRC) &sect;&sect; 6055 and 6056 reporting in early 2020.</p> <p style="text-align: justify;"><strong><u>Conclusion</u></strong></p> <p style="text-align: justify;">For plans and TPAs, being well-informed on regulatory developments is always of the upmost importance. Plan sponsors should review their plan documents as well as their plan administration procedures to ensure they are compliant.</p> <div> <div id="ftn1"> <p><em><sup>1</sup>Texas v. United States</em>, Partial Summary Judgment, <a href="https://www.documentcloud.org/documents/5629711-Texas-v-US-Partial-Summary-Judgment.html">https://www.documentcloud.org/documents/5629711-Texas-v-US-Partial-Summary-Judgment.html</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn2"> <p><em><sup>2</sup>DeOtte v. Azar</em>, Summary Judgment Order, <a href="https://affordablecareactlitigation.files.wordpress.com/2019/06/deotte-summary-judgment-order.pdf">https://affordablecareactlitigation.files.wordpress.com/2019/06/deotte-summary-judgment-order.pdf</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn3"> <p><em><sup>3</sup>DeOtte v. Azar</em>, Plaintiffs&rsquo; Class-Action Complaint, <a href="https://affordablecareactlitigation.files.wordpress.com/2019/05/deotte-complaint.pdf">https://affordablecareactlitigation.files.wordpress.com/2019/05/deotte-complaint.pdf</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn4"> <p><em><sup>4</sup>Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act,</em> 26 CFR Part 54, 29 CFR Part 2590, 45 CFR Part 147, October 13, 2017, <a href="https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21851.pdf">https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21851.pdf</a>, (last visited October 1, 2019).</p> </div> <div id="ftn5"> <p><em><sup>5</sup>Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act</em>, 26 CFR Part 54, 29 CFR Part 2590, 45 CFR Part 147, October 13, 2017, &nbsp;<a href="https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21852.pdf">https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21852.pdf</a>, (last visited October 1, 2019).</p> </div> <div id="ftn6"> <p><em><sup>6</sup>Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020</em>, 45 CFR Parts 146, 147, 148, 153, 155, and 156, April 25, 2019, <a href="https://www.govinfo.gov/content/pkg/FR-2019-04-25/pdf/2019-08017.pdf">https://www.govinfo.gov/content/pkg/FR-2019-04-25/pdf/2019-08017.pdf</a>, (last visited October 1, 2019).</p> </div> <div id="ftn7"> <p><sup>7</sup>Internal Revenue Bulletin: 2019-22, Rev. Proc. 2019-25, May 28, 2019, <a href="https://www.irs.gov/irb/2019-22_IRB#REV-PROC-2019-25">https://www.irs.gov/irb/2019-22_IRB#REV-PROC-2019-25</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn8"> <p><sup>8</sup>Employee Benefits Security Administration, <em>Frequently Asked Questions (FAQs) about Affordable Care Act (ACA) Implementation Part 40</em>, August 26, 2019, <a href="https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-40">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-40</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn9"> <p><sup>9</sup>Internal Revenue Bulletin No. 2004-33, August 16, 2004, <a href="https://www.irs.gov/pub/irs-irbs/irb04-33.pdf">https://www.irs.gov/pub/irs-irbs/irb04-33.pdf</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn10"> <p><em><sup>10</sup>Coverage of Certain Preventive Services Under the Affordable Care Act</em>, 26 CFR Part 54, 29 CFR Parts 2510 and 2590, 45 CFR Part 147, July 14, 2015, <a href="https://www.govinfo.gov/content/pkg/FR-2015-07-14/pdf/2015-17076.pdf">https://www.govinfo.gov/content/pkg/FR-2015-07-14/pdf/2015-17076.pdf</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn11"> <p><sup>11</sup>U.S. Preventive Services Task Force, <em>Skin Cancer Prevention: Behavioral Counseling</em>, March 2018, <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-counseling2">https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-counseling2</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn12"> <p><sup>12</sup>U.S. Preventive Services Task Force, <em>Osteoporosis to Prevent Fractures: Screening</em>, June 2018, <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosis-screening1?ds=1&amp;s=osteoporosis">https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosis-screening1?ds=1&amp;s=osteoporosis</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn13"> <p><sup>13</sup>Health Resources &amp; Services Administration, <em>Recommendations to HHS Secretary with Responses: Spinal Muscular Atrophy (SMA)</em>, <a href="https://www.hrsa.gov/advisory-committees/heritable-disorders/recommendations-reports/index.html">https://www.hrsa.gov/advisory-committees/heritable-disorders/recommendations-reports/index.html</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn14"> <p><sup>14</sup>U.S. Preventive Services Task Force, <em>Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions</em>, September 2018, <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-interventions1">https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-interventions1</a>, (Last visited October 1, 2019).</p> </div> <div id="ftn15"> <p><sup>15</sup>U.S. Preventive Services Task Force, <em>Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening</em>, October 2018, <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening1?ds=1&amp;s=violence">https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening1?ds=1&amp;s=violence</a>, (Last visited October 1, 2019).</p> <p>_________________________________________________________________________________________________</p> <p><span style="color:#0071CE;"><span style="font-size:130%;"><strong>The Tower of Babel &ndash; Talking Heads Talking Past Each Other</strong></span></span></p> <p><strong><span style="font-size:130%;"><span style="color:#0071CE;">By: Ron E. Peck, Esq. </span></span></strong></p> <p>As the 2020 Presidential Election draws closer, the topic of healthcare continues to dominate the airwaves.&nbsp; Be it media or debate, this is one of the (if not the) issue about which everyone is talking; but pay close attention and you&rsquo;ll notice they aren&rsquo;t all speaking the same language.</p> <p><strong><u>Access vs. Care vs. Insurance</u></strong></p> <p>One word everyone can agree upon is &ldquo;affordability.&rdquo;&nbsp; The issue, however, is that depending upon whom you ask, what it is that ought to be &ldquo;affordable&rdquo; differs.&nbsp; Some people throw the term &ldquo;access&rdquo; around, while others seek affordable &ldquo;care,&rdquo; whilst still others focus (candidly) on affordable insurance.</p> <p>Interestingly, for many, the term they use (access versus healthcare) matters little, as &ndash; once their position is better defined &ndash; a shrewd listener will note that the goal is ultimately the same; make insurance cheaper.&nbsp; They seem to believe that insurance is healthcare, and cheaper insurance is thereby cheaper healthcare.&nbsp; Further, they believe that the only &ldquo;cost&rdquo; of healthcare, incurred by an insured person is their premium, co-pay, coinsurance, and deductible.</p> <p>This, then, is one misconception that continues to dominate political, regulatory, and economic discourse; that by attacking the cost of insurance for the general populace (i.e. premiums/contributions, co-pays, coinsurance, and deductibles), you somehow fix the problem of limited access and/or the high cost of healthcare.</p> <p><strong><u>Health Insurance is Not Healthcare</u></strong></p> <p>I&rsquo;ve written in the past, and continue to argue today, that health insurance is not healthcare.&nbsp; Health insurance is one means by which the risk of payment for healthcare is shifted from the consumer of healthcare to a third-party payer.&nbsp; Changing who pays for healthcare doesn&rsquo;t (on its own) address how much the healthcare costs.&nbsp; For instance, before you argue that Congress should establish a funding mechanism to support the &ldquo;cost of caring&rdquo; for those with significant medical needs, ask first what it means to pay for care.&nbsp; Are you referring to the cost of insurance, or the cost of the &ldquo;actual&rdquo; health care for which insurance pays?</p> <p>Some might argue, however, that when a &ldquo;new&rdquo; payer is designated, (be it insurance, a self-funded plan, or the government), if they are large enough and possess enough clout, they can strongarm the provider into accepting lower prices for care &ndash; thereby reducing the actual cost of care.&nbsp; Thus, while making insurance more affordable doesn&rsquo;t in and of itself reduce the cost of care, by providing more lives (and this negotiation power) to the payer, those payers in turn are provided with more &ldquo;power&rdquo; to force providers into accepting lower prices.&nbsp; Indeed, a single-payer would hold all the cards, and thus name their own price.</p> <p>In a vacuum it makes sense, and if we were purchasing potatoes or tires it may work (in a truly free-market environment), however, in healthcare some features apply that are unique to this industry.</p> <p><strong><u>A Non-Market Market</u></strong></p> <p>In any other market, a vendor of goods or services can set any price for those goods or services.&nbsp; Supply, demand, and competition will then force the vendor to increase or reduce their price or fail.&nbsp; This allows the &ldquo;free market&rdquo; to naturally set prices at a level both the seller and buyer can live with.&nbsp; In healthcare, however, providers leverage things like technology, reputation, rankings, and sponsorships to compete for &ldquo;customers&rdquo; (a/k/a patients), rather than the price.&nbsp; Providers compete for these other things; if and when price is a matter over which there is competition between vendors (providers), it&rsquo;s a competition to see who can charge the most.&nbsp; Indeed, one of the big pushbacks against transparent pricing in healthcare is that some providers will see that other providers &ldquo;get away&rdquo; with charging higher prices for the same services &hellip; and will increase their rates to match.&nbsp; Imagine if that same argument applied to every other industry; that the cost of bananas couldn&rsquo;t be transparent, because grocers will compete to raise prices faster than the competition.&nbsp; Welcome to a world where the consumer has no skin in the game, and no price-based incentive to pick the lower cost options exists.</p> <p>In healthcare, where patients don&rsquo;t know, or (they think) pay the price of healthcare (at the time the care is consumed), and the consumer doesn&rsquo;t appreciate the impact of higher healthcare prices on insurance costs, providers are able to freely raise prices without the negative repercussions vendors in other industries would immediately suffer.&nbsp; Additionally, even if patients know the price, if they (at least in their mind) don&rsquo;t think they are the ones paying the price, then higher prices will &ndash; at best &ndash; not dissuade them from consuming care, and &ndash; at worst &ndash; will steer them away from reasonably priced care to higher cost providers, thanks to an (inaccurate) assumption that higher price equates to higher quality.&nbsp;</p> <p><strong><u>Quantum Meruit</u></strong></p> <p>At the same time, contract law states that a customer who agrees to pay a certain price for a service or product has entered into a contract with the vendor.&nbsp; This preemptive agreement between the customer and vendor, regarding what will be paid, and what will be received by the customer, is titled a &ldquo;meeting of the minds.&rdquo;&nbsp; If the customer later fails to pay the amount to which they&rsquo;d previously agreed, this would be deemed a breach of contract.&nbsp; Even if objectively, one could argue the agreed upon price is excessive, assuming the customer had the requisite capacity to enter into such a deal, the contract is binding.&nbsp; If, however, someone receives a good or service but there was no meeting of the minds (agreement about what would be provided, and a specific price for said goods or services), the customer will be forced to pay an objectively reasonable price &ndash; determined by an objective third party, using objective pricing parameters &ndash; and NOT whatever price the vendor chooses to collect.&nbsp; This concept, called Quantum Meruit, ensures vendors are adequately compensated based upon objectively reasonable parameters, and customers are not unjustly enriched (don&rsquo;t &ldquo;get something for nothing&rdquo;) but also aren&rsquo;t forced to pay a price they never agreed to (and which is excessive by all reasonable, objective measurements).</p> <p>In healthcare, however, rarely can we say there is truly a meeting of the minds.&nbsp; It is rare indeed to see a provider (the vendor) and patient (the consumer) agree upon a price prior to the provision of services.&nbsp; Yet, despite this, Quantum Meruit &ndash; applicable to other commercial exchanges &ndash; has no place in healthcare, and rather, the provider is allowed to balance bill the patient whatever amount it wants &ndash; usually the amount that exists between the provider&rsquo;s &ldquo;charge master&rdquo; price, and what it already received from the applicable carrier or benefit plan.&nbsp; Note that the only prohibition on this billing practice is the prior existence of a contract between a payer and the provider, by whose terms the provider agrees to accept the payer&rsquo;s payment as payment in full.&nbsp; This agreement, many argue, is the greatest value a network offers.</p> <p>Given that the law protects a provider&rsquo;s right to charge whatever they wish &ndash; with no limits based in reasonableness, meeting of the minds, or Quantum Meruit &ndash; and limited only by pre-negotiated contracts, payers generally negotiate from a weak position.</p> <p>As such, simply ensuring everyone has insurance will not drastically reduce the cost of healthcare itself.&nbsp; Further, people &ndash; whether they are insured or not &ndash; will pay the cost when healthcare is too expensive.&nbsp; Be it balance bills for the uninsured, or rising premiums and deductibles for the insured &ndash; the money needs to come from somewhere.</p> <p>Compounding the issue further is that fact that Americans generally suffer from a lack of long-term vision.&nbsp; We are, as a society, driven by a need for instant gratification.&nbsp; People use credit cards to buy things now, that they can&rsquo;t afford later.&nbsp; People purchase homes and take out mortgages now, that they can&rsquo;t afford later.&nbsp; Likewise, people obtain healthcare now that they can&rsquo;t afford later.&nbsp; Make no mistake; even those with insurance pay the cost later, in the form of higher premiums, co-pays, deductibles, and co-insurance.&nbsp; Therein lies the rub &ndash; people are quick to target out of pocket expenses at the time care is received, and the cost of insurance in general, but they do so without asking why insurance is expensive or addressing that root cause.</p> <p>Until people understand that &ndash; with or without insurance &ndash; patients will ultimately be responsible for the actual cost of care, then the issue will not be resolved.&nbsp; In other words, focusing on the rising out of pocket expenses, such as premiums, co-pays, and deductibles &ndash; without also focusing on why these expenses are increasing &ndash; addresses a symptom without diagnosing the disease.</p> <p><strong><u>What Does This Mean for Us?</u></strong></p> <p>Many candidates and their supporters are proponents of the so-called &ldquo;Medicare for All&rdquo; plan, yet even many who support those candidates are beginning to hesitate, worrying that under Medicare payment rates (forced down providers&rsquo; throats by a single payer monopoly), some hospitals struggling to stay open might close. &nbsp;Here, then, we see the opposite issue &ndash; ushered in when a monopoly is in place.&nbsp; A single payer with too much power can force opposition into accepting unduly low, unfair rates.</p> <p>Is there a happy medium?&nbsp; Some have argued that a so-called &ldquo;public option&rdquo; may be one such &ldquo;middle ground,&rdquo; but this idea cannot live in harmony with private benefits for long &hellip; resulting in the demise of private plans, and eventual monopoly that is a single payer, and which (as already discussed) most agree needs to be avoided.</p> <p>Consider as &ldquo;Exhibit A&rdquo; the State of Washington.&nbsp; Washington is set to become the first state to enter the private health insurance market with a so-called &ldquo;public option,&rdquo; at rates supporters say will be 10% cheaper than comparable private insurance.&nbsp; Almost as if the lawmakers read my article above (before I even wrote it), they claim these savings will be achieved thanks to a cap on rates paid to providers.</p> <p>Without going into too much detail regarding the pricing model (spoiler alert &ndash; it&rsquo;s a percentage of Medicare), if this public option is indeed available to all residents, and if they can &ldquo;force&rdquo; providers to accept these payments as payment in full (thereby preventing balance billing), why would anyone sign up for a private plan?&nbsp; If, then, all private plan members are steered by sheer common sense to this public option, private plans will cease to exist and &ndash; in this way &ndash; a single payer emerges from the exchange.</p> <p>It was this threat that caused a public option to be removed from the proposed PPACA legislation, but now it&rsquo;s back, at the State level as well as in proposals presented by Democratic candidates for the Presidency.</p> <p>In the end, unless private plans and providers can achieve a meeting of the minds &hellip; and make healthcare affordable long term &hellip; this may be the future sooner than we think.</p> </div> </div> 927Empowering Plans: P75 – Free Health Benefits at Phiahttps://www.phiagroup.com/Media/Posts/PostId/923/empowering-plans-p75-free-health-benefits-at-phiaPodcastsFri, 03 Jan 2020 20:11:57 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/lQBeR8Z56sc" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;">We finally did it! <span class="pre_wrap">Join Adam Russo and Ron Peck as they discuss the different tactics used to offer Phia&#39;s employees FREE health benefits! This is not a podcast that you can afford to miss.</span></span></p> <p style="text-align: justify;"><a href="https://youtu.be/lQBeR8Z56sc"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/lQBeR8Z56sc"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 923The Phia Group Announces the Offering of Free Health Benefits to Employees and Their Familieshttps://www.phiagroup.com/Media/Posts/PostId/919/the-phia-group-announces-the-offering-of-free-health-benefits-to-employees-and-their-familiesPress ReleasesThu, 19 Dec 2019 17:39:00 GMT<p style="text-align:justify">For Immediate Release<o:p></o:p></p> <p style="text-align:justify">December 19, 2019<o:p></o:p></p> <p style="text-align:justify">Braintree, MA – The Phia Group, LLC is pleased to announce that with the ringing in of the new year, it will be offering FREE HEALTH BENEFITS to employees and their families.  Specifically, plan participants that have been enrolled in the plan for five or more years will be enrolled in 2020 and have zero contribution or premium; 100% of the cost of their and their families’ membership is paid for by The Phia Group.  <o:p></o:p></p> <p style="text-align:justify">This remarkable achievement is made possible thanks to the application and utilization of cost containment measures developed and provided by The Phia Group to the self-funded health benefits community, and proactive efforts on the part of its own plan membership to be educated, and cost-conscious “consumers” of healthcare.<o:p></o:p></p> <p style="text-align:justify">The Phia Group’s CEO, Adam V. Russo, Esq., remarked – in response to those that believe cost-shifting the burden of rising healthcare costs onto employees is inevitable – that, with the right tactics in place, health benefits can be affordable and employees do not need to bear the burden of an inefficient health plan.  “If our approach to health benefits didn’t work,” Adam continued, “… could we afford to maintain our contribution levels, year after year?  Could we continue to offer benefits with no co-pays or deductible?  The answer is no.”<o:p></o:p></p> <p style="text-align:justify">Ron E. Peck, Esq., Executive Vice President and General Counsel of The Phia Group explained, “Our mission is to ensure health benefits are robust and affordable for hard working Americans.  Very few people work as hard as our own employees, so providing them with the best, most affordable benefits is us living our mission.”<o:p></o:p></p> <p style="text-align:justify">“We are very proud to be able to offer our employees and their families the types of benefits they’d only see at a very small number of businesses, nationwide;” Adam concluded.<o:p></o:p></p> <p style="text-align:justify">For more information regarding The Phia Group, it’s benefit plan, and the services that make these incredible results possible, please contact Vice President Tim Callender by email at <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a> or by phone at <a href="tel:781-535-5631">781-535-5631</a>.<o:p></o:p></p> <p style="text-align:justify">About The Phia Group:<o:p></o:p></p> <p style="text-align:justify">The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, <a href="https://www.phiagroup.com/Services/Plan-Plan-Drafting-Services">plan drafting</a>, <a href="https://www.phiagroup.com/Services/Save-Subrogation-Recovery-Services">subrogation</a> and other cost containment solutions, The Phia Group is truly Empowering Plans.<o:p></o:p></p> 919Empowering Plans: P74 – Medicare Podcast for All!https://www.phiagroup.com/Media/Posts/PostId/918/empowering-plans-p74-medicare-podcast-for-allPodcastsThu, 19 Dec 2019 13:43:16 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/bA3lQIFPMzM" width="560"></iframe></p> <p>This is it!&nbsp; This is it!&nbsp; Ron and Brady pick apart Elizabeth Warren&rsquo;s Medicare-for-All proposal, and the concept as a whole; the good, the bad, and the really bad. You can&rsquo;t afford to ignore this one.</p> <p style="text-align: justify;"><a href="https://youtu.be/bA3lQIFPMzM"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/bA3lQIFPMzM"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 918 A Perfect Vision for 2020https://www.phiagroup.com/Media/Posts/PostId/916/a-perfect-vision-for-2020WebinarsTue, 17 Dec 2019 16:18:00 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/VmmrOxixEDE" width="560"></iframe></p> <p style="text-align: justify;">Looking back at the year that was, 2019 gives us perspective and allows us to view 2020 with both optimism and concern. Open your eyes (and ears) and join the team as they review the issues, topics, and innovations of 2019 that they believe will impact 2020, as well as the strategies you need to implement now to conquer the coming year.</p> <p style="text-align: justify;"><a href="https://youtu.be/VmmrOxixEDE">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 916Empowering Plans: P73 – Preparing Your Plan Document for 2020https://www.phiagroup.com/Media/Posts/PostId/915/empowering-plans-p73-preparing-your-plan-document-for-2020PodcastsWed, 11 Dec 2019 20:28:37 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/dZmWuKJEWwM" width="560"></iframe></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><span style="color:#000000;">The Phia Group&rsquo;s Executive Vice President and General Counsel, Ron E. Peck, and Senior Vice President of Consulting, Jen McCormick, sit down to discuss the top-rated topic chosen by Phia&rsquo;s webinar listeners. Our webinar listeners spoke (hypothetically) and we listened! Make sure you tune in to find out what Ron and Jen have to say about plan documents and learn the do&rsquo;s and don&rsquo;ts when it comes to reviewing and updating your plan document in 2020!</span></p> <p style="text-align: justify;"><a href="https://youtu.be/dZmWuKJEWwM"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/dZmWuKJEWwM"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and <a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">Apple Podcast</a> </span><span style="color:#000000;">Channels!)</span></p> 915Empowering Plans: P72 – The Young & The Restlesshttps://www.phiagroup.com/Media/Posts/PostId/909/empowering-plans-p72-the-young-the-restlessPodcastsThu, 21 Nov 2019 15:37:07 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/4RVkpDPtqGY" width="560"></iframe></p> <p style="text-align: justify;"><span class="pre_wrap">Adam Russo and Brady Bizarro sit down with Craig Clemente, Chief Operations Officer at Specialty Care Management and outgoing Chairman of the SIIA Future Leaders Committee, to discuss the future of the committee and the many ways they intend on engaging the younger generation. Make sure you tune in to find out what SIIA has in store for 2020 and beyond.</span></p> <p style="text-align: justify;"><a href="https://youtu.be/4RVkpDPtqGY"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/4RVkpDPtqGY"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 909Faces of Phia: Episode 19 – Shauna Makes a Comebackhttps://www.phiagroup.com/Media/Posts/PostId/906/faces-of-phia-episode-19-shauna-makes-a-comebackPodcastsFri, 15 Nov 2019 14:54:11 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/JZwDd6qa8kM" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;">Join Adam Russo and Ron Peck as they interview Shauna Mackey, The Phia Group&rsquo;s Associate General Counsel. Shauna is back in New England after moving to London, and was fortunate to have had private health insurance through her husband&rsquo;s company, as opposed to utilizing the public healthcare offered to all residents in England. Tune in to learn more about Shauna and her experience with both public and private healthcare throughout her pregnancy and delivery.</span></p> <p style="text-align: justify;"><a href="https://youtu.be/JZwDd6qa8kM"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/JZwDd6qa8kM"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 906Plan Language, Rx, and Lawsuits to Watch (and File): Innovation for a Changing Industryhttps://www.phiagroup.com/Media/Posts/PostId/905/plan-language-rx-and-lawsuits-to-watch-and-file-innovation-for-a-changing-industryWebinarsWed, 13 Nov 2019 22:37:00 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/suQ-qXeBn0c" width="560"></iframe></p> <p style="text-align: justify;">In the face of evolving pricing models, ever-increasing drug costs, difficulties in administering claims, and increased regulatory burdens, the players in the self-funding industry need change. Not just any change, though; creative change that promotes cost-containment and makes life easier for those who support health benefit plans in one way or another.<br /> <br /> Join The Phia Group’s legal team as they discuss innovative programs to manage vendor fees, balance-bill <span class="details" style="display: inline;">litigation, Rx manufacturer assistance, and other ideas being proposed by players in the industry. Join us to assure you are able to manage new regulatory frameworks and keep up with the industry’s progress.</span></p> <p style="text-align: justify;"><a href="https://youtu.be/suQ-qXeBn0c">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 905Faces of Phia: Episode 18 – Battling Balance-Billinghttps://www.phiagroup.com/Media/Posts/PostId/901/faces-of-phia-episode-18-battling-balance-billingPodcastsMon, 04 Nov 2019 15:46:54 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/VqPKDXTxFbU" width="560"></iframe></p> <p>Join Adam Russo and Ron Peck as they interview Lyneka Hubbert, a Medical Claim Negotiator here at The Phia Group. Lyneka has worked in six different departments throughout her five years at Phia, and has more in store for her future here. Tune in to learn more about Lyneka and her experience with protecting patients from balance bills.</p> <p style="text-align: justify;"><a href="https://youtu.be/VqPKDXTxFbU"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/VqPKDXTxFbU"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 901Tales From the Plan: Episode 5 – Translating Phia’s Benefit Planhttps://www.phiagroup.com/Media/Posts/PostId/898/tales-from-the-plan-episode-5-translating-phias-benefit-planPodcastsThu, 24 Oct 2019 21:29:28 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/E88H44z3nng" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;">Join Adam Russo and Ron Peck as they interview The Phia Group&rsquo;s Human Resources Manager, Linda Pestana. Learn how Linda was able to navigate our health plan and negotiate with a provider to make her son&rsquo;s hearing aids affordable. Additionally, Linda discusses another story regarding Phia&rsquo;s health plan, and how it has completely erased the out-of-pocket expense for a medication another employee previously paid $800.00 a month for. </span></p> <p style="text-align: justify;"><a href="https://youtu.be/E88H44z3nng"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/E88H44z3nng"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 8982020 Forecast - Storm Clouds, Clear Skies, and the Issues that will Dominate Next Yearhttps://www.phiagroup.com/Media/Posts/PostId/897/2020-forecast-storm-clouds-clear-skies-and-the-issues-that-will-dominate-next-yearWebinarsWed, 23 Oct 2019 16:05:00 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/msTySbAgbvw" width="560"></iframe></p> <p style="text-align: justify;">2020 is almost here, and The Phia Group continues its webinar series dedicated to preparing you for renewals, and the coming year. Join the team for this free webinar as they discuss the issues that impacted 2019, and are poised to dominate 2020, including (but not limited to) Mental Health Parity, Paid Leave, Health Insurance Taxes, Drug Prices, Regulations, and Coupons.</p> <p style="text-align: justify;"><a href="https://youtu.be/msTySbAgbvw">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 897The Phia Group's 4th Quarter 2019 Newsletter https://www.phiagroup.com/Media/Posts/PostId/895/the-phia-groups-4th-quarter-2019-newsletterNewslettersMon, 21 Oct 2019 15:09:37 GMT<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: #000000; } .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/Newsletter%202019%20Q1/header2019.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/icons5_2.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p1"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b14thqtr19.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b4thqtr19.png" 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="53%"><br /> <br /> <img height="341" src="/Portals/phiagroup/Newsletter%202018%20Q2/adam.jpg" width="300" /></td> <td valign="top" width="47%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">It&rsquo;s renewal season here at The Phia Group, and in the self-insured industry, I can tell you that it&rsquo;s busier than ever. It seems like finally all of the industry experts, advisors, and brokers are seeing the light and realizing that the time for change is now. It&rsquo;s not just enough to disrupt, its time for a revolution in healthcare, and we are more than happy to lead the fight for higher quality, more transparency, and lower costs. We have seen a greater emphasis on empowering plans through data access, incentive based language in plans documents, and carve-outs through specific centers of excellence. The days of overgrown networks are slowing down with narrow networks, and better disease management opportunities are growing. I hope you have a great 4th quarter and success in your opportunities. We are always here to help. Happy reading.</p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </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%202018%20Q2/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p12">Service Focus of the Quarter: Plan Appointed Claim Evaluator&reg; (PACE)</a><br /> <a href="#p3">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2019 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">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>&nbsp;</p> <p><a id="p12" name="p12"></a></p> <p class="heading1">Service Focus of the Quarter: Plan Appointed Claim Evaluator&reg; and PACE Certification</p> <p class="heading1" style="text-align: justify;"><strong><span style="font-size:12px;">Plan Appointed Claim Evaluator&reg;, or &ldquo;PACE&rdquo;</span></strong></p> <p class="bodytext" style="text-align: justify;">Some years ago, in response to growing industry concerns over the difficulty of exercising fiduciary duties with respect to internal appeals, The Phia Group created its Plan Appointed Claim Evaluator&reg; (PACE) service. PACE is a fiduciary transfer service for applicable final-level internal appeals. It is designed solely to help the health plan ensure that it has made correct determinations, thereby insulating the health plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations.</p> <p class="bodytext" style="text-align: justify;">PACE includes:</p> <p class="bodytext" style="text-align: justify; margin-left: 40px;">&bull; Plan Document and stop-loss policy &ldquo;Gap Reviews&rdquo; ensure compliance, eliminate coverage gaps, and ensure PACE readiness<br /> &bull; Advanced-level webinars exclusively for PACE clients<br /> &bull; Assessment of eligible final internal appeals via written directive as a fiduciary<br /> &bull; 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;">Beginning August 2019, we will also begin offering complimentary PACE Certification &ndash; whereby your organization can enhance your PACE business, improve your internal appeals processes, ensure regulatory compliance, and improve your business as a whole.</p> <p class="bodytext" style="text-align: justify;">Chapter One of PACE Certification explores the ins and outs of self-funding; Chapter 2 takes a deeper dive into the laws and regulations applicable to self-funded health plans; Chapter 3 explains what PACE is, how it works, and how it can best be utilized.</p> <p class="bodytext"><a id="p12" name="p12"></a></p> <p class="bodytext"><strong>PACE Certification</strong></p> <p class="bodytext" style="text-align: justify;">PACE Certification provides access to a multimedia educational program! Through videos and interactive knowledge materials, you will emerge educated and entertained! Once PACE certified, you will enhance your PACE business and increase revenues, improve your appeals processes, and assure regulatory compliance!</p> <p class="bodytext" style="text-align: justify;">Chapter One: Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.</p> <p class="bodytext" style="text-align: justify;">Chapter Two: Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from preemption to adverse benefit determinations and appeals.</p> <p class="bodytext" style="text-align: justify;">Chapter Three: Explain what PACE is, what PACE does, and how it&rsquo;s obtained, implemented, and utilized.</p> <p class="bodytext" style="text-align: justify;">To learn more about either PACE or PACE Certification, please contact Tim Callender at 781-535-5631 or <a href="mailto:tcallender@phiagroup.com" target="_blank">tcallender@phiagroup.com</a>.</p> <p class="bodytext">&nbsp;</p> <a name="p3"></a> <p class="heading1">Phia Case Study: Independent Consultation &amp; Evaluation (ICE)&nbsp;</p> <p class="bodytext" style="text-align: justify;">A client of The Phia Group&rsquo;s ICE service approached our consulting team with an inquiry whereby an employee had accrued two weeks of paid time off (PTO) pursuant to the employer&rsquo;s own internal policies, and that employee was about to take leave to deliver her first child. The inquiry was specifically regarding whether the employee could first take her accrued PTO for two weeks, and then begin FMLA leave, for leave totaling 14 weeks (two weeks PTO plus twelve weeks FMLA).</p> <p class="bodytext" style="text-align: justify;">Our response focused on some guidance provided by the Department of Labor. In March 2019, the DOL was very specific in its mandate that once an employer knows that a leave of absence qualifies under FMLA, the employer must designate the leave as FMLA leave, regardless of any available PTO or other employer-approved leave.</p> <p class="bodytext" style="text-align: justify;">In other words, the DOL requires the FMLA and PTO leaves to run concurrently; since the PTO totaled 2 weeks and the FMLA totaled 12 weeks, those first 2 weeks would have the leaves running concurrently, and then, if taken, there would be only ten additional weeks available of solely FMLA.</p> <p class="bodytext" style="text-align: justify;">It&rsquo;s important to mention in this context that employers have a wide berth to structure their own policies, grant leave, and other employment-type things &ndash; but continuation under the health plan should be pursuant to Plan terms, rather than only employer policies; this is important for many reasons, not the least of which being stop-loss coverage.</p> <p class="bodytext" style="text-align: justify;">If the employer granted two weeks of continuation coverage in addition to the twelve guaranteed by FMLA, claims incurred in weeks 13 and 14 would likely not be covered by stop-loss, (since, again, the DOL requires that the two weeks of PTO be fully exhausted concurrently with the FMLA leave, resulting in twelve total weeks rather than fourteen). If the employer had offered those two additional weeks of continued coverage after the first twelve, it would have been neither FMLA nor PTO (i.e. it would have been a &ldquo;favor&rdquo; done by the employer), and therefore the stop-loss insurer could determine that it is not covered leave sufficient to invoke coverage under the stop-loss policy.</p> <p class="bodytext" style="text-align: justify;">We therefore opined that allowing the employee to delay designation of FMLA for the purposes of extending coverage beyond 12 weeks would not only violate the DOL&rsquo;s rules, but it may also result in issues with stop-loss reimbursement for claims incurred after the exhaustion of FMLA as proscribed by the DOL &ndash; both of which can carry serious repercussions.</p> <p class="bodytext" style="text-align: justify;">While this issue deserves more analysis than what is described in this case study, this knowledge may have helped save the employer from violating federal regulations as well as potential stop-loss denials!</p> <hr class="horiz" /> _ <p>&nbsp;</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Following the SPD &ndash; Unless Inconsistent with the Law! </strong></p> <a id="p12" name="p12"></a> <p class="bodytext" style="text-align: justify;">You may have heard of the so-called &ldquo;greatest of three&rdquo; rule with respect to out-of-network emergency services. This regulation &ndash; codified at 45 CFR 147.138(b)(3). This regulation, in a nutshell, requires that for out-of-network emergency services, self-funded health plans allow claims at the greatest of (1) 100% of Medicare, (2) the amount the plan would allow for non-emergent out-of-network claims (in other words, Usual and Customary, Maximum Allowable Charge, etc.), or (3) the median contracted rate for emergency services.</p> <p class="bodytext" style="text-align: justify;">Many health plans and TPAs disregard this &ldquo;greatest of three&rdquo; rule, either by not containing the proper plan language or simply not following the regulation. In fact, in the performance of The Phia Group&rsquo;s PACE service, we often need to ask our clients regarding their median contracted rate for emergency services &ndash; and we are sometimes informed that the TPA does not know.</p> <p class="bodytext" style="text-align: justify;">They say &ldquo;knowledge is power,&rdquo; but in this case, &ldquo;knowledge is compliance!&rdquo; Without knowing each of those three elements, it is impossible to know which one is truly highest. This becomes especially dangerous for plans that pay out-of-network emergency claims based on Medicare rates; for such plans, it is incredibly common for the median contracted rate to be higher than the Plan&rsquo;s chosen percent of Medicare &ndash; so knowing the median contracted rate can be the only way to compliantly adjudicate an out-of-network emergency claim.</p> <p class="bodytext" style="text-align: justify;">There are two action items: first, make sure your SPDs are specific on this &ldquo;greatest of three&rdquo; rule, such that for non-contracted emergency claims, they are paid pursuant to this regulation &ndash; and second, make sure you are acutely aware of the median contracted rate for emergency services, since we have seen more and more providers raising this point in appeals of non-contracted emergency claims!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Success Story of the Quarter: The Balance-Billing &ldquo;End Game&rdquo;</strong></p> <p class="bodytext" style="text-align: justify;">A health plan had a member who was visiting some out-of-state relatives, and that member happened to sustain a non-emergent injury while playing frisbee with his family. He didn&rsquo;t go to the emergency room, but instead (wisely!) visited a local Urgent Care facility, which referred him to a local ASC. The health plan of which this individual was a member utilized a small regional network in its home state, with Phia Unwrapped for non-network claims. Since neither the Urgent Care facility nor the ASC was not part of that regional network, this claim became subject to Phia Unwrapped, and was consequently priced at 165% of Medicare &ndash; a rate the health plan had chosen.</p> <p class="bodytext" style="text-align: justify;">The ASC billed $17,000 for the eventual care provided, of which 165% of Medicare totaled around $7,500. The member was subsequently billed for the remainder.</p> <p class="bodytext" style="text-align: justify;">The ASC was adamant that its billing was reasonable, and cited the fact that it had billed at only 375% of Medicare; when Phia&rsquo;s balance-billing support team pointed out that 375% of Medicare is not a reasonable amount, the provider outright refused to negotiate its bill, and continued to bill the patient. The refusal to negotiate is a rare stance, but this ASC was so confident in its ability to collect that it felt it was appropriate.</p> <p class="bodytext" style="text-align: justify;">Unfortunately for this ASC, the particular benefit plan and TPA had had enough with this type of provider mentality; after much discussion, the TPA and plan &ndash; with Phia&rsquo;s assistance &ndash; engaged local counsel to file a lawsuit on behalf of the patient to challenge the provider&rsquo;s billing as unreasonably high. Prior to that filing, we warned the ASC that if we were unable to settle, litigation would likely ensue, but the ASC balked in disbelief.</p> <p class="bodytext" style="text-align: justify;">Fast-forward about two weeks: the very same day the complaint was served upon the ASC, we received correspondence indicating that the ASC would accept Phia&rsquo;s prior offer of an additional $1,500 to close the claim.</p> <a name="p1"></a> <p class="bodytext"><strong>New Service Offered by Phia: Patient Defender</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to introduce its &ldquo;Patient Defender&rdquo; program. For a small PEPM fee, every plan participant has access to legal representation against lawsuits targeting patients, or crippling balances being sent to collections, when efforts to amicably resolve these disputes fail, Patient Defender is the ultimate weapon in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan &ndash; from reference-based pricing plans to traditional network plans; if and when a patient is threatened by these increasingly aggressive tactics, Patient Defender will be there.</p> <p class="bodytext" style="text-align: justify;">Patient Defender finally plugs the gap that has existed across the industry in relation to reference-based pricing programs and balance billing concerns. With Patient Defender, a small PEPM rate ensures that a trusted law firm is placed on retainer, ready and willing to assist the patient when balance-billing occurs. Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.</p> <p class="bodytext" style="text-align: justify;">To learn more about Patient Defender or any of The Phia Group&rsquo;s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or <a href="mailto:tcallender@phiagroup.com" target="_blank">tcallender@phiagroup.com</a>.</p> <p>&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p5" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext" style="text-align: justify;">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/09/23/drug-manufacturer-coupons-and-out-of-pocket-limits-what-employers-need-to-know/" target="_blank">Drug manufacturer coupons and out-of-pocket limits: What employers need to know</a> &ndash; September 23, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Reference-Based Pricing- Pitfalls for a New Era by Jon Jablon.pdf" target="_blank">Reference-Based Pricing: Pitfalls For A New ERA</a> &ndash; September 3, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/08/26/universal-health-care-comparing-what-looks-nice-on-paper-to-reality/" target="_blank">Universal health care: Comparing what looks nice on paper to reality</a> &ndash; August 26, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/How Self-Insured Health Plans Are Helping by Philip Qualo%2C J_D.pdf" target="_blank">How Self-Insured Health Plans Are Helping Employers Compete In A Challenging Talent Marketplace</a> &ndash; August 5, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/07/31/blocking-tv-drug-price-disclosures-whats-next/?utm_source=SocialFlow&amp;utm_medium=BenefitsPro&amp;fbclid=IwAR2lORCXgUTeif38bJeREJDTAsmQrCOiQA78VrzFL2u0r_IFoUjAwHkPTp0" target="_blank">Blocking TV drug price disclosures: What&#39;s next?</a> &ndash; July 31, 2019</p> <p class="bodytext" style="text-align: justify;">&bull; Free Market Healthcare Solutions - <a href="http://ushealthmedia.com/senate-finance-committee-tackles-prescription-drug-prices/" target="_blank">Senate Finance Committee Tackles Prescription Drug Prices</a> &ndash; July 21, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Big Pharma Facing Big Losses Tied To Opoid Epidemic Fallout by Sean Donnelly.pdf" target="_blank">Big Pharma Facing Big Losses Tied To Opioid Epidemic Fallout</a> &ndash; July 4, 2019<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/882/lots-of-moving-parts" target="_blank">Lots of Moving Parts</a>. Put your Reference-Based Pricing knowledge to the test.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/878/controversy-surrounds-the-most-expensive-drug-in-the-world" target="_blank">Controversy Surrounds the Most Expensive Drug in the World</a>. A drug designed to help kids that will bankrupt their parents.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/875/theres-a-new-notice-on-the-block" target="_blank">There&rsquo;s a New Notice on the Block</a>. On July 17, 2019 the Internal Revenue Service issued Notice 2019-45.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/874/health-care-cadillac-tax-repeal-bill-passed-by-the-house" target="_blank">Health Care &ldquo;Cadillac Tax&rdquo; Repeal Bill Passed by the House</a>. This Cadillac Tax could hit your wallet and leave a mark.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/866/network-contract-drafting-youre-doin-it-wrong" target="_blank">Network Contract Drafting: You&rsquo;re Doin&rsquo; It Wrong</a>. Watch you contract language!</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx">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="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;">&nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On September 17, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/884/2020-renewal-season-decisions-today-uncertain-tomorrow" target="_blank">2020 Renewal Season - Decisions Today, Uncertain Tomorrow</a>,&rdquo; where we discuss important issues impacting plan renewals, address known roadblocks, and perform an assessment of the candidates&rsquo; positions on healthcare &ndash; with an eye toward what we should be doing today to prepare for an uncertain tomorrow.</p> <p class="bodytext" style="text-align: justify;">&bull; On August 21, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/880/back-to-school-2020-renewals" target="_blank">Back to School: 2020 Renewals</a>,&rdquo; where we provide the education needed to help you meet your obligations and keep your business safe &ndash; and provide the information you need to earn a &ldquo;passing grade&rdquo; during renewal season!</p> <p class="bodytext" style="text-align: justify;">&bull; On July 23, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/873/trumps-executive-order-on-transparency-how-it-will-effect-each-segment-of-our-industry" target="_blank">Trump&rsquo;s Executive Order on Transparency: How it Will Effect Each Segment of Our Industry</a>,&rdquo; where we discuss the executive order point by point; they&rsquo;ll touch on what they like and don&rsquo;t like about it, and &ndash; more importantly &ndash; what this all means for you.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:</span></p> <p class="bodytext" style="text-align: justify;"><span class="heading1">Empowering Plans</span><br /> &nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On September 18, 2019, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/885/empowering-plans-p71-politics-politics-politics" target="_blank">Politics! Politics! Politics!</a>,&rdquo; where our hosts, Ron Peck and Brady Bizarro, discuss Obamacare, the state of health care versus health insurance, and the political environment as we move toward the 2020 election.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span class="heading1">Face of Phia</span></p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On September 4, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/881/faces-of-phia-episode-16-crunching-numbers-with-desmond-campbell" target="_blank">Crunching Numbers with Desmond Campbell</a>,&rdquo; where our host, Ron Peck, sits down with Desmond Campbell, the man, the myth, the legend.</p> <p class="bodytext" style="text-align: justify;">&bull; On August 16, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/879/faces-of-phia-episode-15-the-fine-fan-club" target="_blank">The Fine Fan Club!</a>,&rdquo; where our hosts, Adam and Ron, learn more about the life and background of Andrew Fine, Phia&rsquo;s Lead Intake Specialist.</p> <p class="bodytext" style="text-align: justify;">&bull; On August 1, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/876/faces-of-phia-episode-14-the-magical-kingdom" target="_blank">The Magical Kingdom!</a>,&rdquo; where our hosts, Adam and Ron, interview Mattie Sesin, our Director of Recovery Services.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span class="heading1">Tales From the Plan</span></p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; ON September 23, 2019, The Phia Group Presented, &ldquo;A Vision for Savings,&rdquo; where Adam Russo and Michael Vaz sit down to discuss his experience with The Phia Group&rsquo;s health plan and how he was able to save money for the plan and get rewarded for doing so.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 17, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/870/tales-from-the-plan-episode-3-direct-to-the-point" target="_blank">Direct &amp; To The Point!</a>,&rdquo; where The Phia Group&rsquo;s VP of Legal Recovery Services, Chris Aguiar, Esq., discusses his experiences before and after becoming a happy participant in Direct Primary Care.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 8, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/868/tales-from-the-plan-episode-2-mrs-peck-its-cancer" target="_blank">Mrs Peck, It&rsquo;s Cancer&hellip;</a>,&rdquo; where our host, Ron Peck, tells us about his family&rsquo;s battle against cancer, and lessons we can all learn from their experience.</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"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/Apple%20Podcasts.jpg" style="width: 251px; height: 78px; float: left;" title="" /><br /> <br /> &nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2019 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2019 charity is the Boys &amp; Girls Club of Brockton.</p> <p><img src="/Portals/phiagroup/Newsletter%20Q1%202018/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton 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 style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Back to School</strong></p> <p class="bodytext" style="text-align: justify;">Our friends from the Boys &amp; Girls Club of Brockton 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 3,500 school supplies/backpacks and $1,700 in monetary donations. We hope all of the amazing children are enjoying their new school supplies!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/school3.jpg" style="width: 550px; height: 150px;" title="" /></p> <p>&nbsp;</p> <p class="bodytext"><strong>Volunteer Day</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Family was out and about a few months back, celebrating our annual volunteer day at the Boys &amp; Girls Club of Brockton. There were a variety of activities for the kids to participate in, between archery, rock climbing, basketball, hiking, and so much more. In addition to partaking in activities with the kids, we all got to see the new pavilion that was donated by The Phia Group. Next year, we are planning on decorating the pavilion for the kids. That being said, we are already looking forward to next year!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/vol1.jpg" style="width: 550px; height: 550px;" title="" /></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">Reference-Based Pricing: Pitfalls For a New Era</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">By: Jon Jablon, Esq. &ndash; September 2019 &ndash; <a href="https://www.sipconline.net/files/Reference-Based Pricing Pitfalls for a New ERA by Philip Qualo%2C J_D_ .pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">How many times have you read an article or listened to a sales pitch about how great reference-based pricing is? RBP can add a lot of value, and many of us have seen that first-hand. But that is not the purpose of this article. As a consultant in the self-funded industry, The Phia Group has lots of opportunities to review and assess reference-based pricing plans and various claims situations. We have seen plans experience a great deal of RBP success &ndash; but we have also seen many RBP failures.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As many of you reading this have found out the hard way, and often unexpectedly, there are certain ways that RBP can go poorly and cause harm to an employer&rsquo;s health plan, employee base, or even business reputation.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/892/the-stacks-4th-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p><br /> <span class="bodytext"><strong>How Self-Insured Health Plans Are Helping Employers Compete In A Challenging Talent Marketplace </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Philip Qualo, J.D. &ndash; August 2019 &ndash; <a href="https://www.sipconline.net/files/How Self-Insured Health Plans Are Helping by Philip Qualo%2C J_D.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Prior to joining The Phia Group, LLC, an experienced health care cost-containment company specializing in self-insured plans, my knowledge and experience with the self-insured industry could fit on the tip of my pinky. My previous work experience was exclusively in the fully-insured sector, where I quickly learned that uttering the words &ldquo;self-insurance&rdquo; was considered almost offensive. On a more personal level, I had been covered under various fully-insured health plans since my very first job after graduating law school. From the start, my experience with fully-insured plans jaded my perception of health benefits. I eventually accepted that medical insurance was a necessary evil that I would have to learn to live with. Although my employers genuinely cared about the well-being of their employees, the ability to offer comprehensive medical benefits became increasingly difficult due to the monumental annual increases in the cost of fully-insured coverage.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/892/the-stacks-4th-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p>&nbsp;</p> <p class="bodytext"><strong>Big Pharma Facing Big Losses Tied To Opioid Epidemic Fallout</strong></p> <p class="bodytext">By: Sean Donnelly, Esq. &ndash; July 2019 &ndash; <a href="https://www.sipconline.net/files/Big Pharma Facing Big Losses Tied To Opoid Epidemic Fallout by Sean Donnelly.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="text-align: justify;">In 2017, a total of 70,237 people in the United States died from a drug overdose. A staggering 67.8% of those deaths involved the use of opioids, a startling escalation that has been classified as a national epidemic. Deaths attributed to synthetic opioids have become increasingly prevalent, accounting for 59.8% of all opioid overdose deaths.</p> <p class="bodytext" style="text-align: justify;">Every day, an average of 46 people in the United States die from overdoses specifically involving prescription opioids. The highest prescription opioid-involved death rates in 2017 were in West Virginia, Maryland, Kentucky and Utah. According to the National Institute on Drug Abuse, drug overdose deaths involving opioids that were prescribed rose from 3,442 in 1999 to 17,029 in 2017.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/892/the-stacks-4th-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a>Phia&rsquo;s 2019 Speaking Engagements:</p> <p class="bodytext"><br /> <br /> &bull; 1/9/2019 &ndash; FMMA Conference &ndash; Austin, TX</p> <p class="bodytext">&bull; 2/27/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Denver, CO</p> <p class="bodytext">&bull; 3/8/2019 &ndash; UnitedAg Conference &ndash; Anaheim, CA</p> <p class="bodytext">&bull; 3/19/2019 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charlotte, NC</p> <p class="bodytext">&bull; 3/21/2019 &ndash; CGI Business Solutions Seminar &ndash; Woburn, MA</p> <p class="bodytext">&bull; 3/26/2019 &ndash; HFTA Broker Meeting &ndash; Tyler, TX</p> <p class="bodytext">&bull; 4/3/2019 &ndash; BenefitsPRO Broker Expo &ndash; Miami, FL</p> <p class="bodytext">&bull; 4/5/2019 &ndash; Pareto Conference &ndash; Nashville, TN</p> <p class="bodytext">&bull; 4/7/2019 &ndash; Captive Symposium &ndash; Cayman Islands</p> <p class="bodytext">&bull; 4/8/2019 &ndash; National Beer Wholesalers Association Legislative Conference &ndash; Washington DC</p> <p class="bodytext">&bull; 4/12/2019 &ndash; FMMA 2019 Annual Conference &ndash; Dallas, TX</p> <p class="bodytext">&bull; 4/23/2019 &ndash; Johns Hopkins Industry Education Series &ndash; Baltimore, MD</p> <p class="bodytext">&bull; 4/24/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 4/25/2019 &ndash; BevCap&rsquo;s Best Practices Workshop &ndash; Orlando, FL</p> <p class="bodytext">&bull; 4/26/2019 &ndash; Society of Professional Benefit Administrators Annual Conference &ndash; Washington, D.C.</p> <p class="bodytext">&bull; 5/2/2019 &ndash; MassAHU Benefest 2019 Conference &ndash; Westborough, MA</p> <p class="bodytext">&bull; 5/14/2019 &ndash; Cypress Unversity &ndash; Las Vegas, NV</p> <p class="bodytext">&bull; 5/30/2019 &ndash; Contrarian Captive &ndash; Austin, TX</p> <p class="bodytext">&bull; 6/11/2019 &ndash; Leavitt Conference &ndash; Big Sky, MT</p> <p class="bodytext">&bull; 7/16/2019 &ndash; HCAA TPA Summit &ndash; Dallas, TX</p> <p class="bodytext">&bull; 7/31/2019 &ndash; 2019 MVP Academy &ndash; Wellesley, MA</p> <p class="bodytext">&bull; 8/20/2019 &ndash; Pritchard &amp; Jerden Employee Benefits Forum &ndash; Brookhaven, GA</p> <p class="bodytext">&bull; 9/17/2019 &ndash; WebTPA Annual Conference&ndash; Dallas, TX</p> <p class="bodytext">&bull; 9/19/2019 &ndash; Employee Benefits Planning Association Conference&ndash; Seattle, WA</p> <p class="bodytext">&bull; 9/30/2019 &ndash; SIIA National Educational Conference &amp; Expo &ndash; San Francisco, CA</p> <p class="bodytext">&bull; 10/27/2019 &ndash; 2019 Annual NASP Conference &ndash; Washington DC</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employee of the Quarter:<br /> Lyneka Hubbert</span></p> <p class="bodytext" style="text-align: justify;">Lyneka is a truly dedicated case handler for the Provider Relations department. She has a vast knowledge of the most proficient and effective ways to work each file. Perhaps even more importantly, she is a great communicator with our clients. One of the most important aspects of this role is to keep our clients updated and confident in the work we are doing. We need to present a clear understanding of where our files stand while providing our clients with multiple options on how we can proceed. Lyneka does a fabulous job of communicating these types of things to our clients in a timely manner. She is persistent with the providers when trying to get a balance written off or a settlement reached. She explores all possible arguments with the providers so that she can have optimum success with her files.</p> <p class="bodytext" style="text-align: justify;">She is also a great team member and is always willing to go above and beyond what is expected of her. Whether this means staying late, helping a team member catch up on work, or executing tasks not normally assigned to her, she is always there to step up with a positive attitude.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/lyneka.jpg" style="width: 535px; height: 760px;" title="" /></p> <p class="bodytext">Congratulations Lyneka, and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Phia News</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>PACE&reg; Certification Has Arrived!</strong></p> <p class="bodytext" style="text-align: justify;">The PACE Certification program educates you using 3 distinct chapters of information:</p> <p class="bodytext" style="text-align: justify;"><span style="color:#0071CE;"><strong>Chapter One</strong></span><br /> Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.</p> <p class="bodytext" style="text-align: justify;"><span style="color:#0071CE;"><strong>Chapter Two</strong></span><br /> Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.</p> <p class="bodytext" style="text-align: justify;"><span style="color:#0071CE;"><strong>Chapter Three</strong></span><br /> Explain what PACE is, what PACE does, and how it&#39;s obtained, implemented, and utilized.</p> <p class="bodytext" style="text-align: justify;">The PACE Certification program is free of charge and creates immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.</p> <p class="bodytext" style="text-align: justify;">Additionally, the PACE Certification program provides education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.</p> <p class="bodytext" style="text-align: justify;">Please see the <a href="https://www.phiagroup.com/Portals/phiagroup/2019%20Flyers/PACE%20Cert%20Flyer.pdf" target="_blank">PACE Certification flyer</a>, as well as <a href="https://www.youtube.com/watch?v=8xNqiSuyiP0" target="_blank">this video</a> for more information.</p> <p class="bodytext" style="text-align: justify;">Please contact Michael Vaz (<a href="mailto:mvaz@phiagroup.com" target="_blank">mvaz@phiagroup.com</a>) for more information and to sign up today!</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Team Building</strong></p> <p class="bodytext" style="text-align: justify;">After a fun day of volunteering with the children from the Boys &amp; Girls Club of Brockton, the Phia Family took the remainder of the day to work on some good, old-fashioned team-building exercises. Throughout the day, the Phia Family was split into groups and faced with a variety of different tasks. After all of the exercises were complete, the Phia Family felt closer than ever. Check out the picture below to see how exciting the games were!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/teambuilding.jpg" style="width: 600px; height: 400px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Our Louisville, KY Office is Now Open</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group, LLC is pleased to announce the opening of a new office in Louisville, KY. Under the leadership of the newly appointed Vice President of Operations and Total Quality Management, Scott Byerley, Esq., this new location strengthens The Phia Group&#39;s presence in the central United States - just as it did in the west with its Boise, ID, office - continuing to allow The Phia Group to identify, recruit, and hire the most talented professionals, nationwide.</p> <p class="bodytext" style="text-align: justify;">With a focus on subrogation and claims recovery, as well as other cost containment activities, the Louisville team shares the same passion as the entirety of the &quot;Phia Family,&quot; to deliver robust yet affordable health benefits to as many hard working Americans as possible. &quot; We&#39;re very excited to bring The Phia Group to Louisville. This is a continuation of year after year growth for The Phia Group,&quot; remarked Mr. Byerley. &quot;The Phia Family made this happen with their dedication and passion for everything cost containment and reducing the costs of healthcare.&quot;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/ky.jpg" style="width: 618px; height: 406px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Cornhole Tournament and Phia BBQ</strong></p> <p class="bodytext" style="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 Harry Horton and Jeff Hannah. Congrats on the win, it was a close game!</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/cornhole.jpg" style="width: 550px; height: 500px;" title="" /></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p><span class="boldtext">Job Opportunities:</span></p> <p>&bull; Health Benefit Document Drafter</p> <p>&bull; Health Benefits - Case Investigator I</p> <p>&bull; Claim and Case Support Analyst</p> <p>&bull; Client Intake Specialist</p> <p>&bull; Overpayments Care Representative</p> <p>&bull; Customer Care Representative</p> <ul class="bodytext"> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Promotions </strong><br /> <br /> &bull; Kelly Dempsey, Esq. has been promoted from Director, Independent Consultation and Evaluation Services to Director, Consulting and ICE Services</p> <p class="bodytext" style="text-align: justify;">&bull; Dylan Fry has been promoted from Marketing &amp; Accounts Intern to Claim Recovery Specialist</p> <p class="bodytext" style="text-align: justify;">&bull; Dante Tylerbest has been promoted from Customer Service Representative to Overpayment Recovery Assistant</p> <p class="bodytext" style="text-align: justify;">&bull; Denise Swienc has been promoted from Customer Service Representative to Case Investigator</p> <p class="bodytext"><br /> &nbsp;</p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> &bull; Crystal Cascante was hired as an Intern</p> <p class="bodytext">&bull; William Lovejoy was hired as an IT Systems Administrator</p> <p class="bodytext">&bull; Craig Malcolmson was hired as an Intake Specialist</p> <p class="bodytext">&bull; John Shearer was hired as a Health Benefit Plan Admin - Attorney I</p> <p class="bodytext">&bull; Shauna Mackey was hired as an Associate General Counsel</p> <p class="bodytext">&bull; Brian Wentworth was hired as a Claims Specialist II, Provider Relations</p> <p class="bodytext">&bull; Dillon Fosa was hired as a Marketing &amp; Accounts Coordinator</p> <p class="bodytext">&bull; Larice Booker was hired as an Overpayments Recovery Specialist</p> <p class="bodytext">&bull; Brittney Willoughby was hired as a Sr. Claims Recovery Specialist</p> <p class="bodytext">&bull; Elizabeth McAlister was hired as a Sr. Claims Recovery Specialist</p> <p class="bodytext">&bull; Melanie Brown was hired as an Intake Specialist</p> <p class="bodytext">&bull; Ashley Jancaterino was hired as an Intake Specialist</p> <p class="bodytext">&bull; Cornelius Mance was hired as an Attorney I</p> <p class="bodytext">&bull; Ervin Morice was hired as a Case Investigator I</p> <p class="bodytext">&bull; Jason Pence was hired as a Sr. Claims Recovery Specialist</p> <p class="bodytext">&bull; Heather Breckenridge was hired as a PACE Client Intake Coordinator</p> <p class="bodytext">&bull; Allison Britton was hired as a Case Investigator I</p> <p class="bodytext">&bull; Aditya Sukumar was hired as a Business Analyst</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/footerlogo.png" 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> 895Faces of Phia: Episode 17 – Reminiscing on Memories with Mrs. Marshhttps://www.phiagroup.com/Media/Posts/PostId/893/faces-of-phia-episode-17-reminiscing-on-memories-with-mrs-marshPodcastsWed, 16 Oct 2019 19:59:45 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/YCpfksbY0n4" width="560"></iframe></p> <p style="text-align: justify;">Join Adam Russo and Ron Peck as they interview Jen Marsh, a dedicated employee that dates back to 2007, when Phia was one-third of the size it is today. Jen turns back time and goes over the past 12 years of her career here at Phia, from where she started as a Case Evaluator, to where she is today as the Client Satisfaction &amp; Quality Control Manager... and you won&#39;t believe who used to work for her!</p> <p style="text-align: justify;"><a href="https://youtu.be/YCpfksbY0n4"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/YCpfksbY0n4"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 893The Stacks - 4th Quarter 2019https://www.phiagroup.com/Media/Posts/PostId/892/the-stacks-4th-quarter-2019NewslettersWed, 16 Oct 2019 17:01:53 GMT<p><span style="font-size:2.3em;"><span style="color:#0071CE;"><strong>Reference-Based Pricing: Pitfalls For a New Era</strong></span></span></p> <h2>By: Jon Jablon, Esq</h2> <p style="text-align: justify;"><span style="color:#000000;">How many times have you read an article or listened to a sales pitch about how great reference-based pricing is? RBP can add a lot of value, and many of us have seen that first-hand. But that is not the purpose of this article. As a consultant in the self-funded industry, The Phia Group has lots of opportunities to review and assess reference-based pricing plans and various claims situations. We have seen plans experience a great deal of RBP success &ndash; but we have also seen many RBP failures.</span></p> <p style="text-align: justify;"><span style="color:#000000;">As many of you reading this have found out the hard way, and often unexpectedly, there are certain ways that RBP can go poorly and cause harm to an employer&rsquo;s health plan, employee base, or even business reputation.</span></p> <p style="text-align: justify;"><span style="color:#000000;">RBP is a powerful payment methodology used by thousands of health plans around the country, but like so many cost-containment tools, a full understanding of the entire process and a strong implementation of the key elements are absolutely crucial to its success &ndash; and even seemingly inconsequential flaws in the process can prove to be problematic down the road. Let&rsquo;s go through some of the biggest pitfalls.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Lack of Preparation: Poor Supporting SPD Language</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Like so many things in the self-funded industry, a health plan&rsquo;s rights with respect to RBP pricing are only as good as the plan&rsquo;s language. A plan document should contain language to both allow the plan to pay claims as it sees fit, and to create arguments against balance-billing. A lack of adequate plan language makes the health plan especially vulnerable to appeals and lawsuits.</span></p> <p style="text-align: justify;"><span style="color:#000000;">To provide a practical example, I was recently presented with a case where a health plan had neglected its Plan Document through the years. It was last restated in the late &lsquo;90s, it had over 30 amendments, and it was just plain old confusing to read. That group utilized an RBP methodology, and yet there was a complete lack of payment limitation language, except for one sentence: &ldquo;Expenses allowed at an amount the Supervisor deems reasonable.&rdquo;</span></p> <p style="text-align: justify;"><span style="color:#000000;">There are two main problems there: one is that the Supervisor was the TPA (so the first moral of this story is that TPAs should be wary of that type of unexpected liability), and the other is that this does not reference the 155% of Medicare at which rate the group&rsquo;s RBP vendor had been pricing claims for six months.</span></p> <p style="text-align: justify;"><span style="color:#000000;">What happened next? A large hospital system decided that it wanted to appeal, rather than jumping straight to balance-billing, and in the course of the appeal, the Plan Document was produced. I can just imagine the hospital&rsquo;s attorney&rsquo;s eyes filling with gigantic dollar signs when it saw that non-existent RBP language; the result is that while the vendor was repricing claims and raking in its fee, the Plan Document had not supported the program, and the Plan had not limited its exposure. Rather than face a lawsuit, the Plan had no choice but to pay the hospital&rsquo;s demand in full&hellip; and </span><em><span style="color:#000000;">hopefully</span></em><span style="color:#000000;"> amend its Plan Document language as soon as possible.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The seldom-referenced section 402(b)(4) of ERISA requires a health plan to &ldquo;specify the basis on which payments are made to and from the plan.&rdquo; There is precious little law to interpret exactly what that means, but it is the backbone of the sentiment that &ldquo;your rights are only as good as your language,&rdquo; and it seems safe to say that the particular provision within this health plan does not meet the relatively low standard of specifying how payments are made.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Poor Explanations: Inaccurate EOBs</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">There are two extremely common mistakes that health plans make when generating Explanations of Benefits with respect to RBP claims: (1) providing inaccurate or nonspecific remark codes, and (2) calling the amount over the Plan&rsquo;s allowable amount a &ldquo;discount.&rdquo;</span></p> <p style="text-align: justify;"><span style="color:#000000;">The former is a compliance problem; ERISA requires that EOBs contain not only an explanation of why the claim was priced as it was (according to the regulations at 29 CFR 2560-503.1, &ldquo;The specific reason or reasons for the adverse determination&rdquo;), but also a reference to the specific provision in the Plan Document that allows the denial (&ldquo;Reference to the specific plan provisions on which the determination is based&rdquo;).</span></p> <p style="text-align: justify;"><span style="color:#000000;">The latter is a business issue; a &ldquo;discount&rdquo; is something that is allowed by the provider (typically in the contractual sense), whereas the excess or disallowed amount is, by definition, not agreed-upon in advance by the provider. Incorrectly using the term &ldquo;discount&rdquo; is problematic because not only is it incorrect, but it starts all parties out on the wrong foot &ndash; and working with a hospital to write off a bill is much more difficult when the provider goes into the conversation already thinking that the payor has tried to take advantage.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Incorrect Implementation: Applying RBP Payments to Contracted Claims</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">RBP results can be so good that some employers are tempted to apply RBP to contracted claims as well, the theory being that the contracted rate is still higher than what the plan deems reasonable, so the RBP savings are desirable for <em>all</em> claims, even contracted ones. While the contracted rate may well be just as arbitrary and overbilled as the original billed charges, it&rsquo;s important to remember that contracts are legally-binding instruments, and contracted providers sometimes have powerful legal backing.</span></p> <p style="text-align: justify;"><span style="color:#000000;">This is perhaps another topic for another article &ndash; suffice it to say that unless the applicable fee agreement allows it, the health plan&rsquo;s chosen pricing cannot be applied to contracted claims without violating that agreement. It is a frighteningly-popular misconception within the self-funded industry that network or other fee agreements generally allow health plans to apply the contractual discount <em>on top of</em> the plan&rsquo;s chosen edits or reductions (including Medicare rates).</span></p> <p style="text-align: justify;"><span style="color:#000000;">Consider the example of a $50,000 claim subject to a mandatory contractual 10% discount, yielding a contractual payment rate of $45,000. The payor priced the claim at 150% of Medicare based on the Plan Document, which totaled $10,000. While the contractual rate would require that this claim be paid at $45,000, an alarming number of health plans and TPAs will apply that contractual 10% discount on top of the Medicare-based $10,000 (yielding payment of $9,000). Given the large discrepancy between payment of $9,000 and payment of $45,000, it is not difficult to assume that a contracted medical provider will push back, and <em>hard</em>.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Bad Negotiation Tactics: Not Having an End-Game</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">One of the hallmarks of a successful RBP program is patient protection, which can come in many forms &ndash; including direct contracts, case-by-case settlements, balance-bill indemnification, attorney representation, and other options, depending on the particular program used.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Settling claims is perhaps the simplest way of protecting patients; by eliminating balances via settlements, balance-billing is extinguished. Likewise, if a third party offers to indemnify the patient, then the patient is protected in that manner as well &ndash; and hiring litigation counsel on behalf of the patient can be an effective tool in combatting balance-billing or spurring settlement negotiations where a provider was otherwise hesitant to negotiate.</span></p> <p style="text-align: justify;"><span style="color:#000000;">As has been proven time and time again, the state of the industry is such that medical providers are generally permitted to charge any amounts they choose. Charge masters are arbitrary yet still enforced by many courts, and providers are free to send patients to collections or file lawsuits when they have not received their full billed charges &ndash; and some providers feel even more inclined to do that if the provider has been paid at a percentage of the Medicare rate. Many medical providers treat a Medicare-based payment as a personal assault on the value of their treatment, and seek to abuse health plans even more because of that!</span></p> <p style="text-align: justify;"><span style="color:#000000;">Some consider there to be two &ldquo;separate&rdquo; responsibilities to settle RBP claims or otherwise provide patients an avenue of protection from balance-billing &ndash; a social responsibility, and a legal responsibility. The social responsibility can be thought of in terms of the employer&rsquo;s desire to provide its employees with sufficient coverage and a desirable program of health insurance; even though reference-based pricing and balance-billing are permitted by law, most employers utilizing this type of model are typically loathe to allow patients to be balance-billed, and desire to settle claims as part of the normal RBP process. For many employers, seeing a valued employee be sent to collections or become the defendant in a hospital&rsquo;s lawsuit is the worst-case scenario.</span></p> <p style="text-align: justify;"><span style="color:#000000;">There is, despite popular misconception, a legal responsibility to settle claims as well. A few years ago now, the Department of Labor came out with set 31 of its series on Frequently Asked Questions on the Affordable Care Act. While previous guidance provides that balance-billed amounts do <em>not</em> count toward the patient&rsquo;s out-of-pocket limit, this FAQ indicates that that rule applies only when there is an &ldquo;adequate network of providers&rdquo; who will refrain from balance-billing. When there is no adequate network of providers, however, the guidance suggests that health plans must </span><span style="color:#000000;">in fact</span><span style="color:#000000;"> pay for balance-billed amounts that exceed the patient&rsquo;s out-of-pocket max.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Although the Department of Labor has neglected to provide additional guidance and make sure people understand what the FAQ guidance really means, the general opinion is that health plans must have a systematic program of settling balance-bills one way or another &ndash; and in fact most health plans utilizing RBP <em>do</em> have some system, whether direct contracts, a narrow network, or simply making sure they settle claims on the back-end. This is certainly a relevant factor for reference-based pricing, but not necessarily one that is prohibitive. This is an indication that RBP must evolve in order to remain compliant &ndash; and evidence that the threat of walking away the negotiation table may not be an option for many health plans.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Thinking That RBP is &ldquo;All or Nothing&rdquo;</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">When employers are sold on RBP by TPAs, brokers, or vendors, often those entities fall into the common sales trap of promoting only the positive aspects of RBP, without painting a full picture of some of the potential snares as well. As a result, since RBP results do tend to add value, many employers immediately jump to leaving their respective PPO networks and applying the RBP methodology to all claims. After all, more claims subject to RBP theoretically means more added value, right?</span></p> <p style="text-align: justify;"><span style="color:#000000;">In practice, however, it often proves extremely beneficial to utilize some system of agreements as part of the overall RBP process. This ensures that employees have &ldquo;safe harbors&rdquo; to visit, promoting employee security, ease of use, and even compliance (see above!).</span></p> <p style="text-align: justify;"><span style="color:#000000;">There are no pre-set requirements for what RBP is or is not; though many enter into it with a set of preconceived notions of how it <em>should</em> work, </span><span style="color:#000000;">an</span><span style="color:#000000;"> RBP program can be tailored to suit a given health plan&rsquo;s needs (subject to the vendor&rsquo;s and TPA&rsquo;s standard practices and capabilities, of course). Many health plans using RBP combine it with narrow networks, direct provider contracts, physician-only networks, or even primary networks (using RBP only for out-of-network claims).</span></p> <p style="text-align: justify;"><span style="color:#000000;">Since RBP is meant only for non-contracted claims (see above, again!), RBP can </span><span style="color:#000000;">in theory</span><span style="color:#000000;"> be used for <em>any</em> claims that the health plan has not previously agreed to pay at a certain rate.</span></p> <p style="text-align: justify;"><span style="color:#000000;">On that note, the last point:</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Not Realizing that RBP is Just U&amp;C for the Modern Era!</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">When providers say &ldquo;we expect payment at U&amp;C&rdquo; or similar things, it can be useful to take a step back and think about what RBP really is. At its core, RBP is just a way of pricing claims. It&rsquo;s not a unique type of health plan, nor is it a way of changing the claims processes. It&rsquo;s simply a way to determine how much money to pay on a given claim.</span></p> <p style="text-align: justify;"><span style="color:#000000;">&ldquo;Hang on,&rdquo; you may be saying, &ldquo;but isn&rsquo;t that what Usual and Customary is?&rdquo; Yes, it is! RBP can be conceptualized in many ways, but one of the most familiar is as a way of determining U&amp;C. Just like RBP, &ldquo;Usual and Customary&rdquo; is not necessarily a pre-set term with a well-defined meaning; it is the way that a health plan determines what is payable. Interestingly, hospitals tend to suggest that &ldquo;U&amp;C&rdquo; has to be defined as what other area providers charge for the same service, yet there is no support for that requirement. In fact, many health plans define &ldquo;usual and customary&rdquo; as an amount that hospitals commonly <em>accept</em> as payment for a given code. That can take into account private payors and even &ndash; gasp! &ndash; <em>Medicare</em>.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The employer determines the definitions within the Plan Document. If your plan defines its payable amount as U&amp;C, and bases that amount on Medicare rates, then you can honestly say that your plan <em>does</em> pay U&amp;C.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In conclusion: take care to ask your vendor &ndash; or <em>potential</em> vendor &ndash; lots of questions about their processes and how they manage these and other elements of their respective programs. With so many vendors in the industry, there can be lots of conflicting information, so make sure you&rsquo;ve got your facts straight prior to signing on the dotted line.</span></p> <p><span style="color:#000000;">__________________________________________________________________________________________</span></p> <p><span style="color:#0071CE;"><span style="font-size:2.3em;"><strong>How Self-Insured Health Plans Are Helping Employers Compete In A Challenging Talent Marketplace</strong></span></span></p> <h2>By: Philip Qualo, J.D.</h2> <p style="text-align: justify;"><span style="color:#000000;">Prior to joining The Phia Group, LLC, an experienced health care cost-containment company specializing in self-insured plans, my knowledge and experience with the self-insured industry could fit on the tip of my pinky. My previous work experience was exclusively in the fully-insured sector, where I quickly learned that uttering the words &ldquo;self-insurance&rdquo; was considered almost offensive. On a more personal level, I had been covered under various fully-insured health plans since my very first job after </span><span style="color:#000000;">graduating</span><span style="color:#000000;"> law school. From the start, my experience with fully-insured plans jaded my perception of health benefits.&nbsp; I eventually accepted that medical insurance was a necessary evil that I would have to learn to live with. Although my employers genuinely cared about the well-being of their employees, the ability to offer comprehensive medical benefits became increasingly difficult due to the monumental annual increases in the cost of fully-insured coverage.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">As employers who sponsor fully-insured health plans are generally limited to an &ldquo;off the shelf&rdquo; one size fits all plan options designed by their respective carriers, the limited ability to design benefits to meet the specific needs of their employees is an additional obstacle. As a fairly healthy individual who has never broken a bone or required surgery (knock on wood), I have spent most of my adult life stuck paying a premium for benefits that I rarely used. I viewed medical insurance as an unpleasant necessity, expensive but necessary just in case I was hit by a bus. This was especially the case when I experienced the dreaded fully-insured high deductible health plan. Although high deductible plans have become a popular compromise for employers to keep healthcare premiums at an affordable rate, as a low claims plan participant I struggled with the fact that I was not only paying a high premium, but also paying out of pocket for occasional provider visits and generic medications from my own hard-earned money. Due to my infrequent need to seek medical services, in all my years covered by a high deductible health plan, I <em>never</em> reached my deductible amount &ndash; not once. So, in reality, I was paying for coverage that I never really used. &nbsp;Unfortunately, the astronomical profits that fully-insured carriers were reporting at that time did not help to alleviate what I perceived as an unpleasant necessity. </span></p> <p style="text-align: justify;"><span style="color:#000000;">Then I interviewed with The Phia Group, my current employment, who not only specializes in self-insured health </span><span style="color:#000000;">plans,</span><span style="color:#000000;"> but practices what they preach by sponsoring their own self-insured health plan for their employees. Where most employers usually avoid describing their health benefits in the interview process, my experience interviewing with The Phia Group was complete the </span><span style="color:#000000;">opposite,</span><span style="color:#000000;"> and opened my eyes to not only the beauty of self-insured health </span><span style="color:#000000;">plans,</span><span style="color:#000000;"> but how it can be used as an effective recruiting tool. &ldquo;Ummm&hellip; can you repeat that?&rdquo;, I exclaimed, as my eyes widened in bewilderment. &ldquo;Which part?&rdquo;, the Talent Acquisition Specialist asked, &ldquo;The part about no co-pay for generic medications, no co-pay if I choose to take part in the Direct Primary Care (&ldquo;DPC&rdquo;) program, or the list of &nbsp;incentives that can actually result in extra cash in your pocket for helping the plan contain costs?&rdquo; Needless to say, this was the first time ever, in my </span><span style="color:#000000;">lengthy</span><span style="color:#000000;"> professional career that I ever considered healthcare benefits as a factor in making my decision to work for an employer. Since enrolling in our health plan over a year ago, my health plan contributions have been consistent and more affordable than they&rsquo;ve ever been. Most importantly, my trauma from paying the full cost for health services under a fully-insured high deductible health plan had finally faded, as the total I have spent on healthcare since I joined The Phia Group has totaled $0. This is when I first realized how important offering and sponsoring a self-insured plan can be, as self-insurance can </span><span style="color:#000000;">be &nbsp;an</span><span style="color:#000000;"> employer&rsquo;s &ldquo;secret weapon&rdquo; for marketability in an ever-increasing competitive market for top talent.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Why is There a Struggle to Find &amp; Retain Top Talent? </strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">In May 2019, the</span> <a href="https://www.whitehouse.gov/articles/unemployment-rate-falls-lowest-level-nearly-50-years-u-s-economy-adds-263000-new-jobs-april/">White House</a> <span style="color:#000000;">announced that the unemployment rate in </span><span style="color:#000000;">United</span><span style="color:#000000;"> States had dropped to 3.6 percent&mdash;the lowest unemployment rate since December 1969, according to a Bureau of Labor Statistics&rsquo; (&ldquo;BLS&rdquo;) household survey. Although this was great news for our economy as a whole, a low unemployment rate can be a challenge for employers seeking to expand their workforce and attract and retain top talent. Although U.S. job growth has been consistently strong, a low unemployment rate indicates there are more jobs than there are job seekers.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Another challenge employers are currently facing is increasingly high turnover rates, or what is generally referred to as high &ldquo;quit rates&rdquo; meaning voluntary separations initiated by employees. According to the</span> <a href="https://www.bls.gov/web/jolts/jlt_labstatgraphs.pdf">April 2019 Bureau of Labor Statistics Job Openings and Labor Turnover Survey Highlights</a><span style="color:#000000;">, high quit rates are indicative of a robust job market. Therefore, the quit rate can serve as a measure of workers&#39; willingness or ability to leave jobs. According to the survey, there were 3.5 million quits in the U.S. in April 2019. This number far exceeded the number of discharge or layoffs for April, which was estimated at 1.8 million. Employers who sponsor self-insured plans and who choose to use the services of Third Party Administrators (&ldquo;TPAs&rdquo;) have been found to save more money on their health plans per enrolled person than they would have with traditional insurance. This is because TPAs work to manage an employer&rsquo;s self-insured plan based on the employer&rsquo;s specifications instead of according to an insurance carrier&rsquo;s policy. </span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>The Recruiting &amp; Retention Advantages for Employers Who Sponsor Self-Insured Health Plans&nbsp; </strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Due to the limited pool of job seekers, and increasingly high quit rates, employers are reviewing their compensation packages, and more importantly, their benefit offerings, to determine what leverage they have to compete in this employee-centered job market. &nbsp;In a 2017 survey conducted by the </span><a href="https://www.shrm.org/hr-today/trends-and-forecasting/research-and-surveys/Documents/2017%20Employee%20Benefits%20Report.pdf">Society for Human Resource Managers (&ldquo;SHRM&rdquo;)</a> <span style="color:#000000;">on the strategic use of benefits, the results yielded that organizations that take a strategic approach to their benefits programs, by leveraging benefits to recruit and retain employees, are nearly twice as likely to have more satisfied employees and to report better business performance compared with organizations that are not strategic with their benefit programs. This </span><span style="color:#000000;">survey&nbsp; reveals</span><span style="color:#000000;"> that benefits are a key driver in recruitment and job satisfaction. If an employer&rsquo;s offerings fail to meet employees&rsquo; health and financial demands, they risk losing top talent to organizations with more complete coverage options.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Employers who sponsor a self-insured health plan have a notable advantage over employers who offer fully-insured coverage, especially when it comes to adjusting their benefits </span><span style="color:#000000;">to &nbsp;attract</span><span style="color:#000000;"> top talent. In order </span><span style="color:#000000;">too</span><span style="color:#000000;"> meet the unique needs of job seekers and candidates as well as current employees, self-insured health plans allow for more flexibility and control over the terms of a plan. Employers have the opportunity to work directly with their service providers to customize their benefits to fit their needs and adjust them over time as needed. More importantly, plan sponsors have the ability to incorporate cost-containment incentives for their employees that allows the employer to not only save </span><span style="color:#000000;">money,</span><span style="color:#000000;"> but also use those savings to enhance their plan offerings and offer them at a low cost. On the other hand, employers who offer fully-insured health plans are generally limited to the costly options available from the carriers within their respective states. In this context, </span><span style="color:#000000;">budget conscious</span><span style="color:#000000;"> employers are usually forced to forego the more comprehensive health plan for the most affordable option, which usually has less than favorable coverage and results in employee dissatisfaction.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Bottom Line</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">According to a survey conducted by</span> <a href="https://www.ahip.org/wp-content/uploads/2018/02/AHIP_LGP_ValueOfESIResearch_Print_2.5.18.pdf">America&rsquo;s Health Insurance Plan</a><span style="color:#000000;">, 56 percent of U.S. adults with employer-sponsored health benefits said that whether or not they like their health coverage is a key factor in deciding to stay at their current job. In addition, the survey found that 46 percent of U.S. adults said health insurance was either the deciding factor or a positive influence in choosing their current job.</span></p> <p style="text-align: justify;"><span style="color:#000000;">For employers who offer self-insured health coverage, the ability to design and modify their plans and enhance savings can be a valuable resource to attract top talent in this expanding job market. In sum, communicating the value of self-insured health benefits to job-seekers, potential job candidates, and existing employees, can be an employer&rsquo;s secret weapon in competing for talent in this job market as well as employee retention.</span></p> <p>__________________________________________________________________________________________</p> <p><span style="color:#0071CE;"><span style="font-size:2.3em;"><strong>Big Pharma Facing Big Losses Tied To Opioid Epidemic Fallout</strong></span></span></p> <h2>By: Sean Donnelly, Esq</h2> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>Background</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">In 2017, a total of 70,237 people in the United States died from a drug overdose.&nbsp; A staggering 67.8% of those deaths involved the use of opioids, a startling escalation that has been classified as a national epidemic.&nbsp; Deaths attributed to synthetic opioids have become increasingly prevalent, accounting for 59.8% of all opioid overdose deaths. </span></p> <p style="text-align: justify;"><span style="color:#000000;">Every day, an average of 46 people in the United States die from overdoses specifically involving <em>prescription</em> opioids.&nbsp; The highest prescription opioid-involved death rates in 2017 were in West Virginia, Maryland, Kentucky and Utah<sup>1</sup>.&nbsp; According to the National Institute on Drug Abuse, drug overdose deaths involving opioids that were prescribed rose from 3,442 in 1999 to 17,029 in 2017<sup>2</sup>. </span></p> <p style="text-align: justify;"><span style="color:#000000;">In particular, oxycodone (such as OxyContin&reg;), hydrocodone (such as Vicodin&reg;), methadone, and fentanyl have been identified as the most common drugs associated with prescription opioid overdose deaths<sup>3</sup>.&nbsp; Fentanyl, a synthetic opioid used to treat severe pain, is one of the chief agents being linked to the recent rash of drug overdose deaths.&nbsp; In 2011, Fentanyl was identified as being the cause of 1,663 deaths; in 2016, that figure surged to 18,335 deaths<sup>4</sup>.&nbsp; Natural and semi-synthetic opioids, a category that includes oxycodone and hydrocodone, accounted for 14,495 deaths in the United States in 2017<sup>5</sup>.&nbsp; On a molecular level, oxycodone is nearly identical to heroin<sup>6</sup>.&nbsp; &nbsp; </span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>States Fight Back</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>Massachusetts</em></span></p> <p style="text-align: justify;"><span style="color:#000000;">In the last decade, more than 11,000 people died from opioid-related overdoses in Massachusetts alone<sup>7</sup>.&nbsp; Massachusetts patients who were prescribed opioids for more than one year were 51 times more likely to die of an opioid-related overdose<sup>8</sup>.&nbsp; The Attorney General for Massachusetts, Maura Healey, alleged in a recent lawsuit<sup>9</sup> against Purdue Pharma that the pharmaceutical giant possessed actual knowledge that its prescription opioid OxyContin was leading to overdose deaths.&nbsp; Since 2009, in Massachusetts alone, 671 people who filled prescriptions for opioids manufactured by Purdue ultimately died from an opioid-related overdose<sup>10</sup>.&nbsp; Yet, Healey claims that the company turned a blind eye towards the evidence of OxyContin&rsquo;s addictive qualities and instead engaged in a large-scale sales blitz in Massachusetts to push sales of the prescription drug while deceiving doctors and patients.&nbsp; Pleadings filed by Healey assert that Purdue&rsquo;s OxyContin offensive included threatening to fire sales reps whose physician targets failed to write sufficient opioid prescriptions, advocating that the powerful drug be used to treat elderly patients with arthritis, and obscuring the risk of addiction in its marketing materials.&nbsp; </span></p> <p style="text-align: justify;"><span style="color:#000000;">Healey&rsquo;s case focuses on Purdue&rsquo;s deceptive practices, which allegedly included making misleading claims in order to push more patients onto its opioids at higher doses and for longer amounts of time, while simultaneously diverting patients away from safer alternatives<sup>11</sup>.&nbsp; Additional counts charge Purdue with creating a public nuisance of addiction, illness, and death and interfering with the public health by engaging in deceptive marketing practices that fostered a dangerous epidemic of opioid addiction in the state<sup>12</sup>.&nbsp; Further, Healey contends that Purdue acted negligently and recklessly with regard to the known risks of its drugs<sup>13</sup>, including by intentionally targeting high-prescribing doctors and rewarding them with gifts and money in exchange for them prescribing more Purdue opioids<sup>14</sup>, even when Purdue knew that its opioids were being misused and harming patients.&nbsp; In one instance, Purdue&rsquo;s governing board had allegedly been warned by staff that two Massachusetts doctors had prescribed opioids inappropriately, but it failed to notify medical licensing officials.&nbsp; Purdue made more than $823,000 off those two doctors alone in just two years<sup>i</sup>.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In March, Purdue&rsquo;s attorneys filed a second motion to dismiss the case that labeled Healey&rsquo;s allegations as &ldquo;oversimplified scapegoating,&rdquo; countering that the company neither created nor caused the opioid epidemic in Massachusetts<sup>15</sup>.&nbsp; Instead, Purdue made the case that unlawful opioids like heroin and illicitly-produced fentanyl were the root cause of the great majority of opioid-related overdose deaths in Massachusetts<sup>16</sup>.&nbsp; Accordingly, Purdue claimed that its FDA-approved OxyContin could not, as a matter of law, be considered the proximate or but-for &ldquo;cause&rdquo; of the state&rsquo;s opioid crisis<sup>17</sup>.&nbsp; The Massachusetts Attorney General&rsquo;s Office is currently opposing Purdue&rsquo;s motion.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>Oklahoma</em></span></p> <p style="text-align: justify;"><span style="color:#000000;">Oklahoma ranked as the leading state in the nation in terms of amount of opioids distributed per adult resident in 2016<sup>18</sup>.&nbsp; In 2018, nearly fifty percent of drug overdose deaths in Oklahoma were caused by pharmaceutical drugs.&nbsp; In that same year, of the more than 3,000 Oklahoma residents who were admitted to a hospital for a non-fatal overdose, eighty percent of those overdoses were due to prescription opioid medications<sup>19</sup>.&nbsp; At the epicenter of this epidemic, Purdue Pharma was again in the crosshairs of a state lawsuit centered on opioid addiction.&nbsp; The case brought by Oklahoma, originally filed in June 2017 by the Oklahoma Attorney General&rsquo;s Office, named opioid manufacturers Purdue Pharma, Johnson &amp; Johnson, and Teva Pharmaceuticals as defendants. &nbsp;Rather than face a televised trial, Purdue in this instance elected to settle with the state to the tune of $270 million.&nbsp; The settlement funds will be used to establish an almost $200 million endowment at the Oklahoma State University&rsquo;s Center for Wellness and Recovery for the purpose of addiction treatment and research.&nbsp; More than $100 million of the settlement proceeds will be used to fund a new addiction treatment and research center at Oklahoma State University.&nbsp; $20 million of that amount will be earmarked for addiction treatment medicines.&nbsp; Another $12.5 million in settlement funds will be dedicated to use by cities and counties to help fight the opioid epidemic.&nbsp; In late May, Teva Pharmaceuticals reached its own $85 million settlement with the state.&nbsp; The case against the remaining defendant, Johnson &amp; Johnson, is moving forward with a bench trial that began on May 28<sup>th</sup>.&nbsp; </span></p> <p style="text-align: justify;"><span style="color:#000000;">The complaint filed by the Oklahoma Attorney General<sup>20</sup>, Mike Hunter, revealed that Purdue&rsquo;s OxyContin sales skyrocketed from $48 million in 1996 to $3 billion in 2009<sup>21</sup>.&nbsp; Hunter alleged that Purdue misrepresented the risks of opioid addition in its marketing materials and promoted unproven benefits in an effort to boost sales.&nbsp; According to the complaint, Purdue caused &ldquo;catastrophic damage&rdquo; in Oklahoma by engaging in a false and deceptive marketing campaign that deluded both doctors and patients into thinking Purdue&rsquo;s opioids were actually less harmful than had originally been warned by the medical community<sup>22</sup>.&nbsp; Specifically, Hunter claims that Purdue falsely downplayed the risk of addiction associated with OxyContin and erroneously maintained that scientific studies had supported the prescription drug&rsquo;s low risk of addiction<sup>23</sup>.&nbsp; One Purdue sales manager is quoted in the complaint as being trained to say that OxyContain was &ldquo;non-habit forming,&rdquo; going so far as to admit he was instructed &ldquo;to say things like [OxyContin] is &lsquo;virtually&rsquo; non-addicting&hellip;It&rsquo;s not right, but that&rsquo;s what they told us to say.&rdquo;<sup>24</sup>&nbsp; The complaint also alleged that Purdue misrepresented the benefits of its opioids, including by falsely promoting that OxyContin had been studied for use with arthritis and recommending that it was effective in treating chronic non-cancer related pain<sup>25</sup>.&nbsp; Abbe Gluck, a professor at Yale Law School, theorized that Purdue&rsquo;s decision to settle the case was largely driven by its apprehension that these allegations by the state would be &ldquo;publically aired against it during a televised trial,&rdquo; thereby risking &ldquo;exposure to what could have been an astronomical jury verdict.&rdquo;<sup>26</sup> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>New York</em></span></p> <p style="text-align: justify;"><span style="color:#000000;">For the first time since the onset of the opioid crisis, <em>criminal</em> charges have been levied against the individual executives running a drug distribution company.&nbsp; The United States Attorney&rsquo;s Office for the Southern District of New York (USAO), in cooperation with the New York Division of the U.S. Drug Enforcement Administration (DEA), announced in late April that criminal charges were filed against two executives of Rochester Drug Co-Operative, Inc.&nbsp; Rochester, which is one of the largest wholesale pharmaceutical distributors in the United States, was accused of unlawfully distributing both oxycodone and fentanyl and conspiring to defraud the DEA.&nbsp; Most notably, the company&rsquo;s former chief executive officer and former chief compliance officer were both individually charged with the illegal distribution of controlled substances, a felony offense.&nbsp; For its part, Rochester admitted culpability for the unlawful distribution and agreed to pay a $20 million fine and allow for future oversight of it operations by an independent monitor.&nbsp; If Rochester adheres to the government&rsquo;s terms over the next five years, the USAO has agreed to dismiss the charges against the company.&nbsp; The press release from the USAO underscored that the unprecedented charges &ldquo;should send shock waves throughout the pharmaceutical industry reminding them of their role as gatekeepers of prescription medication.&rdquo;<sup>27</sup>&nbsp; </span></p> <p style="text-align: justify;"><span style="color:#000000;">With respect to the individual executives, the USAO alleged that they conspired to distribute oxycodone and fentanyl outside of the scope of professional practice and not for a legitimate medical purpose<sup>28</sup>.&nbsp; The indictment alleges that they willfully failed to report suspicious orders of controlled substances to the DEA and likewise failed to advise the DEA that Rochester&rsquo;s customers were diverting the controlled substances for illegitimate use<sup>29</sup>.&nbsp; In particular, over an approximately five-year period, Rochester received 412 orders of fentanyl and 2,530 orders of oxycodone from its pharmacy customers that the company designated as &ldquo;suspicious.&rdquo;<sup>30</sup>&nbsp; Of those almost 3,000 orders that Rochester&rsquo;s internal compliance team red-flagged, the former executives only reported four total orders to the DEA at the direction of Rochester&rsquo;s former CEO<sup>31</sup>.&nbsp; One member of Rochester&rsquo;s compliance team explicitly warned the CEO and other executives that this practice could place the company in the DEA&rsquo;s &ldquo;cross-hairs&hellip;because of [its] willful blindness and deliberate ignorance.&rdquo;<sup>32</sup>&nbsp; The former executives were also cited with having lied to the DEA about conducting due diligence on new pharmacy customers when no proper review was ever performed<sup>33</sup>.&nbsp; These customers were ultimately supplied with opioids from Rochester despite the company and its executives allegedly knowing that the drugs were in turn being sold and used illicitly<sup>34</sup>.&nbsp; Laurence Doud, the former CEO, was charged with one count of conspiracy to distribute controlled substances, which carries a maximum sentence of life in prison and a mandatory minimum sentence of 10 years, and one count of conspiracy to defraud the United States, which carries a maximum term of 5 years.&nbsp; William Pietruszewski, the former Chief Compliance Officer, pled guilty in April to charges of conspiracy to distribute controlled substances, conspiracy to defraud the United States, and failing to file suspicious order reports with the DEA.&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>Proactive Options for Self-Funded Plans</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Plan participants that misuse or intentionally abuse prescription opioids are more likely to incur high-dollar medical charges, whether in the form of emergency room visits, lengthy inpatient hospital stays, or recurrent physician visits.&nbsp; Statistics provided by the Centers for Disease Control and Prevention indicate that over 1,000 people per day receive emergency medical services as a result of misusing prescription opioids<sup>35</sup>.&nbsp; In 2014, there were over 1.27 million emergency room visits and hospital inpatient stays for opioid-related issues, which represented a 99% increase for emergency room treatment and 64% increase for inpatient care from just 2005<sup>36</sup>.&nbsp; These increased emergency room visits, extended hospitalizations, and even a rise in workers&rsquo; compensation claims stemming from opioid addiction are putting a considerable financial strain on employers and the plans they sponsor.&nbsp; Opioid abuse can cost an employer-sponsored plan an additional $10,000 to $20,000 in annual excess costs per patient<sup>37</sup>.&nbsp; Almost one-third of prescription painkillers covered by employer-sponsored plans are abused<sup>38</sup>.&nbsp; Fortunately, there are a number of options available to self-funded plans to combat the epidemic and mitigate the rising costs associated with opioid abuse:</span></p> <ol style="margin-left: 80px;"> <li style="text-align: justify;" value="NaN"><span style="color:#000000;"><em>Plan Design</em> &ndash; Employers can customize their plans to discourage opioid abuse and instead incentivize participants to utilize pain management alternatives, such as acupuncture, chiropractic care, physical and behavioral therapy and heat-focused massage.&nbsp;</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;"><em>Insist on Compliance with CDC and FDA Guidelines</em> &ndash; Employer-sponsored plans should confirm whether the providers in their networks are properly following opioid prescription guidelines established by the Centers for Disease Control and Prevention (CDC).&nbsp; The CDC guidelines were established as a baseline for providers to follow to better ensure that opioids are prescribed safely and appropriately in order to minimize the chances of abuse or misuse.&nbsp; Additionally, plans should take steps to make sure their participants are aware of, and diligently follow, the Food and Drug Administration&rsquo;s (FDA) guidelines that instruct patients on how to properly discard surplus opioids before they can be accessed by other household members who do not have a prescription.&nbsp;&nbsp;&nbsp; &nbsp;</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;"><em>Establish a Limit</em> &ndash; CDC studies have revealed that the likelihood of a patient becoming addicted to opioids spikes on day four of use.&nbsp; Consequently, Plans may want to consider placing a three-day limit on the use of opioid prescriptions for initial pain treatment<sup>39</sup>.&nbsp; Plans should work directly with their utilization management vendor and pharmacy benefit manager to establish strict dosage caps and dispensation/refill limits.&nbsp; &nbsp;&nbsp;&nbsp;</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;"><em>Plan Participant Education</em> &ndash; Employers need to take proactive steps to ensure that their employees are fully-informed of the dangers of opioid addiction and misuse.&nbsp; Group discussions and annual meetings are useful forums for discussing the dangers of opioid side effects, recognizing the symptoms of painkiller abuse, and identifying helpful resources available to employees such as substance abuse hotlines.</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;"><em>Identify Vulnerable Participants</em> &ndash; Plans should analyze their prescription drug data to identify plan participants with a history of excessive prescription drug use who may be more prone to abusing opioids.&nbsp; Plans should then work with their vendors and administrators to preemptively reach out to providers and pharmacists in order to steer susceptible participants towards pain management alternatives, establish prescription limitations, and make such participants aware of assistance networks and other resources at their disposal to help them through substance abuse issues. &nbsp;&nbsp;</span></li> </ol> <div> <div id="ftn1"> <p style="text-align: justify;"><span style="color:#000000;"><sup>1</sup>Preceding statistics derived from Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths &mdash; United States, 2013&ndash;2017. MMWR Morb Mortal Wkly Rep 2019;67:1419&ndash;1427. DOI:</span> <a href="http://dx.doi.org/10.15585/mmwr.mm675152e1" target="_self">http://dx.doi.org/10.15585/mmwr.mm675152e1</a>.&nbsp;&nbsp;</p> </div> <div id="ftn2"> <p style="text-align: justify;"><span style="color:#000000;"><sup>2</sup>See National Institute on Drug Abuse, <em>Overdose Death Rates </em>(Revised January 2019). Retrieved from:</span> <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates</a>.</p> </div> <div id="ftn3"> <p style="text-align: justify;"><span style="color:#000000;"><em><sup>3</sup>Prescription Opioid Data</em>, Centers for Disease Control and Prevention.&nbsp; Dec. 19, 2018.&nbsp; Retrieved from:</span> <a href="https://www.cdc.gov/drugoverdose/data/prescribing.html">https://www.cdc.gov/drugoverdose/data/prescribing.html</a>.&nbsp;&nbsp;</p> </div> <div id="ftn4"> <p style="text-align: justify;"><span style="color:#000000;"><sup>4</sup>Spencer, </span><span style="color:#000000;">Merianne</span><span style="color:#000000;"> Rose; Warner, Margaret; Bastian, Brigham A.; Trinidad, James P.; and Hedegaard, Holly. <em>National Vital Statistics Reports</em> (Vol. 68, No. 3). National Center for Health Statistics, Centers for Disease Control and Prevention. Mar. 21, 2019. Retrieved from:</span> <a href="https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf">https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf</a>.</p> </div> <div id="ftn5"> <p style="text-align: justify;"><span style="color:#000000;"><em><sup>5</sup>Opioid Overdose Deaths by Type of Opioid</em>, Henry J. Kaiser Family Foundation.&nbsp; Retrieved from</span> <a href="https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-type-of-opioid/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Natural%20and%20Semisynthetic%20Opioids%20(e.g.%20oxycodone,%20hydrocodone)%22,%22sort%22:%22desc%22%7D">https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-type-of-opioid/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Natural%20and%20Semisynthetic%20Opioids%20(e.g.%20oxycodone,%20hydrocodone)%22,%22sort%22:%22desc%22%7D</a>.</p> </div> <div id="ftn6"> <p style="text-align: justify;"><span style="color:#000000;"><sup>6</sup>First Amended Complaint at 8, <u>Commonwealth of Massachusetts v. Purdue Pharma, L.P., et al</u>, Mass. Superior Court, 1884-CV-01808 (BLS2).&nbsp;</span></p> </div> <div id="ftn7"> <p style="text-align: justify;"><span style="color:#000000;"><sup>7</sup>Complaint at 4, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.</span></p> </div> <div id="ftn8"> <p style="text-align: justify;"><span style="color:#000000;"><sup>8</sup>First Amended Complaint at 8, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.</span></p> </div> <div id="ftn9"> <p style="text-align: justify;"><span style="color:#000000;"><sup>9</sup>See <u>Commonwealth of Massachusetts v. Purdue Pharma, L.P., et al</u>, Mass. Superior Court, 1884-CV-01808 (BLS2).</span></p> </div> <div id="ftn10"> <p style="text-align: justify;"><span style="color:#000000;"><sup>10</sup>First Amended Complaint at 9, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.&nbsp;</span></p> </div> <div id="ftn11"> <p style="text-align: justify;"><span style="color:#000000;"><sup>11</sup>First Amended Complaint at 10, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.&nbsp;</span></p> </div> <div id="ftn12"> <p style="text-align: justify;"><span style="color:#000000;"><sup>12</sup>First Amended Complaint at 270-272, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>. &nbsp;&nbsp;&nbsp;</span></p> </div> <div id="ftn13"> <p style="text-align: justify;"><span style="color:#000000;"><sup>13</sup>First Amended Complaint at 272, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.</span></p> </div> <div id="ftn14"> <p style="text-align: justify;"><span style="color:#000000;"><sup>14</sup>First Amended Complaint at 12, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.</span></p> </div> <div id="ftn15"> <p style="text-align: justify;"><span style="color:#000000;"><sup>15</sup>Purdue&rsquo;s Memorandum of Law in Support of its Motion to Dismiss Amended Complaint at 1, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.&nbsp;</span></p> </div> <div id="ftn16"> <p style="text-align: justify;"><span style="color:#000000;"><sup>16</sup>Purdue&rsquo;s Memorandum of Law in Support of its Motion to Dismiss Amended Complaint at 5, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.</span></p> </div> <div id="ftn17"> <p style="text-align: justify;"><span style="color:#000000;"><sup>17</sup>See Purdue&rsquo;s Memorandum of Law in Support of its Motion to Dismiss Amended Complaint at 3, <u>Commonwealth of Massachusetts v. Purdue Pharma</u>.</span></p> </div> <div id="ftn18"> <p style="text-align: justify;"><span style="color:#000000;"><sup>18</sup>Petition at 2, <u>State of Oklahoma v. Purdue Pharma L.P. et al.</u>, District Court of Cleveland County, State of Oklahoma, CJ-2017-816.&nbsp;</span></p> </div> <div id="ftn19"> <p style="text-align: justify;"><span style="color:#000000;"><sup>19</sup>Gerszewskii, Alex. <em>Attorney General Hunter Announces Historic $270 Million Settlement with Purdue Pharma, $200 Million to Establish Endowment for OSU Center for Wellness</em>. Office of the Oklahoma Attorney General. Mar. 26, 2019.&nbsp; Retrieved from</span> <a href="http://www.oag.ok.gov/attorney-general-hunter-announces-historic-270-million-settlement-with-purdue-pharma-200-million-to-establish-endowment-for-osu-center-for-wellness">http://www.oag.ok.gov/attorney-general-hunter-announces-historic-270-million-settlement-with-purdue-pharma-200-million-to-establish-endowment-for-osu-center-for-wellness</a>.</p> </div> <div id="ftn20"> <p style="text-align: justify;"><span style="color:#000000;"><sup>20</sup>See <u>State of Oklahoma v. Purdue Pharma L.P. et al.</u>, District Court of Cleveland County, State of Oklahoma, CJ-2017-816.</span></p> </div> <div id="ftn21"> <p style="text-align: justify;"><span style="color:#000000;"><sup>21</sup>Petition at 1, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn22"> <p style="text-align: justify;"><span style="color:#000000;"><sup>22</sup>Petition at 12, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn23"> <p style="text-align: justify;"><span style="color:#000000;"><sup>23</sup>Petition at 12, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn24"> <p style="text-align: justify;"><span style="color:#000000;"><sup>24</sup>Petition at 13, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn25"> <p style="text-align: justify;"><span style="color:#000000;"><sup>25</sup>Petition at 12-13, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn26"> <p style="text-align: justify;"><span style="color:#000000;"><sup>26</sup>Hoffman, Jan. <em>Purdue Pharma and Sacklers Reach $270 Million Settlement in Opioid Lawsuit</em>.&nbsp; The New York Times.&nbsp; Mar. 26, 2019.&nbsp; Retrieved from: </span><a href="https://www.nytimes.com/2019/03/26/health/opioids-purdue-pharma-oklahoma.html">https://www.nytimes.com/2019/03/26/health/opioids-purdue-pharma-oklahoma.html</a>.</p> </div> <div id="ftn27"> <p style="text-align: justify;"><span style="color:#000000;"><em><sup>27</sup>Manhattan U.S. Attorney And DEA Announce Charges Against Rochester Drug Co-Operative And Two Executives For Unlawfully Distributing Controlled Substances</em>. The United States Attorney&rsquo;s Office &ndash; Southern District of New York. Apr. 23, 2019. Retrieved from:</span> <a href="https://www.justice.gov/usao-sdny/pr/manhattan-us-attorney-and-dea-announce-charges-against-rochester-drug-co-operative-and">https://www.justice.gov/usao-sdny/pr/manhattan-us-attorney-and-dea-announce-charges-against-rochester-drug-co-operative-and</a>.</p> </div> <div id="ftn28"> <p style="text-align: justify;"><span style="color:#000000;"><sup>28</sup>Information at 1, <u>U.S. v. Pietruszewski</u>, U.S.D.C. for the S.D.N.Y., 19-cr-___ (WHP).</span></p> </div> <div id="ftn29"> <p style="text-align: justify;"><span style="color:#000000;"><sup>29</sup>Information at 2-3, <u>U.S. v. Pietruszewski</u>.</span></p> </div> <div id="ftn30"> <p style="text-align: justify;"><span style="color:#000000;"><sup>30</sup>Information at 3, <u>U.S. v. Pietruszewski</u>.</span></p> </div> <div id="ftn31"> <p style="text-align: justify;"><span style="color:#000000;"><sup>31</sup>Information at 3, <u>U.S. v. Pietruszewski</u>.</span></p> </div> <div id="ftn32"> <p style="text-align: justify;"><span style="color:#000000;"><sup>32</sup>Indictment at 5, <u>U.S. v. Doud</u>, U.S.D.C. for the S.D.N.Y., 19-cr-285.&nbsp;</span></p> </div> <div id="ftn33"> <p style="text-align: justify;"><span style="color:#000000;"><sup>33</sup>Information at 4, <u>U.S. v. Pietruszewski</u>.</span></p> </div> <div id="ftn34"> <p style="text-align: justify;"><span style="color:#000000;"><sup>34</sup>Information at 4, <u>U.S. v. Pietruszewski</u>.</span></p> </div> <div id="ftn35"> <p style="text-align: justify;"><span style="color:#000000;"><sup>35</sup>Petition at 10, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn36"> <p style="text-align: justify;"><span style="color:#000000;"><sup>36</sup>Petition at 10-11, </span><u><span style="color:#000000;">State</span></u><span style="color:#000000;"><u> of Oklahoma v. Purdue Pharma</u>.</span></p> </div> <div id="ftn37"> <p style="text-align: justify;"><span style="color:#000000;"><sup>37</sup>Kirson, Noam Y.; Scarpati, Lauren M.; Enloe, Caroline J.; Dincer, Aliya P.; Birnbaum, Howard G.; and Mayne, Tracy J.&nbsp; <em>The Economic Burden of Opioid Abuse: Updated Findings</em>. Journal of Managed Care &amp; Specialty Pharmacy. Vol. 23, Issue 4.&nbsp; Retrieved from: </span><a href="https://www.jmcp.org/doi/10.18553/jmcp.2017.16265">https://www.jmcp.org/doi/10.18553/jmcp.2017.16265</a>.&nbsp;&nbsp;</p> </div> <div id="ftn38"> <p style="text-align: justify;"><span style="color:#000000;"><sup>38</sup>Coombs, Bertha. <em>U.S. Companies Losing $10B a Year Due to Workers&rsquo; Opioid Abuse</em>. CNBC. Apr. 20, 2016. Retrieved from: </span><a href="https://www.nbcnews.com/business/business-news/u-s-companies-losing-10b-year-due-workers-opioid-abuse-n559036">https://www.nbcnews.com/business/business-news/u-s-companies-losing-10b-year-due-workers-opioid-abuse-n559036</a>.</p> </div> <div id="ftn39"> <p style="text-align: justify;"><span style="color:#000000;"><sup>39</sup>For a full description of the first three options and other useful measures available to plans </span><span style="color:#000000;">see:</span><span style="color:#000000;"> Qualo, Philip. <em>The </em></span><em><span style="color:#000000;">Opiod</span></em><span style="color:#000000;"><em> Crisis: How Employers &amp; Self-Funded Health Plans Can Combat This Epidemic</em>. The Phia Group. Mar. 5, 2019. Available at:</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/830/the-opioid-crisis-how-employers-self-funded-health-plans-can-combat-this-epidemic">https://www.phiagroup.com/Media/Posts/PostId/830/the-opioid-crisis-how-employers-self-funded-health-plans-can-combat-this-epidemic</a>.</p> </div> </div> <div> <div id="edn1"> <p style="text-align: justify;"><span style="color:#000000;"><sup>i</sup>Willmsen, Christine and Bebinger, Martha. <em>Massachusetts Attorney General Implicates Family Behind Purdue Pharma </em><em>in Opioid Deaths</em>. WBUR.&nbsp; Jan. 16, 2019.&nbsp; Retrieved from:</span> <a href="https://www.npr.org/sections/health-shots/2019/01/16/685692474/massachusetts-attorney-general-implicates-family-behind-purdue-pharma-in-opioid-">https://www.npr.org/sections/health-shots/2019/01/16/685692474/massachusetts-attorney-general-implicates-family-behind-purdue-pharma-in-opioid-</a>. &nbsp;&nbsp;</p> </div> </div> 892Tales From the Plan: Episode 4 - A Vision for Savings https://www.phiagroup.com/Media/Posts/PostId/889/tales-from-the-plan-episode-4-a-vision-for-savingsPodcastsMon, 23 Sep 2019 16:33:43 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Bh4VhwzI4bA" width="560"></iframe></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><span style="color:#000000;">Join Adam, Pat, and this episode&rsquo;s guest &ndash; Michael Vaz &ndash; to hear from a valued employee, whose experience in the industry and as a consumer of healthcare will open your eyes and help you appreciate how much difference a plan can make in a person&rsquo;s life.&nbsp; Containing costs and rewarding employees &ndash; it&rsquo;s a win-win.</span></p> <p style="text-align: justify;"><a href="https://youtu.be/Bh4VhwzI4bA"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/Bh4VhwzI4bA"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#3366ff;">iTunes</span><span style="color:#000000;"> </span></a><span style="color:#000000;">Channels!)</span></p> 889The Phia Group Announces the Opening of its Newest Location in Louisville, Kentuckyhttps://www.phiagroup.com/Media/Posts/PostId/886/the-phia-group-announces-the-opening-of-its-newest-location-in-louisville-kentuckyPress ReleasesThu, 19 Sep 2019 13:51:14 GMT<p style="text-align: justify;"><span style="color:#000000;"><strong>September 19, 2019 - For Immediate Release</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Louisville, KY - The Phia Group, LLC is pleased to announce the opening of a new office in Louisville, KY.&nbsp; Under the leadership of the newly appointed Vice President of Operations and Total Quality Management, Scott Byerley, Esq., this new location strengthens The Phia Group&#39;s presence in the central United States - just as it did in the west with its Boise, ID, office - continuing to allow The Phia Group to identify, recruit, and hire the most talented professionals, nationwide.</span></p> <p style="text-align: justify;"><span style="color:#000000;">With a focus on subrogation and claims recovery, as well as other cost containment activities, the Louisville team shares the same passion as the entirety of the &quot;Phia Family,&quot; to deliver robust yet affordable health benefits to as many </span><span style="color:#000000;">hard working</span><span style="color:#000000;"> Americans as possible.&nbsp; &quot; We&#39;re very excited to bring The Phia Group to Louisville.&nbsp; This is a continuation of year after year growth for The Phia Group,&quot; remarked Mr. Byerley.&nbsp; &quot;The Phia Family made this happen with their dedication and passion for everything cost containment and reducing the costs of healthcare.&quot;</span></p> <p style="text-align: justify;"><span style="color:#000000;">&quot;These days, it seems like everyone wants to meet virtually... but at The Phia Group, we feel being there still matters.&nbsp; By continuously expanding our physical presence, we are not only able to draw from an </span><span style="color:#000000;">ever expanding</span><span style="color:#000000;"> talent-pool, but we can also proudly say that our partners are also our neighbors,&quot; said Adam V. Russo, CEO of The Phia Group.</span></p> <p style="text-align: justify;"><span style="color:#000000;">For more information regarding The Phia Group&#39;s Louisville Office, or to learn more about any of The Phia Group&#39;s other locations and services, please contact Tim Callender by email at </span><a href="mailto:tcallender@phiagroup.com"><span style="color:#000000;">tcallender@phiagroup.com</span></a><span style="color:#000000;"> or by phone at 781-535-5631.</span></p> <p style="text-align: justify;"><span style="color:#000000;">About</span><span style="color:#000000;"> The Phia Group:</span></p> <p style="text-align: justify;"><span style="color:#000000;">The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.&nbsp; By providing </span><span style="color:#000000;">industry leading</span><span style="color:#000000;"> consultation, plan drafting, subrogation </span><span style="color:#000000;">and</span><span style="color:#000000;"> other cost containment solutions, The Phia Group is truly Empowering Plans.</span></p> 886Empowering Plans: P71 – Politics! Politics! Politics!https://www.phiagroup.com/Media/Posts/PostId/885/empowering-plans-p71-politics-politics-politicsPodcastsWed, 18 Sep 2019 13:17:25 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/QsS3B7E38-c" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;">Brady and </span><span class="gr-progress" style="color:#000000;">Ron do</span><span style="color:#000000;"> what they do best, say the things you are thinking!&nbsp; This time, they wax poetic about Obamacare, the state of health care versus health insurance, and the political environment as we move toward the 2020 election.</span></p> <p style="text-align: justify;"><a href="https://youtu.be/QsS3B7E38-c"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/QsS3B7E38-c"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#0071CE;">iTunes </span></a><span style="color:#000000;">Channels!)</span></p> 8852020 Renewal Season - Decisions Today, Uncertain Tomorrow https://www.phiagroup.com/Media/Posts/PostId/884/2020-renewal-season-decisions-today-uncertain-tomorrowWebinarsTue, 17 Sep 2019 18:23:19 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/GhkBkVT82h0" width="560"></iframe></p> <p style="text-align: justify;">It’s plan renewal season, and we find ourselves making decisions that will define how plans will operate over the next year.  This is no easy task!  First, we confront known issues and hurdles – such as increasing drug costs, regulatory crackdowns, and aggressive providers – looming before us.  Additionally, despite the need to make these decisions now, the future is more uncertain than ever before.  Between litigation challenging the constitutionality of the ACA and an already wild 2020 Presidential election, no one truly knows what next year will look like.  How can we make decisions today at renewal, that address the issues of tomorrow – both known and unknown?</p> <p style="text-align: justify;">Join The Phia Group for a “can’t miss” review of important issues impacting plan renewals, address known roadblocks, and perform an assessment of the candidates’ positions on healthcare – with an eye toward what we should be doing today to prepare for an uncertain tomorrow.</p> <p style="text-align: justify;"><a href="https://youtu.be/GhkBkVT82h0">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 884Faces of Phia: Episode 16 - Crunching Numbers with Desmond Campbellhttps://www.phiagroup.com/Media/Posts/PostId/881/faces-of-phia-episode-16-crunching-numbers-with-desmond-campbellPodcastsWed, 04 Sep 2019 14:46:42 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/aeZ5SeGyTkc" width="560"></iframe></p> <p style="text-align: justify;">Join Ron Peck as he interviews Desmond Campbell; the man, the myth, the legend.&nbsp; Desmond has spent time crunching numbers over the past 4 years &ndash; first for clients, now for The Phia Group.&nbsp; A man with experience elsewhere in the industry, Desmond will share what brought him to The Phia Group, and what keeps him here.</p> <p style="text-align: justify;"><a href="https://youtu.be/aeZ5SeGyTkc"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/aeZ5SeGyTkc"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#0071CE;">iTunes </span></a><span style="color:#000000;">Channels!)</span></p> 881Back to School: 2020 Renewalshttps://www.phiagroup.com/Media/Posts/PostId/880/back-to-school-2020-renewalsWebinarsWed, 21 Aug 2019 13:33:57 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yNQv_60USIA" width="560"></iframe></p> <p> </p> <p>As players in the self-funded industry have found out the hard way, keeping business often isn’t easy. Fiduciary obligations and other difficult situations can arise when we all least expect them, and when we are worst-equipped to deal with them (such as in the height of renewal season). By popular demand, this month’s webinar will focus on when fiduciary duties can arise, who needs to be careful, and how those duties might affect your 2020 renewals.<br /> <br /> Join The Phia Group’s legal team<span class="details" style="display: inline;"> as they provide the education needed to help you meet your obligations and keep your business safe – and provide the information you need to earn a “passing grade” during renewal season!</span></p> <p> </p> <p style="text-align: justify;"><a href="https://youtu.be/yNQv_60USIA">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 880Faces of Phia: Episode 15 - The Fine Fan Club!https://www.phiagroup.com/Media/Posts/PostId/879/faces-of-phia-episode-15-the-fine-fan-clubPodcastsFri, 16 Aug 2019 15:55:13 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/rm01UYiC5EQ" width="560"></iframe></p> <p style="text-align: justify;">In this episode, learn more about the life and background of Andrew Fine, Phia&rsquo;s Lead Intake Specialist. Listen in as Andrew discusses his family, the fan club behind him, compliance being the number one priority for plans, and the bittersweet nature of the Celtics. Listen in closely, as the former sports analyst might give you some insider tips!</p> <p style="text-align: justify;"><a href="https://youtu.be/rm01UYiC5EQ"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/rm01UYiC5EQ"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#0071CE;">iTunes </span></a><span style="color:#000000;">Channels!)</span></p> 879Faces of Phia: Episode 14 – The Magical Kingdom!https://www.phiagroup.com/Media/Posts/PostId/876/faces-of-phia-episode-14-the-magical-kingdomPodcastsThu, 01 Aug 2019 21:49:55 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/GQqFtdCvCxM" width="560"></iframe></p> <p style="text-align: justify;">In this episode, prepare to be enchanted by Mattie Sesin, our Director of Recovery Services.&nbsp; Like a toad kissed by a princess, her career has transformed &ndash; and we invite you to join the journey.&nbsp; Marvel at the tales of family, festivities, and food.&nbsp; Miss this one, and you&rsquo;ll likely turn into a pumpkin.</p> <p style="text-align: justify;"><a href="https://youtu.be/GQqFtdCvCxM"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/GQqFtdCvCxM"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#0071CE;">iTunes </span></a><span style="color:#000000;">Channels!)</span></p> 876Trump’s Executive Order on Transparency: How it Will Effect Each Segment of Our Industry https://www.phiagroup.com/Media/Posts/PostId/873/trumps-executive-order-on-transparency-how-it-will-effect-each-segment-of-our-industryWebinarsTue, 23 Jul 2019 14:38:29 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/wl8FsnqlmY8" width="560"></iframe></p> <p style="text-align: justify;">On June 24, 2019, President Trump issued his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” This Order requires hospitals to publicly post their prices, and is designed to give healthcare consumers more choice and better decision-making capabilities.</p> <p style="text-align: justify;">Join The Phia Group’s legal team as they discuss the executive order point by point; they’ll touch on what they like and don’t like about it, and – more importantly – what this all means for you.</p> <p style="text-align: justify;"><a href="https://youtu.be/wl8FsnqlmY8">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 873The Phia Group's 3rd Quarter 2019 Newsletter https://www.phiagroup.com/Media/Posts/PostId/871/the-phia-groups-3rd-quarter-2019-newsletterNewslettersFri, 19 Jul 2019 16:04:49 GMT<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/Newsletter%202019%20Q1/header2019.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/icons5_1.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p12a"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b13rdqtr19.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b3rdqtr19.png" 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="53%"> <p>&nbsp;</p> <p><br /> <img src="/Portals/phiagroup/Newsletter%202018%20Q2/adam.jpg" style="width: 300px; height: 300px;" /></p> </td> <td valign="top" width="47%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">Greetings from the beautiful city of... Braintree, Massachusetts! We are excited about the weeks and months ahead, where - like the weather - things are heating up at The Phia Group. Unlike some others in the industry who look at the summer as a time to kick back and relax, we here at The Phia Group are putting the finishing touches on not one, but TWO huge offerings and upgrades in the coming weeks. When it comes to our mission of empowering plans, and ensuring employers can offer their employees and families the highest quality benefits and health care, for the lowest cost, we never rest. Indeed, we know that this is the time of year you spend preparing for the upcoming renewal and retention season. The services and expertise we provide today will be the tools you use to ensure your continued growth and success tomorrow. I hope you are enjoying your summer thus far - Happy reading, and don&#39;t forget the sunblock.</p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </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%20Q1%202018/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: Plan Appointed Claim Evaluator&reg; (PACE)</a><br /> <a href="#p3">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2019 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12a">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a id="p1" name="p1"></a> <p>&nbsp;</p> <p class="heading1">Service Focus of the Quarter: Plan Appointed Claim Evaluator<sup>&reg;</sup> (PACE)</p> <p class="bodytext" style="text-align: justify;">Some years ago, in response to growing industry concerns regarding fiduciary duties, The Phia Group created its Plan Appointed Claim Evaluator (PACE) service. PACE is a fiduciary transfer service addressing final-level internal appeals. It is designed to help plans ensure they made correct determinations, thereby insulating the health plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations.</p> <p class="bodytext" style="text-align: justify;">PACE includes:</p> <p class="bodytext" style="text-align: justify; margin-left: 40px;">&bull; Plan Document and stop-loss policy &ldquo;Gap Reviews,&rdquo; to both ensure compliance as well as eliminate coverage gaps, all while also ensuring PACE readiness;<br /> &bull; Advanced-level webinars exclusively for PACE clients;<br /> &bull; Assessment of eligible final internal appeals via written directives; and,<br /> &bull; Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (with PACE covering all external review costs).</p> <p class="bodytext" style="text-align: justify;">Beginning August 2019, we will also begin offering complimentary PACE Certification &ndash; whereby your organization can enhance your PACE business, improve your internal appeals processes, ensure regulatory compliance, and improve your business as a whole. Chapter One of PACE Certification explores the ins and outs of self-funding; Chapter 2 takes a deeper dive into the laws and regulations applicable to self-funded health plans; Chapter 3 explains what PACE is, how it works, and how it can best be utilized.</p> <p class="bodytext" style="text-align: justify;">Tim can be reached by phone at 781-535-5631 or by email at TCallender@phiagroup.com.</p> <p class="bodytext">&nbsp;</p> <a id="p3" name="p3"></a> <p class="bodytext"><strong>Phia Case Study: The Tale of the Reluctant ASC</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group was presented with a file, as part of its Phia Unwrapped service, where a patient had visited an out-of-network ambulatory surgery center (ASC), and was receiving a balance-bill following the plan&rsquo;s payment. The health plan adjudicated the claim based on 145% of Medicare rates, whereas the claim was billed at a whopping 1,430% of Medicare. Needless to say, a large balance ensued.</p> <p class="bodytext" style="text-align: justify;">The ASC informed The Phia Group&rsquo;s team that it would not accept any reduction in its billed charges, under any circumstances, and it cited a dozen bogus arguments about how state and federal law prohibited the health plan from utilizing this particular payment methodology.</p> <p class="bodytext" style="text-align: justify;">The Phia Group&rsquo;s legal team put together a strong response to each argument raised by the ASC; we then followed up after one week, and were told the letter was still being reviewed. We followed up after another week, and were told the same thing. Fast-forward two months: same answer. Still being reviewed!</p> <p class="bodytext" style="text-align: justify;">Our legal team pressured the ASC for a response, informing them that our client was considering closing its file and walking away with no possibility of additional payment.</p> <p class="bodytext" style="text-align: justify;">Two weeks later, we finally received a positive response, and our efforts yielded an ultimate settlement at only 18% of billed charges.</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> _ <p>&nbsp;</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Managing Conflicting Agreements </strong></p> <a id="p12" name="p12"></a> <p class="bodytext" style="text-align: justify;">Have you ever seen a health plan incur an in-network claim that is billed at many times the appropriate rate defined in the Plan Document? If so, you&rsquo;re not alone.</p> <p class="bodytext" style="text-align: justify;">Have you ever reviewed that in-network claim against the terms of the Plan Document, and then denied the portion exceeding the Plan Document&rsquo;s terms? If so, you&rsquo;re <i>still</i> not alone.</p> <p class="bodytext" style="text-align: justify;">Have you ever received pushback from that in-network provider, demanding the network rate? If so, you&rsquo;re <i>still</i> not alone.</p> <p class="bodytext" style="text-align: justify;">It&rsquo;s certainly true that the Plan Document prescribes certain limitations on claims payments &ndash; but it&rsquo;s also true that network contracts don&rsquo;t take those limitations into account, and instead require payment based on a percentage off billed charges. Not <i>appropriate</i> billed charges, or <i>allowed</i> billed charges; just <i>billed</i> charges.</p> <p class="bodytext" style="text-align: justify;">For that reason, it&rsquo;s crucial to be aware of what all the relevant contracts say; the Plan Document and the network contract are conflicting, but neither &ldquo;overrules&rdquo; the other. That is, the payor has promised to pay two separate amounts &ndash; one in the Plan Document and one in the network contract &ndash; and of course medical providers are going to expect the higher of those two amounts. Add to that the fact that the provider has privity to the contract guaranteeing the higher amount, and we&rsquo;ve got a situation on our hands.</p> <p class="bodytext" style="text-align: justify;">Moral of this story? Make sure your Plan Document language is synced up to your network contracts! Try to avoid placing a hard limit on all claims payments, instead focusing on non-contracted claims, since once a claim has a contract whereby it must be paid at a certain rate, the Plan Document&rsquo;s global limitations across all claims cannot be applied without violating that contract!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Success Story of the Quarter: The Non-Responsive Plaintiff&rsquo;s Attorney</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group identified a particularly large potential recovery for a client. The patient in question was involved in a motor vehicle accident, and had engaged legal counsel to pursue damages from a wealthy defendant. It seemed likely that this patient would receive a settlement far larger than the health plan&rsquo;s lien, and The Phia Group put the patient&rsquo;s attorney on notice of the lien.</p> <p class="bodytext" style="text-align: justify;">Well, we tried, anyway.</p> <p class="bodytext" style="text-align: justify;">The attorney didn&rsquo;t respond to our letter. Or our phone call. Or any of our subsequent letters or phone calls. Our legal team explored all available avenues, and even spoke to former law firm partners of the attorney, but to no avail.</p> <p class="bodytext" style="text-align: justify;">Finally, our attorneys drafted a very strongly-worded letter, reminding the attorney of his legal obligations, and &ndash; with our client&rsquo;s blessing &ndash; informing the attorney that if he did not live up to his legal and ethical obligations, we would gladly have the state bar issue him a more stern reminder of his responsibilities as an attorney.</p> <p class="bodytext" style="text-align: justify;">Our legal team received a prompt, courteous, and apologetic response from the attorney, along with an assurance that the plan will be reimbursed in full from that settlement (assuming the payout exceeds the plan&rsquo;s lien).</p> <p>&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/06/26/medical-cannabis-should-your-health-plan-cover-it/?utm_medium=BenefitsPro&amp;utm_source=SocialFlow&amp;fbclid=IwAR2XrRS9u7D-ME72OK5QS7AUFWRdWx2Nvi9Lhflna2z-5_Y0MTG87ZAHEYo" target="_blank">Medical cannabis: Should your health plan cover it?</a> &ndash; June 26, 2019</p> <p class="bodytext">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/06/19/impact-of-hhss-proposed-aca-revisions-to-employers/" target="_blank">Impact of HHS&rsquo;s Proposed ACA Revisions to Employers</a> &ndash; June 19, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Seasons of Change by Jennifer M_ McCormick%2C ESQ.pdf" target="_blank">Seasons of Change: How to successfully implement evolving healthcare trends</a> &ndash; June 10, 2019</p> <p class="bodytext">&bull; BenefitsPro - <a href="https://www.benefitspro.com/2019/06/03/what-is-subrogation-and-how-does-it-affect-health-benefit-plans/" target="_blank">What is subrogation, and how does it affect health benefit plans?</a> &ndash; June 3, 2019</p> <p class="bodytext">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/05/20/paid-leave-policies-picking-up-steam-or-is-it-just-hot-air/?slreturn=20190512133925" target="_blank">Paid leave policies: Picking up steam or is it just hot air?</a> &ndash; May 20, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Transparency - A Clear and Almost - Present Danger_ authored by Ron Peck(1).pdf" target="_blank">Transparency - A Clear and Almost-Present Danger?</a> &ndash; May 5, 2019</p> <p class="bodytext">&bull; BefefitsPro - <a href="https://www.benefitspro.com/2019/04/08/getting-ahead-of-erisa-disbursement-claims/" target="_blank">Getting ahead of ERISA disbursement claims</a> &ndash; April 8, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/The Lien%2C Mean%2C Subrogation Machine by Maribel Echeverry McLaughlin%2C Esq.pdf" target="_blank">The Lien, Mean, Subrogation Machine</a> &ndash; April 4, 2019</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/856/list-prices-in-tv-ads-will-this-help" target="_blank">List Prices in TV Ads: Will This Help?</a> Price transparency may be making its way to a TV near you.</p> <p class="bodytext">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/850/big-pharma-executives-testify-before-congress-again" target="_blank">Big Pharma Executives Testify Before Congress (Again)</a>. This could be a tough pill to swallow for big pharma companies.</p> <p class="bodytext">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/838/the-final-ahp-rules-take-a-hard-hit" target="_blank">The Final AHP Rules Take a Hard Hit!</a> There were a lot of bumps and bruises along the way.</p> <p class="bodytext">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/841/new-dol-opinion-letter-employers-may-not-delay-fmla-leave-designations" target="_blank">New DOL Opinion Letter: Employers May Not Delay FMLA Leave Designations.</a> Do you have questions about the FMLA? Here are your answers.</p> <p class="bodytext">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/839/be-transparent-tell-me-what-you-really-want" target="_blank">Be Transparent &ndash; Tell Me What You Really Want!</a> The most expensive options aren&rsquo;t always the best options.</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> &nbsp; <p class="bodytext" style="text-align: justify;">&bull; On June 20, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/862/the-impact-of-state-federal-laws-and-current-market-trends-on-self-funding" target="_blank">&ldquo;The Impact of State, Federal Laws, and Current Market Trends on Self-Funding,&rdquo;</a> where we share some interesting perspectives on the current legislative climate.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 23, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/854/to-pay-or-not-to-pay-the-guide-to-handling-claims-denials-and-appeals" target="_blank">&ldquo;To Pay, or Not to Pay &hellip; The Guide to Handling Claims, Denials, and Appeals,&rdquo;</a> where we discussed the good, bad, and ugly truths about the claims process, and how to safely navigate the various TPA and health plan duties associated with it.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 22, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/847/evolving-healthcare-issues-and-events-you-need-to-know" target="_blank">&ldquo;Evolving Healthcare Issues and Events You Need to Know,&rdquo;</a> where we discussed some of the most relevant topics affecting our industry, and explain what they mean to you and your business.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:</span></p> <p class="bodytext"><span class="heading1">Empowering Plans</span><br /> &nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On June 26, 2019, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/PostId/865/empowering-plans-p70-surprise-balance-bills" target="_blank">&ldquo;Surprise? Balance Bills!,&rdquo;</a> where our hosts define surprise balance billing and discuss movements to curb them (at the State and Federal levels).</p> <p class="bodytext" style="text-align: justify;">&bull; On April 12, 2019, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/PostId/843/empowering-plans-p69-a-healthcare-free-for-all" target="_blank">&ldquo;A Healthcare Free-for-All,&rdquo;</a> where our hosts, Adam, Ron, and Brady tackle the most pressing issues facing our industry, including surprise emergency room bills, drug pricing, medical necessity, and employee incentive programs. Face of Phia</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1">Face of Phia</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On June 12, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/858/faces-of-phia-episode-13-glutton-for-punishment" target="_blank">&ldquo;Glutton for Punishment,&rdquo;</a> where our hosts sit down with Amanda Lima, as she celebrates more than six years with Phia and working closely with Adam.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 7, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/851/faces-of-phia-episode-12-pat-the-man-santos-has-got-it-in-the-bag" target="_blank">&ldquo;Pat &#39;the Man&#39; Santos Has Got it In the Bag,&rdquo;</a> where our hosts sit down with Pat &#39;the Man&#39; Santos &ndash; our silent producer.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 17, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/844/faces-of-phia-episode-11-reminiscing-with-andrew" target="_blank">&ldquo;Reminiscing with Andrew,&rdquo;</a> where our hosts, Adam and Ron, reminisce on Andrew Silverio&#39;s Undergraduate adventure.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 5, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/840/faces-of-phia-episode-10-tales-from-the-lost-filing-room" target="_blank">&ldquo;Tales From The Lost Filing Room,&rdquo;</a> where our hosts, Adam and Ron, dig up tales from the days of old with future industry leader and veteran employee, Amanda Grogan. Tales From the Plan</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1">Tales From the Plan</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;">&bull; On June 14, 2019, The Phia Group presented, <a href="https://www.phiagroup.com/Media/Posts/PostId/859/tales-from-the-plan-episode-1-putting-the-benefit-in-benefit-plan-with-jennifer-mccormick" target="_blank">&ldquo;Putting the Benefit in Benefit Plan with Jennifer McCormick,&rdquo;</a> where our hosts, Adam and Ron, interview The Phia Group&rsquo;s Sr. VP of Consulting, Jennifer McCormick, about her own experience as a consumer of healthcare and member of The Phia Group&rsquo;s health plan.</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="heading1">&nbsp;</p> <p class="bodytext"><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/itunes.png" style="width: 251px; height: 78px;" title="" /></a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2019 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2019 charity is the Boys &amp; Girls Club of Brockton.</p> <p><img src="/Portals/phiagroup/Newsletter%202018%20Q2/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton 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>&nbsp;</p> <p class="bodytext"><strong>Silent Auction</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group hosted a silent auction to help raise money for the Boys &amp; Girls Club of Brockton. Due to some generous bids and donations made by our valued clients, we were able to raise $12,335.00 for the Boys &amp; Girls Club of Brockton. We couldn&rsquo;t have done it without the help of our amazing clients and team. If you are interested in donating to the Boys &amp; Girls Club of Brockton, please visit their <a href="https://www.bgcbrockton.org/newpage" target="_blank">website</a> today. Every dollar goes towards helping a child in need.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/silent.jpg" style="width: 506px; height: 346px;" title="" /></p> <p>&nbsp;</p> <p class="bodytext"><strong>Phia Wiffle-Ballers</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Family is one good-looking group of wiffle-ballers! Our wiffle ball team entered the 8th annual John Waldron Memorial Wiffle Ball Tournament, where we were dominated the field. We were up against some fierce competition, including some courageous Brockton Fire Fighters, that most certainly brought the heat. This tournament raised over $30,000! We are proud of the work our team did.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/wiffle.jpg" style="width: 483px; height: 356px;" title="" /></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">Seasons of Change: How to Successfully Implement Evolving Healthcare Trends</p> <p class="bodytext" style="font-weight: normal">By: Jennifer M. McCormick, Esq. &ndash; June 2019 &ndash; <a href="https://www.sipconline.net/files/Seasons of Change by Jennifer M_ McCormick%2C ESQ.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Have you ever wondered whether you paid more for your flight than the person next to you on the airplane? What about whether you could be doing more (or less) to save money and time? I&rsquo;m confident we all frequently ponder what we can do differently to save.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Whether big or small savings, we&rsquo;re constantly looking for ways save money in all areas of our life. Dinner budgets, car insurance, clothes, general spending - you name it and surely, we have contemplated whether we can reduce that expense. But we also try to balance cost against convenience, expecting to save money and time. For example, we can click a couple of buttons on our phone and groceries appear at our doorstep two hours later, saving us both money and time.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/867/the-stacks-3rd-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p><br /> <span class="bodytext"><strong>Transparency - A Clear and Almost-Present Danger? </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Ron E. Peck, Esq. &ndash; May 2019 &ndash; <a href="https://www.sipconline.net/files/Transparency - A Clear and Almost - Present Danger_ authored by Ron Peck(1).pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Transparency in healthcare, and pricing of care, has been a hot topic &ndash; especially for those in our industry &ndash; for quite some time. That flame has been fed recently by an increase in regulatory and legislative attention. About one year ago, a bipartisan group of Senators unveiled their intention to launch a healthcare price and quality information transparency initiative, and the feedback has been all over the map.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/867/the-stacks-3rd-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p>&nbsp;</p> <p class="bodytext"><strong>The Lien, Mean, Subrogation Machine</strong></p> <p class="bodytext">By: Maribel Echeverry McLaughlin, Esq &ndash; April 2019 &ndash; <a href="https://www.sipconline.net/files/The Lien%2C Mean%2C Subrogation Machine by Maribel Echeverry McLaughlin%2C Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="text-align: justify;">In 1990, the United State Supreme Court ruled in FMC Corp. v. Holliday, that state law will not prevent a private self-funded plan governed under ERISA from obtaining reimbursement. Additionally, the Court ruled that any state law that is contrary to ERISA would be preempted if the Plan&rsquo;s language so provides or there is a clear contradiction to the federal law.</p> <p class="bodytext" style="text-align: justify;">For years, this law went unchallenged until 2006, when Mr. and Mrs. Sereboff were involved in a motor vehicle accident, and the Mid Atlantic Medical Services Employee Health Plan paid related claims in the amount of $74,869.37.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/867/the-stacks-3rd-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a>Phia&rsquo;s 2019 Speaking Engagements:</p> <p class="bodytext"><br /> <br /> &bull; 1/9/2019 &ndash; FMMA Conference &ndash; Austin, TX</p> <p class="bodytext">&bull; 2/27/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Denver, CO</p> <p class="bodytext">&bull; 3/8/2019 &ndash; UnitedAg Conference &ndash; Anaheim, CA</p> <p class="bodytext">&bull; 3/19/2019 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charlotte, NC</p> <p class="bodytext">&bull; 3/21/2019 &ndash; CGI Business Solutions Seminar &ndash; Woburn, MA</p> <p class="bodytext">&bull; 3/26/2019 &ndash; HFTA Broker Meeting &ndash; Tyler, TX</p> <p class="bodytext">&bull; 4/3/2019 &ndash; BenefitsPRO Broker Expo &ndash; Miami, FL</p> <p class="bodytext">&bull; 4/5/2019 &ndash; Pareto Conference &ndash; Nashville, TN</p> <p class="bodytext">&bull; 4/7/2019 &ndash; Captive Symposium &ndash; Cayman Islands</p> <p class="bodytext">&bull; 4/8/2019 &ndash; National Beer Wholesalers Association Legislative Conference &ndash; Washington DC</p> <p class="bodytext">&bull; 4/12/2019 &ndash; FMMA 2019 Annual Conference &ndash; Dallas, TX</p> <p class="bodytext">&bull; 4/23/2019 &ndash; Johns Hopkins Industry Education Series &ndash; Baltimore, MD</p> <p class="bodytext">&bull; 4/24/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 4/25/2019 &ndash; BevCap&rsquo;s Best Practices Workshop &ndash; Orlando, FL</p> <p class="bodytext">&bull; 4/26/2019 &ndash; Society of Professional Benefit Administrators Annual Conference &ndash; Washington, D.C.</p> <p class="bodytext">&bull; 5/2/2019 &ndash; MassAHU Benefest 2019 Conference &ndash; Westborough, MA</p> <p class="bodytext">&bull; 5/14/2019 &ndash; Cypress Unversity &ndash; Las Vegas, NV</p> <p class="bodytext">&bull; 5/30/2019 &ndash; Contrarian Captive &ndash; Austin, TX</p> <p class="bodytext">&bull; 6/11/2019 &ndash; Leavitt Conference &ndash; Big Sky, MT</p> <p class="bodytext">&bull; 7/16/2019 &ndash; HCAA TPA Summit &ndash; Dallas, TX</p> <p class="bodytext">&bull; 7/31/2019 &ndash; 2019 MVP Academy &ndash; Wellesley, MA</p> <p class="bodytext">&bull; 8/20/2019 &ndash; Pritchard &amp; Jerden Employee Benefits Forum &ndash; Brookhaven, GA</p> <p class="bodytext">&bull; 9/30/2019 &ndash; SIIA National Educational Conference &amp; Expo &ndash; San Francisco, CA</p> <p class="bodytext">&bull; 10/27/2019 &ndash; 2019 Annual NASP Conference &ndash; Washington DC</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employees of the Quarter:<br /> Katie Delaney &amp; Corrie Cripps</span></p> <p class="bodytext" style="text-align: justify;">Congratulations to Katie Delaney &amp; Corrie Cripps, The Phia Group&rsquo;s Q3 2019 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;">Katie and Corrie have both been dedicated employees at The Phia Group for many years, and we are so fortunate to have them on our team. With Corrie being a Consultant, II and PGC Internal Process Auditor, and Katie being a Senior Training &amp; Development Specialist, it is clear that they are both key players in the success we have at The Phia Group.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/employ2.jpg" style="width: 600px; height: 420px;" title="" /></p> <p class="bodytext">Congratulations Katie &amp; Corrie, and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a>Phia News</span></p> <p class="bodytext"><span class="heading1"><a id="p12a" name="p12a"></a></span></p> <p class="bodytext"><span style="font-size:130%;"><strong>PACE<sup>&reg;</sup> Certification is Almost Here!</strong></span></p> <p class="bodytext" style="text-align: justify;">The PACE Certification program will educate you using 3 distinct chapters of information:</p> <p class="bodytext" style="text-align: justify;"><strong>Chapter One</strong><br /> Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.</p> <p class="bodytext" style="text-align: justify;"><strong>Chapter Two</strong><br /> Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.</p> <p class="bodytext" style="text-align: justify;"><strong>Chapter Three</strong><br /> Explain what PACE is, what PACE does, and how it&#39;s obtained, implemented, and utilized.</p> <p class="bodytext" style="text-align: justify;">The PACE Certification program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.</p> <p class="bodytext" style="text-align: justify;">Additionally, the PACE Certification program will provide education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.</p> <p class="bodytext" style="text-align: justify;">The PACE Certification program will be released to all those interested starting August 1, 2019.</p> <p class="bodytext" style="text-align: justify;">Please see the <a href="https://www.phiagroup.com/Portals/phiagroup/2018 Flyers/PACE CERT Flyer.pdf" target="_blank">PACE Certification flyer</a>, as well as <a href="https://www.youtube.com/watch?v=8xNqiSuyiP0" target="_blank">this video</a> for more information.</p> <p class="bodytext" style="text-align: justify;">Please contact Tim Callender (<a href="mailto:tcallender@phiagroup.com" target="_blank">tcallender@phiagroup.com</a>), or Garrick Hunt (<a href="mailto::ghunt@phiagroup.com" target="_blank">ghunt@phiagroup.com</a>), for more information.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Śmigus-dyngus at Phia</strong></p> <p class="bodytext" style="text-align: justify;">On April 22nd (Easter Monday), The Phia Family celebrated a traditional Polish holiday called Śmigus-dyngus, with a Polish lunch graciously provided by our CEO, Adam Russo. Normally, the holiday includes a big water fight, but we decided not to go down that route. We did however have some delicious Polish meats and pastries, accompanied by a delicious Polish fruit beverage.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/phiabbq2.jpg" style="width: 600px; height: 400px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Opening Day BBQ</strong></p> <p class="bodytext" style="text-align: justify;">It has become tradition at The Phia Group to celebrate Opening Day! We invite all Phia employees to dress up in their favorite sports team gear. As you can see, we have a heavy variety of team spirit here at The Phia Group. Some New York Yankees fans, Cleveland Indians fans, and of course, Boston Red Sox fans. Towards the end of the day, the Phia Family comes together outside of our office to celebrate with hotdogs, cold beverages, and great conversations.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/redsox3.jpg" style="width: 618px; height: 406px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Betting on the Bruins!</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Family suited up in their finest Bruins gear (with the exception of a few Phians) to show their pride and support as the Bruins entered the Stanley Cup Final, in an attempt to win their 7th Stanley Cup. Although the Bruins fell a bit short, they still made it to the final round, which is a victory in itself.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/bruins2.jpg" style="width: 619px; height: 412px;" title="" /></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p><span class="boldtext">Job Opportunities:</span></p> <p><span style="font-size:12px;">&bull; Marketing &amp; Accounts Coordinator</span></p> <p><span style="font-size:12px;">&bull; Health Benefit Plan Drafter</span></p> <p><span style="font-size:12px;">&bull; Health Benefits - Case Investigator I</span></p> <p><span style="font-size:12px;">&bull; Attorney 1</span></p> <p><span style="font-size:12px;">&bull; IT Intern</span></p> <p><span style="font-size:12px;">&bull; PACE Intake Client Coordinator</span></p> <p><span style="font-size:12px;">&bull; Health Benefit Plan Attorney I</span></p> <p><span style="font-size:12px;">&bull; Client Intake Specialist</span></p> <p><span style="font-size:12px;">&bull; Senior Claims Specialist II, Provider Relations</span></p> <p>&nbsp;</p> <ul class="bodytext"> </ul> <p class="bodytext"><span style="font-size:12px;">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Promotions </strong><br /> <br /> &bull; Francesca Russo has been promoted from Claim Recovery Specialist III to Claim Recovery Specialist IV</p> <p class="bodytext" style="text-align: justify;">&bull; Colleen Ahern has been promoted from Claim Recovery Specialist III to Sr. Claim Recovery Specialist</p> <p class="bodytext" style="text-align: justify;">&bull; Nicole Russo has been promoted from Case Investigator to Claim Recovery Specialist III</p> <p class="bodytext">&bull; Brittany Grueter has been promoted from Case Investigator to Claim Recovery Specialist III<br /> &nbsp;</p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> &bull; Nasim Hassan was hired as an Intake Specialist</p> <p class="bodytext">&bull; David Ostrowsky was hired as a Plan Drafter</p> <p class="bodytext">&bull; Denise Swienc was hired as a Customer Care Representative</p> <p class="bodytext">&bull; Darlene Zarella was hired as a Claim Specialist II</p> <p class="bodytext">&bull; Kelly Gaunya was hired as an Subrogation Recovery Intern</p> <p class="bodytext">&bull; Erin Daley was hired as a Customer Care Representative</p> <p class="bodytext">&bull; Kaitlyn Lucier was hired as a Customer Care Representative</p> <p class="bodytext">&bull; Caelin McDonald was hired as an HR Intern</p> <p class="bodytext">&bull; Matthew Williams was hired as a Sr. Subrogation Attorney</p> <p class="bodytext">&bull; Jackie Andrews was hired as a Provider Relations Concierge</p> <p class="bodytext">&bull; Dylan Fry was hired as a Marketing &amp; CAM Intern</p> <p class="bodytext">&bull; Bryan Dunton was hired as a Plan Drafter</p> <p class="bodytext">&bull; Krista Belanger was hired as a Plan Drafter</p> <p class="bodytext">&bull; Brenna Jackson was hired as a Legal Assistant</p> <p class="bodytext">&bull; Donna Harman was hired as a Overpayments Assistant</p> <p class="bodytext">&bull; Kevin Brady was hired as an Attorney I</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/footerlogo.png" 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> 871 Tales From the Plan: Episode 3 – Direct & To The Point!https://www.phiagroup.com/Media/Posts/PostId/870/tales-from-the-plan-episode-3-direct-to-the-pointPodcastsWed, 17 Jul 2019 16:03:46 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/faFO4ikV6-U" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size: 11pt; font-family: &quot;Calibri&quot;, sans-serif;">In this episode of Empowering Plans &ndash; Tales from the Plan, The Phia Group&rsquo;s VP of Legal Recovery Services discusses his experiences before and after becoming a happy participant in Direct Primary Care.&nbsp; If you are one of the many people who&rsquo;ve heard about &ldquo;DPC&rdquo; but still wonder how it will be received by the plan participants, tune in.</span> </span></p> <p style="text-align: justify;"><a href="https://youtu.be/faFO4ikV6-U"><span style="color:#0071CE;">Click here to check out the podcast!</span></a><span style="color:#0071CE;">&nbsp;</span><span style="color:#000000;"> (Make sure you subscribe to our </span><a href="https://youtu.be/faFO4ikV6-U"><span style="color:#0071CE;">YouTube</span></a><span style="color:#000000;"> and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><span style="color:#000000;">iTunes </span></a><span style="color:#000000;">Channels!)</span></p> 870Tales From the Plan: Episode 2 – Mrs Peck, It’s Cancer…https://www.phiagroup.com/Media/Posts/PostId/868/tales-from-the-plan-episode-2-mrs-peck-its-cancerPodcastsMon, 08 Jul 2019 17:01:21 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/5PC2lHpOaKw" width="560"></iframe></p> <p style="text-align: justify;">In this meaningful episode, Ron Peck tells us about his family&rsquo;s battle against cancer, and lessons we can all learn from their experience.&nbsp; Health benefits play a role in our health and survival. You can&rsquo;t afford to miss this one.</p> <p style="text-align: justify;"><a href="https://youtu.be/5PC2lHpOaKw">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/5PC2lHpOaKw">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 868The Stacks - 3rd Quarter 2019https://www.phiagroup.com/Media/Posts/PostId/867/the-stacks-3rd-quarter-2019NewslettersTue, 02 Jul 2019 16:21:19 GMT<h1><span style="font-size:130%;"><b style="mso-bidi-font-weight:normal"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">The Lien, Mean, Subrogation Machine</span></b> </span></h1> <h2 style="text-align: justify;"><span style="color:#28166F;"><span style="font-size:larger;"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">By: </span></span>Maribel Echeverry McLaughlin, Esq<span style="font-size:larger;"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;"> </span></span></span></h2> <p style="text-align: justify;"><span style="color:#000000;">When you think of personal injury attorneys, you may imagine men in trench coats with cheesy tag lines with inflated promises, and commercials with ambulances blaring in the background.&nbsp; Fortunately, I do not like trench coats, my tag lines are only sometimes cheesy, and ambulances terrify me. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">While attending law school, I worked for an attorney who became a state legislator, which meant I was forced to learn the ins and outs of running a practice in a very short period of time.&nbsp; That experience ultimately left a bad taste in my mouth for opening my own firm.&nbsp; Eventually, after graduating law school, I started my career as a junior associate in the personal injury firm down the street and became the partner&rsquo;s main resource for research&hellip; and coffee. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Working there opened my eyes to new experiences, such as the opportunity to practice law with a team of partners and senior associates.&nbsp; We met once a week and strategized on how to win the most amount of money for our clients and, obviously, for the firm.&nbsp; Sometimes those two goals conflicted with each other and we would work to find a resolution that would make sense for all parties involved. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Interestingly enough, that typically meant negotiating with healthcare providers and health insurance plans.&nbsp; In my tenure with this firm, I may have come across at least five (5) liens from private self-funded benefit plans.&nbsp; After much negotiation and push back from the plans, each of them </span><span style="color:#000000;">were</span><span style="color:#000000;"> resolved.&nbsp; But it was not until I left that world that I realized how little personal injury attorneys actually know about the Employment Retirement Income Security Act (ERISA), self-funded health plans, and how they function in our world. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Overview of the Law:<br /> In 1990, the United State Supreme Court ruled in FMC Corp. v. Holliday,<sup>1</sup> that state law will not prevent a private self-funded plan governed under ERISA from obtaining reimbursement. Additionally, the Court ruled that any state law that is contrary to ERISA would be preempted if the Plan&rsquo;s language so provides or there is a clear contradiction to the federal law.</span></p> <p style="text-align: justify;"><span style="color:#000000;">For years, this law went unchallenged until 2006, when Mr. and Mrs. Sereboff </span><span style="color:#000000;">were</span><span style="color:#000000;"> involved in a motor vehicle accident, and the Mid Atlantic Medical Services Employee Health Plan paid related claims in the amount of $74,869.37. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">The Sereboff&rsquo;s eventually settled their personal injury claim for $750,000.00 and did not reimburse the self-funded Plan.&nbsp; The Plan eventually filed suit in the U.S. District Court for the District of Maryland, claiming a right to collect from the Sereboffs under &sect; 502(a)(3) of ERISA. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">The Court ruled in Sereboff v. Mid Atlantic Medical Services<sup>2</sup> that the federal courts have subject matter jurisdiction over actions where an ERISA-covered Plan seeks equitable relief.&nbsp; The Court further ruled that if an ERISA-covered Plan has paid medical benefits arising from an act or omission of a </span><span style="color:#000000;">third-party</span><span style="color:#000000;"> for which a plan participant obtains a settled or jury award, the Plan has a right to right to enforce the terms of the Plan Document pursuant to ERISA 502(a)(3), for equitable relief.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Shortly after, the Supreme Court held again in US Airways, Inc. v. McCutchen<sup>3</sup>, that the terms of an ERISA-covered Plan would be enforced as written, despite any contrary state law or equitable principle. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">This was a landmark decision as it clarified that the &ldquo;common fund&rdquo; and &ldquo;made-whole&rdquo; doctrines could be disclaimed by an ERISA Plan in their Plan Document language.&nbsp; Whether adopted by state statute or relying on common law, neither of these doctrines can be used to defeat the Plan&rsquo;s right of full reimbursement as long as there is clear language in the Plan Document disclaiming the application of these principles.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Most recently, the Court decided in Montanile v. Board of Trustees of Nat. Elevator Industry Health Benefit Plan<sup>4</sup>, when a participant in an ERISA plan dissipates a third-party settlement on non-traceable items, the plan fiduciary may not bring suit to attach the participant&#39;s separate assets<sup>5</sup>.&nbsp; In other words, the Plan is only entitled to &ldquo;their&rdquo; money, but if it cannot be traced in an asset that was paid for with that money, then the Plan cannot sue for the member&rsquo;s general assets. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Decisions to Settle and Negotiate Liens by Personal Injury Attorneys:<br /> While working for the trench coats, I realized that large insurance carriers, such as Blue Cross, United, etc., were willing to settle without much work and negotiation.&nbsp; At that time, it was easier to settle those liens than trying to work out a balance with a provider and proved to be more financially sound for the member. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">After negotiating with many private self-funded Plans, I realized they were, and still are, the most difficult to negotiate.&nbsp; Attorneys will advocate zealously for their clients, whether they are victims of a horrific car accident case, or for the Plans themselves.</span></p> <p style="text-align: justify;"><span style="color:#000000;">I received a letter not too long ago, from </span><span style="color:#000000;">a lien</span><span style="color:#000000;"> resolution company in California, that was fifteen pages long, filled with arguments for the Plan to reduce their lien. Interestingly enough, after doing a quick internet search, it happens to be a string of arguments that many plaintiff attorneys are making to work through the private self-funded Plans governed by ERISA. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Some of these arguments are easy to argue away, such as the common fund and made-whole arguments, especially if they are disclaimed in the Plan&rsquo;s language. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">The attorney from the lien resolution company was representing a member and their attorney, for reimbursement and subrogation claims.&nbsp; He sent me exactly what the member&rsquo;s attorney had requested for </span><span style="color:#000000;">a reimbursement</span><span style="color:#000000;">, and interestingly enough, the Plan had previously refused to reduce their interest.&nbsp; He made many arguments throughout those 15 pages and frankly only two </span><span style="color:#000000;">stuck</span><span style="color:#000000;"> out to me.</span></p> <p style="text-align: justify;"><span style="color:#000000;">He titled one &ldquo;Deficiencies in the Plan Documentation&rdquo;<sup>6</sup>; in which he alleged that the Plan administrator must properly disclose any reimbursement provision to Plan beneficiaries in the Plan document.</span></p> <p style="text-align: justify;"><span style="color:#000000;">He opined that the Ninth Circuit, 29 C.F.R. 2520.102-2(b) requires that &ldquo;(1) the description of summary of [a] restrictive provision must be placed in close conjunction with the description or summary of benefits, or (2) the pages on which the restrictive provision is described must be noted adjacent to the benefit description.&rdquo;<sup>7</sup>&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">The Court ruled that a reasonable Plan participant should not have to read every provision of a Plan&rsquo;s documentation in order to ensure they have read every restrictive provision.<sup>8</sup>&nbsp; The Court invalidated an inconspicuously-placed provision where the limitations for third party liability and out-of-pocket maximums were separated from the Plan&rsquo;s description of benefits by multiple unrelated plan provisions, without cross-references or indexing. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Our client&rsquo;s Plan had the reimbursement provision entirely isolated from other provisions of the Plan&rsquo;s documentation, and as such, would be invalidated by the Ninth Circuit.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The second argument cited was titled &ldquo;Out of Pocket Maximum.&rdquo;<sup>9</sup> Here, he alleged that the Plan Document provided that individual beneficiaries would not pay more than a specific amount toward medical expenses.&nbsp; He explained that the &ldquo;Out of Pocket Maximum&rdquo; should be a defined term, but in this document, it was not.&nbsp; He also pointed out that the Plan Document does not define the terms &ldquo;reimbursement&rdquo;, &ldquo;subrogation&rdquo;, &ldquo;lien&rdquo; or other terms relevant to the third-party provision.<sup>10</sup></span></p> <p style="text-align: justify;"><span style="color:#000000;">As a former plaintiff&rsquo;s attorney, I can understand and appreciate the zealous advocacy that this attorney was providing to his client.&nbsp; It is difficult to balance all the interests especially when the common understanding is that the insurance companies have an abundance of money and that this lien interest would not break the bank. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">In reality, after explaining the concept of self-funding and paying claims out of the pool of money for all members that pay their premiums, attorneys tend to appreciate the advocacy we provide on behalf of these Plans.&nbsp; These are not big bad insurance companies, as many people perceive; these are usually smaller companies, with the hope of keeping the risk low, and claims paid.&nbsp; The opportunity for reimbursement for </span><span style="color:#000000;">third party</span><span style="color:#000000;"> claims keeps the premiums low for the members, a concept that eventually attorneys or members understand completely. &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">After reviewing these arguments with other attorneys in our office, we agreed that we should amend our major medical template to include these definitions and add references to certain places in our Flagship Plan document, in order to avoid these sorts of arguments from other attorneys in the future.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Specialists in plan document drafting and subrogation attorneys will be able to review your plan document to ensure we address all of the arguments to meet the needs of self-funded groups and their members.<br /> ________________________________________</span></p> <p><span style="color:#000000;">&nbsp; <sup>1</sup>FMC Corp. v. Holliday, 498 U.S. 52 (1990)<br /> &nbsp;<sup> 2</sup>Sereboff v. Mid Atlantic Medical Services, 547 U.S. 356 (2006)<br /> &nbsp; <sup>3</sup>US Airways, Inc. v. McCutchen, et al., 133 S.Ct. 1537 (2013)<br /> &nbsp; <sup>4</sup>Montanile v. Board of Trustees of Nat. Elevator Industry Health Benefit Plan, 135 S.Ct. 651 (2016),<br /> &nbsp; <sup>5</sup>Id. at 655<br /> &nbsp; <sup>6</sup>John J. Rice, Esq, LTR #3 to Phia - Clariza (2018)<br /> &nbsp; <sup>7</sup>Spinedex Physical Therapy USA Inc. v. United Healthcare of Arizona, Inc. (9th Cir. 2014) 770 F.3d 1282, 1295<br /> &nbsp; <sup>8</sup>Id. at 1296.<br /> &nbsp; <sup>9</sup>John J. Rice, Esq, LTR #3 to Phia - Clariza (2018)<br /> &nbsp; <sup>10</sup>Id.</span></p> <o:p>__________________________________________________________________________________________</o:p> <h1>Transparency &ndash; A Clear and Almost-Present Danger?</h1> <h2><span style="color:#28166F;">By: Ron E. Peck, Esq</span></h2> <p style="text-align: justify;"><span style="color:#000000;">Transparency in healthcare, and pricing of </span><span style="color:#000000;">care,</span><span style="color:#000000;"> has been a hot topic &ndash; especially for those in our industry &ndash; for quite some time.&nbsp; That flame has been fed recently by an increase in regulatory and legislative attention.&nbsp; About one year ago, a bipartisan group of Senators unveiled their intention to launch a healthcare price and quality information transparency initiative, and the feedback has been all over the map.</span></p> <p style="text-align: justify;"><span style="color:#000000;">I recently published a blog post regarding failed attempts at transparency in retail.&nbsp; The two examples I shared therein I&rsquo;ve also described below.&nbsp; The response I received was passionate &ndash; from </span><span style="color:#000000;">support,</span><span style="color:#000000;"> to opposition; it seems as if everyone feels &ldquo;something&rdquo; when it comes to &ldquo;transparency.&rdquo;&nbsp; Before you read any further, let me state clearly and unequivocally that I am a staunch supporter of transparency &ndash; as a concept, as well as a tool to be used in our never-ending quest to minimize costs while maximizing benefits in health coverage and care.&nbsp; Like so many other useful tools, however, transparency in overabundance or without other key ingredients will not only fail to move the needle (as it relates to the cost of health care) but may result in an increase in spending. </span></p> <p style="text-align: justify;"><span style="color:#000000;">To get you up to speed, the examples of transparency (gone wrong) that I love to share are as follows &ndash;</span></p> <p style="margin-left: 0.5in; text-align: justify;"><span style="color:#000000;">Exhibit A: JC Penny&rsquo;s.&nbsp; Recall in 2011, when JC Penny&rsquo;s made what most experts have deemed a catastrophic, strategic mistake, regarding its pricing strategy.&nbsp; What horrific miscalculation did the retail giant make? &nbsp;It replaced &ldquo;sales&rdquo; (a/k/a &ldquo;discount&rdquo;) and &ldquo;coupons&rdquo; with everyday low prices.&nbsp; JC Penny&rsquo;s told consumers: &ldquo;Hey!&nbsp; We aren&rsquo;t going to bamboozle you by inflating </span><span style="color:#000000;">prices,</span><span style="color:#000000;"> and then throwing arbitrary discounts at you.&nbsp; Instead, we&rsquo;ll offer you fair prices without any games.&rdquo;&nbsp; This was one example where transparency failed miserably.</span></p> <p style="margin-left: 0.5in; text-align: justify;"><span style="color:#000000;">Exhibit B: Payless.&nbsp; If you want to buy some sneakers from Payless, you&rsquo;d better do it soon.&nbsp; Payless ShoeSource, Inc. is closing for good.&nbsp; I&rsquo;ve never shopped at Payless myself, but they hold a special place in my heart by virtue of something they did in November of 2018.&nbsp; Yes indeed; it was only a few months ago that they supported my theory that transparency without quality awareness is not only </span><span style="color:#000000;">useless,</span><span style="color:#000000;"> but potentially dangerous.&nbsp; Payless opened a fake luxury store, dubbed &ldquo;</span><span style="color:#000000;">Palessi</span><span style="color:#000000;">.&rdquo;&nbsp; At this &ldquo;boutique,&rdquo; they displayed shoes (for which they normally charge $20 at their Payless stores), with price tags that ranged up to $600+ (a 1,800% markup).&nbsp; Shoppers saw </span><span style="color:#000000;">the higher</span><span style="color:#000000;"> prices and assumed that &ndash; if it costs more, it must be better. </span></p> <p style="text-align: justify;"><span style="color:#000000;">Another example of transparency that not only fails to reduce </span><span style="color:#000000;">spending,</span><span style="color:#000000;"> but increases it, is also tethered to healthcare.&nbsp; Unlike many other expenses about which we industry members are dealing, (expenses for which the lion&rsquo;s share of the cost is borne by the benefit plan and as such, the patient has no &ldquo;skin in the game&rdquo;), one example of healthcare costs for which plan participants are fully responsible to pay is over the counter pain medication.&nbsp; Enter any retail pharmacy and you&rsquo;ll see brand name medication, and identical store brand drugs, sharing shelf space.&nbsp; The store brand is clearly marked with a lower price than the brand name drug &ndash; </span><span style="color:#000000;">who&rsquo;s</span><span style="color:#000000;"> </span><span style="color:#000000;">price</span><span style="color:#000000;"> is also clearly labeled.&nbsp; Additionally, both medications list the ingredients on the package; identical ingredients and percentages.&nbsp; This is the ultimate cross-roads between healthcare, patient skin in the game, and transparency.&nbsp; So, of </span><span style="color:#000000;">course</span><span style="color:#000000;"> people buy the store brand drug &ndash; it&rsquo;s the same drug, costs less, and the patient is financially responsible to pay the price.&nbsp; Transparency works, right?&nbsp; Wrong!&nbsp; People overwhelmingly purchase the branded drug.</span></p> <p style="text-align: justify;"><span style="color:#000000;">I&rsquo;ve said it before, and I&rsquo;ll say it again &ndash; people want the most expensive option.&nbsp; People don&rsquo;t want to pay for the most expensive option, but they want to have the most expensive option. </span></p> <p style="text-align: justify;"><span style="color:#000000;">Look no further than the credit crisis bankrupting so many Americans.&nbsp; Credit cards made it so easy for people to buy more than they could </span><span style="color:#000000;">afford,</span><span style="color:#000000;"> because they made it &ldquo;feel&rdquo; like it was someone else&rsquo;s money.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Sound familiar?</span></p> <p style="text-align: justify;"><span style="color:#000000;">People inherently want the most expensive option, because they are convinced price is an indicator of quality.&nbsp; Additionally, luxury purchases are a status symbol. </span></p> <p style="text-align: justify;"><span style="color:#000000;">So we (human beings) want the best.&nbsp; We assume the most expensive option must be the best option &ndash; ever hear someone say, &ldquo;you get what you pay for?&rdquo;&nbsp; Additionally, we want other people to think we have the best (a/k/</span><span style="color:#000000;">a the</span><span style="color:#000000;"> most expensive) stuff as well.&nbsp; The only roadblock is that we don&rsquo;t always have enough money with which to buy the best (most expensive) stuff.&nbsp; Drat.</span></p> <p style="text-align: justify;"><span style="color:#000000;">But, when someone gives me a magical &ldquo;card&rdquo; and that &ldquo;card&rdquo; grants me access to deeper pockets than my own, I can now use that &ldquo;card&rdquo; to buy the best (a/k/a most expensive) stuff.&nbsp; The fact that I will tomorrow be asked to pay for that &ldquo;stuff&rdquo; later (either in the form of credit card payments &hellip; or &hellip; [assuming my metaphor didn&rsquo;t go over your head] insurance premiums) won&rsquo;t stop me from running up an unaffordable bill today.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Transparency did nothing to stop people from getting themselves into credit card debt.&nbsp; Transparency will do nothing to curb people&rsquo;s health care spending, and I actually foresee it making things worse.&nbsp; Consider the proposals to have drug prices on TV advertisements.&nbsp; I&rsquo;m watching the Patriots beat another </span><span style="color:#000000;">opponent,</span><span style="color:#000000;"> when a commercial for Viagra pops up; (pun intended).&nbsp; The commercial ends by telling me the cost of the drug is $400.&nbsp; Next, a commercial for Cialis </span><span style="color:#000000;">appears,</span><span style="color:#000000;"> and tells me that drug costs $600.&nbsp; Well &ndash; don&rsquo;t I and my spouse deserve the best?&nbsp; Cialis it is!</span></p> <p style="text-align: justify;"><span style="color:#000000;">I&rsquo;d like to say that I am the first to spot these phenomena, but I&rsquo;m not.&nbsp; In 2016, the Journal of the American Medical Association published a study<sup>1</sup> that supports my assertion that transparency on its own doesn&rsquo;t lead to savings.&nbsp; In this study, two employers offered web-based tools to their employee plan participants, providing them with &ldquo;transparent&rdquo; healthcare prices.&nbsp; It empowered these participants to compare prices and &ldquo;shop around&rdquo; for their care.&nbsp; The result?&nbsp; The tools were rarely accessed, despite the introduction of high deductibles.&nbsp; In fact, as a side note, the high deductibles caused more participants to seek more costly care, in an effort to burn through the out of pocket maximum as quickly as possible.&nbsp; Additionally, for the reasons already discussed earlier, researchers discovered that the participants with access to pricing ended up picking the more expensive options, more often than participants without access to pricing.</span></p> <p style="text-align: justify;"><span style="color:#000000;">This report supports my theory above that patients always apply the type of rational behavior upon which traditional economic theory is based, especially when they are shopping for health care.&nbsp; Rational behavior and economics would anticipate that a consumer will buy a less costly option unless the more expensive option includes additional features worth the added expense to the consumer.&nbsp; That attitude, however, fails to take into account people&rsquo;s need to &ldquo;be seen&rdquo; as affluent (and flaunt non-existent wealth), as well as their unfounded belief that if something costs more it must be better, and is worth the added expense.&nbsp; Consider, for instance, the blind taste tests where a person is given two glasses of wine, and they are told one is a $100 glass of wine, and the other is a $10 glass of wine.&nbsp; Without fail, the drinker claims the more expensive wine is better tasting &ndash; even though (you guessed it) the wine in the glasses is the same wine!</span></p> <p style="text-align: justify;"><span style="color:#000000;">Looking at the impact of transparency on a broader scale, Professor David De Cremer of Cambridge University&rsquo;s Judge Business School, published a fascinating article about transparency, and when it backfires.<sup>2</sup>&nbsp; In it, he lists four negative side effects of transparency.&nbsp; He discusses how it: creates a culture of blame (people become hyper-focused on what they are seeing and reacting to it, rather than identify bigger picture issues, causes for those issues, and solutions); increases distrust (those whose work is constantly under the microscope feel micro-managed and unable to take risks); increases cheating (those who are constantly being watched begin to look for, and take advantage of, any opportunity to game the system when the albeit rare opportunity arises); and sparks resistance (people refuse to do any work that will be hyper-examined, protesting the lack of faith).</span></p> <p style="text-align: justify;"><span style="color:#000000;">Finally, let&rsquo;s not lose sight of the fact that not everyone agrees on what transparency in healthcare even is.&nbsp; Consider the Federation of American Hospitals which wrote to Congress that: &ldquo; &hellip;the healthcare price transparency initiative should focus on sharing out-of-pocket costs. Patients undergoing the same procedure could end up paying different amounts based on their health plan. Therefore, out-of-pocket cost information is more valuable to consumers &hellip; effective price transparency should involve the release of information that is clear, accessible, and actionable so that consumers easily can determine the cost of their premiums, deductibles, copayments, and non-covered services (out-of-pocket costs), prior to purchasing health insurance coverage as well as receiving medical services.&rdquo;&nbsp; Yikes.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Dr. Niran S. Al-Agba, MD posted on the MedPage Today Professional &ldquo;KevinMD Blog&rdquo;<sup>3</sup> &ndash; &ldquo;Comprehensive transparency is only relevant if packaged in a reliable comparative context.&nbsp; Information regarding cost, value, and effectiveness should be readily accessible to patients enabling them to make meaningful comparisons across providers and specialists. However, choices must be incentivized properly, so they are not only empowered but also motivated to use the information to make informed choices.&rdquo;&nbsp; I totally agree.&nbsp; Unless and until reliable quality measurements are included in the transparency discussion, and that information is delivered in such a way that the consumer will understand and appreciate that price has no relationship with quality, I fear &ldquo;price transparency&rdquo; on its own is not only a step too short, but potentially a step </span><span style="color:#000000;">backwards</span><span style="color:#000000;">, in Palessi boots.<br /> ____________________________________________</span></p> <p>&nbsp;</p> <div> <div id="ftn1"> <p><span style="color:#000000;"><sup>1</sup>https://jamanetwork.com/journals/jama/fullarticle/2518264<br /> <sup>2</sup>https://hbr.org/2016/07/when-transparency-backfires-and-how-to-prevent-it<br /> <sup>3</sup>https://www.kevinmd.com/blog/2017/03/problem-price-transparency.html</span><br /> __________________________________________________________________________________________</p> <h1>Seasons of Change: How to Successfully Implement Evolving Healthcare Trends</h1> <h2><span style="color:#28166F;">By: Jennifer M. McCormick, Esq.</span></h2> <p style="text-align: justify;"><span style="color:#000000;">Have you ever wondered whether you paid more for your flight than the person next to you on the airplane? What about whether you could be doing more (or less) to save money and time?&nbsp; I&rsquo;m confident we all frequently ponder what we can do differently to save.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Whether big or small savings, we&rsquo;re constantly looking for ways </span><span style="color:#000000;">save</span><span style="color:#000000;"> money in all areas of our life.&nbsp; Dinner budgets, car insurance, clothes, general spending - you name it and surely, we have contemplated whether we can reduce that expense.&nbsp; But we also try to balance cost against convenience, expecting to save money and time.&nbsp; For example, we can click a couple of buttons on our phone and groceries appear at our doorstep two hours later, saving us both money and time. </span></p> <p style="text-align: justify;"><span style="color:#000000;">Can we say the same for our self-funded plan documents? Regulatory changes and medical technologies are continually advancing. &nbsp;Why aren&rsquo;t we applying these new technologies, endeavoring to save money and time, to our self-funded plans? It&rsquo;s probably because we don&rsquo;t know how to get started. </span></p> <p style="text-align: justify;"><span style="color:#000000;">Hopefully</span><span style="color:#000000;"> this discussion will help provide a framework to allow employers and plans to implement new medical technologies and other time and cost savers! We will break down some steps to help simplify </span><span style="color:#000000;">implementation</span><span style="color:#000000;"> of new regulations and technologies.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><em>Step 1: Ask Questions!</em></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">When approached about a new idea ask this question - what problem are you trying to solve?&nbsp; Not only is it key to understand what problem the new idea, new regulation, or new technology would be solving, but it is imperative to first determine whether it is a problem that needs to be solved!</span></p> <p style="text-align: justify;"><span style="color:#000000;">When it comes to savings, time is money too. As a result, the first part of </span><span style="color:#000000;">an analysis</span><span style="color:#000000;"> should be ensuring that the full scope of the problem requiring resolution is realized.&nbsp; What is &lsquo;costing&rsquo; the most &hellip; time, money, or both?</span></p> <p style="text-align: justify;"><span style="color:#000000;">After understanding the extent of the problem, review whether the idea would mitigate or eliminate the problem.&nbsp; For example, assume Fictitious Company A has the proven and medically (and dentally) backed solution to effectively reduce the cost of elective cosmetic dental surgeries by 50% for a low monthly cost to the plan.&nbsp; An employer might think that would be fantastic, but after reviewing a copy of the plan document and summary plan description realized that elective cosmetic dental surgeries are excluded.&nbsp; In that example, even though real savings could exist, the solution does not solve a problem for the employer (i.e. with an exclusion the employer pays 0% for elective cosmetic dental surgeries).</span></p> <p style="text-align: justify;"><span style="color:#000000;">Assume instead that the employer was hoping to remove the exclusion for elective cosmetic dental surgeries.&nbsp; </span><span style="color:#000000;">Employer</span><span style="color:#000000;"> wants to offer this benefit to participants of the self-funded plan it sponsors but wants to control costs.&nbsp; The services offered by Fictitious Company A might be a perfect fit! Here, the idea solves a problem for the employer. </span></p> <p style="text-align: justify;"><span style="color:#000000;">The next set of questions should aim to proactively troubleshoot barriers to </span><span style="color:#000000;">implementation</span><span style="color:#000000;"> of the idea. How can hurdles be eliminated and what alternatives exist to address the concerns? Is there a way to take the hurdle and create an opportunity?</span></p> <p style="text-align: justify;"><span style="color:#000000;">For example, many states are implementing paid family leave laws.&nbsp; For employers, the problem that needs to be solved here is investigating what must be done to comply, how must it be done, and how can it be financed.&nbsp; In addition to understanding what state regulations would apply, employers may wish to review their current plan materials.&nbsp; Does the employer currently have a policy in place that addresses the regulations? If not, can you make updates to existing benefits? Would this be a good opportunity to investigate whether establishing a self-funded benefit might solve the </span><span style="color:#000000;">problem,</span><span style="color:#000000;"> while offering employer convenience and cost savings? </span></p> <p style="text-align: justify;"><span style="color:#000000;">Assuming the answer is yes, the next step would be to investigate any impediments.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><em>Step 2: Investigate Impediments </em></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">It&rsquo;s important to investigate impediments to an employer&rsquo;s or plan&rsquo;s ability to successfully implement a valuable idea.&nbsp; This requires understanding what agreements should be in place, certain legal hurdles that could prevent taking further steps, and whether the claims systems would need changes to address the new technology or solution.</span></p> <p style="text-align: justify;"><span style="color:#000000;">For example, assume a self-funded plan has many members seeking various chronic pain treatments.&nbsp; A progressive employer, looking to offer an alternative to </span><span style="color:#000000;">high cost</span><span style="color:#000000;"> treatments, investigates medical cannabis. &nbsp;Coverage of this benefit would save the plan money. In this case, the employer is located in a state that has legalized medical cannabis. The employer decides to investigate </span><span style="color:#000000;">modification</span><span style="color:#000000;"> of the plan design.&nbsp; Upon investigation, the employer uncovers that the addition of this benefit would be problematic.&nbsp; While legal at the state level, it is still considered a schedule I drug under federal law.&nbsp; As a result, it may not be prescribed for medical use (See Section II &lsquo;General Requirements&rsquo; of the Practitioner&rsquo;s Manual from documentation issued by the United States Department of Justice, Drug Enforcement Agency, Office of Diversion Control for additional information). With this discovery, the employer decides that while coverage may be beneficial, medical cannabis is not a prudent addition to the plan terms.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Alternatively, let&rsquo;s assume that instead of medical cannabis the benefit that the employer wanted to cover was Chronic Pain Treatment B, a brand-new cutting-edge medical technology.&nbsp; Upon investigation, the employer identifies that there are no legal hurdles; however, it determines that this new medical technology is considered investigational and experimental.&nbsp; Not only does the plan have a current exclusion for items considered investigational and experimental, but an applicable </span><span style="color:#000000;">stop loss</span><span style="color:#000000;"> policy would not provide reimbursement for related claims.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Now, assume the same facts as above, except the medical technology in this instance is not considered investigational or experimental. The employer would seek to determine whether any executed agreements would impact implementation.&nbsp; Would a new agreement need to be executed, would that agreement conflict with any existing agreements (i.e. </span><span style="color:#000000;">stop loss</span><span style="color:#000000;"> policy, network agreement, PBM agreement, etc.)? Assuming no conflicts, the employer could implement the new solution or technology. </span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><em>Step 3: Implementation</em></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">A solution free of impediments has been identified to solve a problem.&nbsp; Does </span><span style="color:#000000;">implementation</span><span style="color:#000000;"> of the solution require a plan update? If so, does the solution create a new benefit or reduce a current benefit? Will the solution be implemented mid-year via an amendment or at plan renewal? Will other documents need to be updated as well, like the Summary of Benefits and Coverage (SBC)? Are there concerns about the Affordable Care Act (ACA) or the Employee Retirement Income Security Act (ERISA) timelines or rules?</span></p> <p style="text-align: justify;"><span style="color:#000000;">For example, assume an employer wants to implement New Benefit C. This new (FDA-approved) technology will save patients and the plan both time and money. The new technology, however, is so new that claims systems have not been updated to accommodate this type of service.&nbsp; New Benefit C is offered in collaboration with </span><span style="color:#000000;">a common</span><span style="color:#000000;"> medical treatment, but it is unclear how coding for New Benefit C would be handled. In this example, the administrator would need to be aware of how this would be identified to ensure correct processing. &nbsp;Simple adoption (or modification or removal) of plan language may not be enough; a review of how (or whether) a claim may be processed is also necessary.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Instead, assume an employer wants to offer </span><span style="color:#000000;">more</span><span style="color:#000000;"> expansive leave of absence provisions for its employees.&nbsp; The employer modifies the employee handbook and has a staff meeting to address the new provisions.&nbsp; The employer, however, fails to address this policy change in the relevant plan materials, or with the </span><span style="color:#000000;">stop loss</span><span style="color:#000000;"> carrier.&nbsp; As a result, implementation of the benefit may inadvertently create a coverage gap among </span><span style="color:#000000;">stop loss</span><span style="color:#000000;"> coverage, the plan document, and the employee handbook.&nbsp; When implementing a new benefit, it is imperative to analyze the impact on other entities.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><em>Step 4: Engagement </em></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Engagement is going to help make the idea or solution successful.&nbsp; At this point, a problem was identified, a solution was envisioned, and implementation was completed.&nbsp; How can the employer or plan ensure the idea or solution is being </span><span style="color:#000000;">utilized,</span><span style="color:#000000;"> since utilization is the key to success (i.e. savings)?</span></p> <p style="text-align: justify;"><span style="color:#000000;">For example, assume an employer opted to add a new plan option to the current plan design at renewal.&nbsp; This new plan option includes direct primary care but will require participants to affirmatively elect that option.&nbsp; This plan option should not only be enticing for participants, but it has the opportunity to save the plan money.&nbsp; Since the employer&rsquo;s participants are unaware of direct primary care the employer elects to hold an educational meeting.&nbsp; This session educates participants about direct primary care and what new and exciting benefits </span><span style="color:#000000;">are </span><span style="color:#000000;">be</span><span style="color:#000000;"> available under this new plan option.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In addition to educational meetings to inform participants of new benefits, employers can encourage engagement by financially incentivizing programs. For example, employers can reduce copays to encourage utilization of the new idea or solution.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Employers can also seek ways to encourage engagement outside of the plan design.&nbsp; For example, why not incentivize employees to ask questions about health benefit options available to them?&nbsp; An employer could create a program offering a reward if an employee voluntarily opted to chat with human resources about a planned treatment. </span></p> <p style="text-align: justify;"><span style="color:#000000;">A combination of education, incentives (or penalties), and employee rewards can help employers ensure engagement in programs that are designed to protect participants and save the plan money.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Don&rsquo;t let new advances pass by!&nbsp; Keep the plan in check and on trend with the latest and greatest healthcare innovations without sacrificing compliance. Follow this simple framework to ensure new ideas are successfully implemented so the plan, employer and members stay happy - and realize savings!</span></p> </div> </div> <p>&nbsp;</p> 867 Empowering Plans: P70 – Surprise? Balance Bills!https://www.phiagroup.com/Media/Posts/PostId/865/empowering-plans-p70-surprise-balance-billsPodcastsWed, 26 Jun 2019 20:41:05 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yNdgktqpu7Q" width="560"></iframe></p> <p style="text-align: justify;">With this episode, the guys define surprise balance billing, discuss movements to curb them (at the State and Federal levels), and harass Pat &ldquo;The Man&rdquo; Santos as well.&nbsp; Stop reading this description and start listening!&nbsp;</p> <p style="text-align: justify;"><a href="https://youtu.be/yNdgktqpu7Q">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/yNdgktqpu7Q">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 865The Impact of State, Federal Laws, and Current Market Trends on Self-Fundinghttps://www.phiagroup.com/Media/Posts/PostId/862/the-impact-of-state-federal-laws-and-current-market-trends-on-self-fundingWebinarsThu, 20 Jun 2019 13:51:33 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/-bmy5jN8k1A" width="560"></iframe></p> <p style="text-align: justify;">Attention, self-funders: things are happening! State and federal governments have been busy beavers, either passing legislation or at least looking into it. Whether it's surprise billing laws, Medicare-for-all initiatives, or public exchange options, you need to know about it.</p> <p style="text-align: justify;">Join The Phia Group's legal team as they share some interesting perspectives on the current legislative climate.</p> <p style="text-align: justify;"><a href="https://youtu.be/-bmy5jN8k1A">Click Here to View Our Full Webinar on YouTube</a></p> <p style="text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 862Tales From the Plan: Episode 1 – Putting the Benefit in Benefit Plan with Jennifer McCormick https://www.phiagroup.com/Media/Posts/PostId/859/tales-from-the-plan-episode-1-putting-the-benefit-in-benefit-plan-with-jennifer-mccormickPodcastsFri, 14 Jun 2019 15:36:50 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/IlsqA710v30" width="560"></iframe></p> <p style="text-align: justify;">In our inaugural episode of &ldquo;Tales from the Plan,&rdquo; our own Sr. VP of Consulting, Jennifer McCormick, opens up and candidly discusses her own experience as a consumer of healthcare and member of The Phia Group&rsquo;s health plan.&nbsp; Jen is brutally honest, and will make you realize that anyone can be taken advantage of, and anyone can take advantage of, our nation&rsquo;s healthcare system.&nbsp; This is mandatory listening.</p> <p style="text-align: justify;"><a href="https://youtu.be/IlsqA710v30">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/IlsqA710v30">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 859Faces of Phia: Episode 13 – Glutton for Punishmenthttps://www.phiagroup.com/Media/Posts/PostId/858/faces-of-phia-episode-13-glutton-for-punishmentPodcastsWed, 12 Jun 2019 14:59:27 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/9CQvLxDvitY" width="560"></iframe></p> <p style="text-align: justify;"><span class="pre_wrap">Amanda Lima celebrates more than 6 years with Phia (most of that time working closely with Adam), by chatting about her time here, the company, and the amazing work she&rsquo;s doing on our clients&rsquo; behalves &ndash; delving deeply into matters of excessive and abusive provider billing. This is a topic about which everyone is buzzing, and Amanda has got the dirt!</span></p> <p style="text-align: justify;"><a href="https://youtu.be/9CQvLxDvitY">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/9CQvLxDvitY">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 858To Pay, or Not to Pay … The Guide to Handling Claims, Denials, and Appealshttps://www.phiagroup.com/Media/Posts/PostId/854/to-pay-or-not-to-pay-the-guide-to-handling-claims-denials-and-appealsWebinarsThu, 23 May 2019 15:21:10 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/uEPkCoFSd2g" width="560"></iframe></p> <p style="text-align: justify;">A claim arrives. Is it payable? Such a simple question triggers so many complex scenarios. In this era of steadily increasing appeals, to pay or exclude is only the first step. Even if it’s covered, how much is payable? Are there network entanglements or stop-loss issues? Employer bias or HR concerns? Never mind gaps! Even IF the claims are properly handled, has the written notification of adverse benefit determination been issued properly? Who can file an appeal? How? What timelines apply? What steps do you take, to set yourself up to triumph, if and when it ends up in front of a court of law? As so many administrators have discovered the hard way, it is all too easy to make mistakes that can come back to bite you later. DON’T PANIC! Join The Phia Group’s legal team as they discuss the good, bad, and ugly truths about the claims process, and how to safely navigate the various TPA and health plan duties associated with it.</p> <p><a href="https://youtu.be/uEPkCoFSd2g">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 854Faces of Phia: Episode 12 – Pat 'the Man' Santos Has Got it In the Baghttps://www.phiagroup.com/Media/Posts/PostId/851/faces-of-phia-episode-12-pat-the-man-santos-has-got-it-in-the-bagPodcastsTue, 07 May 2019 19:20:50 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/O7-9AGbEodw" width="560"></iframe></p> <p>&nbsp;</p> <p>In this groundbreaking episode, Pat &#39;the Man&#39; Santos &ndash; our silent producer, is silent no longer!&nbsp; Listen (if you dare) as he grabs the mic and goes toe to toe with our hosts.&nbsp; Learn of his daring escape from mediocrity, journey of self-awareness, and eventual role with The Phia Group.&nbsp; This is the one you&rsquo;ve been waiting for.&nbsp; Don&rsquo;t miss it.</p> <p><a href="https://youtu.be/O7-9AGbEodw">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/iOc-8TLW898">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 851 Evolving Healthcare Issues and Events You Need to Know https://www.phiagroup.com/Media/Posts/PostId/847/evolving-healthcare-issues-and-events-you-need-to-knowWebinarsMon, 22 Apr 2019 19:40:34 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/dk0dnqFaRyM" width="560"></iframe></p> <p style="text-align: justify;"> </p> <p style="text-align: justify;">The healthcare space is rapidly evolving – and self-funding is no exception. Legislators, regulators, and courts are constantly providing new guidance – some good, some not. For this month’s webinar, we’re going to present some current events; we’ll discuss how they can help or hurt self-funded players, and what you can do to take advantage of them (or avoid the pitfalls created).</p> <p style="text-align: justify;">Join The Phia Group’s legal team for an hour as they tackle some of the most relevant topics currently affecting our industry, and explain what they mean to you and your business.</p> <p><a href="https://youtu.be/dk0dnqFaRyM">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 847The Phia Group's 2nd Quarter 2019 Newsletter https://www.phiagroup.com/Media/Posts/PostId/846/the-phia-groups-2nd-quarter-2019-newsletterNewslettersMon, 22 Apr 2019 14:57:35 GMT<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/Newsletter%202019%20Q1/header2019.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/icons5.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p1"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b12ndqtr19.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b2ndqtr19.png" 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="53%"> <p>&nbsp;</p> <p><br /> <img height="363" src="/Portals/phiagroup/Newsletter%20Q1%202018/adam.jpg" width="322" /></p> </td> <td valign="top" width="47%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">We are in full spring mode here at The Phia Group, enjoying warmer weather and record breaking growth. My pool is open, the Indians are playing (more like winning) baseball, and we are already seeing an uptick in renewals on behalf of our clients. While the self-funded space has more energy than ever, we are also seeing some situations where employers and brokers aren&rsquo;t fully aware of what they are getting themselves into. Yes, you can be innovative and save money, but you must also understand that you are now a fiduciary, you must take on added exposure and risk. There are many moving pieces in the self-funded space, so the plug and play approach won&rsquo;t always work. In fact, you will get the best results by not plugging and playing anything. This is where we come in, from setting up your plan design to handling your appeal issues, Phia is here to ensure you have a positive self-funding experience. I hope you enjoy the great newsletter we have put together for you. Happy reading!</p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </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%20Q1%202018/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: Unwrapped and CNS</a><br /> <a href="#p3">Phia Group Case Study - Frightening ASA Provisions</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2019 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a name="p1"></a> <p>&nbsp;</p> <p class="heading1">Service Focus of the Quarter: Unwrapped and CNS</p> <p class="bodytext" style="text-align: justify;">We have all witnessed instances of abusive provider billing. When imposed upon a self-funded health plan, the effects seem most disastrous. To combat this, some groups have migrated to a no-network, full reference-based pricing model. While that is ideal for some groups, it is still a small minority of plan sponsors who are willing or able to bear the risks associated with a full reference-based pricing program.</p> <p class="bodytext" style="text-align: justify;">A more traditional way of combating high claims is one-off claim negotiations. The Phia Group calls this our Claim Negotiation &amp; Signoff service (or CNS). Through this service, The Phia Group puts its legal team and expert negotiators to work, to combine legal expertise with objective cost data to obtain case-by-case negotiations with medical billers. A comprehensive set of data helps determine market-based prices, to put payors on a level playing field with their members&rsquo; medical providers, and secure written payment agreements that avoid balance-billing.</p> <p class="bodytext" style="text-align: justify;">The Phia Group proudly boasts a 51% average discount off billed charges on claims within the CNS service. Unlike CNS, however, Phia Unwrapped is anything but traditional. Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited rights. With Phia Unwrapped, The Phia Group replaces wrap network access and modifies non-network payment methodologies, securing payable amounts that are unbeatably low. 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&rsquo;s payment as payment in full.</p> <p class="bodytext" style="text-align: justify;">Out-of-network claims run through The Phia Group&#39;s Unwrapped program yielded a whopping average savings of 74% off billed charges (three times the average wrap discount in 2018). 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 applied nationwide.</p> <p class="bodytext" style="text-align: justify;">Contact our Vice President of Sales and Marketing, attorney Tim Callender, to learn more about CNS or Phia Unwrapped. Tim can be reached by phone at 781-535-5631 or by email at TCallender@phiagroup.com.</p> <p class="bodytext">&nbsp;</p> <a id="p3" name="p3"></a> <p class="bodytext"><strong>Phia Case Study: Frightening ASA Provisions</strong></p> <p class="bodytext" style="text-align: justify;">The broker of a self-funded benefit plan was presented with an Administrative Services Agreement (or ASA), by which the prospective TPA would administer claims for the health plan. The broker presented our consulting division with the Administrative Services Agreement to review, as a matter of ordinary diligence. This review was focused on a holistic approach, rather than any particular provisions that were previously identified as troublesome.</p> <p class="bodytext" style="text-align: justify;">Upon reading the ASA, The Phia Group&rsquo;s reviewer noticed a provision relating to the network, which provided that the plan would be required to pay certain types of claims despite issues with medical necessity or experimental status. This ASA essentially rendered those important Plan exclusions unusable, which, needless to say, is a problem.</p> <p class="bodytext" style="text-align: justify;">Among other issues to address within the ASA, The Phia Group placed a great deal of emphasis on that provision when providing the client with the review, and the broker was grateful that this matter was brought to light. This is especially important from a stop-loss perspective; it&rsquo;s tough to know how exactly a given carrier will treat a particular situation without a discussion, and this language within the ASA couldn&rsquo;t be discussed until it was identified.</p> <p class="bodytext" style="text-align: justify;">With the information provided by The Phia Group, the broker and group were able to discuss the matter with the TPA and reach a resolution favorable to all parties involved &ndash; and the plan no longer had to worry that its ASA required it to pay claims that stop-loss would almost certainly deny!</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> _ <p>&nbsp;</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Ensuring Proper Application of OOP Limits! </strong></p> <a id="p12" name="p12"></a> <p class="bodytext" style="text-align: justify;">The Department of Labor has explained that amounts that must be applied to an individual&rsquo;s out-of-pocket maximum do not (but may, at the plan&rsquo;s option) include &ldquo;premiums, balance billing amounts for non-network providers, or spending for non-covered services.&rdquo; A claim subject to reference-based pricing, as opposed to one subject to a contract with a provider, necessarily entails an out-of-network claim. Thus, according to the DOL&rsquo;s original interpretation, balance-billed amounts resulting from non-network reference-based pricing are not included in the individual&rsquo;s out-of-pocket cost limitations.</p> <p class="bodytext" style="text-align: justify;">Subsequently, however, the DOL got wind of this whole reference-based pricing phenomenon, and altered its stance a bit. According to the regulators:</p> <p class="bodytext" style="text-align: justify;">&ldquo;&hellip;a plan that utilizes a reference-based pricing design (or similar network design) may treat those providers that accept the reference-based price as the only in-network providers and not count an individual&rsquo;s out-of-pocket expenses for services rendered by other providers towards the MOOP limit only if the plan is using a reasonable method to ensure adequate access to quality providers at the reference price.&rdquo;</p> <p class="bodytext" style="text-align: justify;">In other words, it&rsquo;s still the case that a patient&rsquo;s OOP does not include balance-billed amounts &ndash; but that&rsquo;s only if the plan &ldquo;is using a reasonable method to ensure adequate access to quality providers at the reference price.&rdquo; Our interpretation of that has been that reference-based pricing is still alive and well according to the DOL &ndash; but a given RBP plan must count balance-billed amounts toward patient OOP unless the plan provides patients options to avoid balance-billing. The DOL has not elaborated on what those options may be, but a reasonable interpretation is that contracts of any kind would work. Some plans choose to use a full PPO and only use RBP for out-of-network claims; other plans use a narrow network; others choose to sign contracts with certain choice facilities to provide their members with safe options; others still opt to sign no contracts whatsoever, but are sure to settle claims on the back-end to avoid balance-billing.</p> <p class="bodytext" style="text-align: justify;">Whatever option you choose for your RBP plan, make sure you&rsquo;re following the regulations! One important fiduciary duty of a Plan Administrator is to accurately calculate member OOP &ndash; and when it comes to reference-based pricing, that can get tricky.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Success Story of the Quarter: Overpayment Recovery</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group&rsquo;s overpayment department was presented with a file whereby the TPA identified a claim that was overpaid to a medical provider; the overpayment reason was that Medicare was primary on the claims, but the TPA placed the self-funded health plan as primary in error. The plan had paid $76,000. The TPA knew that the plan would need to pay something as secondary, but certainly not its entire allowable. Further, the TPA had concerns that the group and its broker would hold the TPA responsible if the money couldn&rsquo;t be recovered.</p> <p class="bodytext" style="text-align: justify;">The Phia Group&rsquo;s overpayment experts reached out to the provider, and initially were given the cold shoulder. After continuous communication with the provider and making sure to stay on the hospital&rsquo;s radar, eventually the claim was escalated to the hospital&rsquo;s CFO. After a series of lengthy discussions, the hospital&rsquo;s CFO finally agreed to resubmit the claims to Medicare, but only agreed to refund the Plan the portion of the claim that was not in fact payable by Medicare, effectively treating the plan as secondary up to the full, billed charges.</p> <p class="bodytext" style="text-align: justify;">At that point, one of The Phia Group&rsquo;s attorneys contacted the hospital&rsquo;s CFO, in an attempt to explain that even though the self-funded health plan pays secondary to Medicare, the health plan&rsquo;s allowable amount is defined within the Plan Document, and is not the full billed charges. After The Phia Group&rsquo;s overpayment team went back and forth for many weeks and explained the plan&rsquo;s language numerous times the CFO seemed to understand.</p> <p class="bodytext" style="text-align: justify;">Ultimately, it was revealed that Medicare paid the claims in question at the rate of $58,000. Because the plan&rsquo;s allowable was the original $76,000, the plan paid the difference of $18,000 as secondary, but was refunded the $58,000 that Medicare paid as primary.</p> <p class="bodytext" style="text-align: justify;">The moral of this story? If you find that money has been overpaid, The Phia Group can help you recover it! Contact our Vice President of Sales and Marketing, attorney Tim Callender, to learn more about The Phia Group&rsquo;s overpayment recovery services. Tim can be reached by phone at 781-535-5631 or by email at <a href="mailto:TCallender@phiagroup.com">TCallender@phiagroup.com</a>.<br /> &nbsp;</p> <p>&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext">&bull; Free Market Healthcare Solutions &ndash; <a href="https://issuu.com/fidelispublish/docs/solutions_02_19" target="_blank">You Have the Right to Know the Price</a> &ndash; March 10, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/The Self-Funded Case-Back to Basics by Tim Callender.pdf" target="_blank">The Self-Funded Case-Back To Basics</a> &ndash; March 8, 2019</p> <p class="bodytext">&bull; BenefitsPro &ndash; <a href="https://www.benefitspro.com/2019/03/06/the-evolution-of-paid-family-leave-laws/" target="_blank">How close are we to a federal paid family leave law?</a> &ndash; March 6, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/The Profit Motive-A Necessary Evil_ by Andrew Silverio.pdf" target="_blank">The Profit Motive-A Necessary Evil?</a> &ndash; February 5, 2019</p> <p class="bodytext">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/A Texas Federal Judge Declares The Affordable Care Act Unconstitutional- What Next by Brady Bizarro%2C Esq.pdf" target="_blank">A Texas Federal Judge Declares The Affordable Care Act Unconstitutional: What Next?</a> &ndash; January 16, 2019</p> <p class="bodytext">&bull; Money Inc. &ndash; <a href="https://moneyinc.com/texas-v-united-states-the-events-that-followed-and-the-impact-of-the-government-shutdown/" target="_blank">Texas v. United States: The Events that Followed and the Impact of the Government Shutdown</a> &ndash; January 14, 2019</p> <p class="bodytext">&bull; Managed Healthcare Executive &ndash; <a href="https://www.managedhealthcareexecutive.com/managed-care-executive/top-4-challenges-healthcare-executives-face-2019/" target="_blank">Top 4 Challenges Healthcare Faces in 2019</a> &ndash; January 11, 2019</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/831/foreign-drugs-savings-worth-traveling-for" target="_blank">Foreign Drugs: Savings Worth Traveling For</a>. A roadtrip that might be worth taking.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/827/to-rbp-or-not-to-rbp-that-is-one-of-the-questions" target="_blank">To RBP, or Not to RBP: That is (one) of the Question(s)</a>. Reference-based pricing is one of the most mysterious self-funding structures out there.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/822/hey-watch-your-language" target="_blank">Hey, Watch Your Language!</a> Clear language describes what the plan will pay in a comprehensible manner.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/821/new-action-on-drug-pricing-medicare-like-rates" target="_blank">New Action on Drug Pricing: Medicare-Like Rates?</a> From ending pharmacy gag rules to outlawing the use of co-pay coupons.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/810/blocking-the-birth-control-rule" target="_blank">Blocking the Birth Control Rule.</a> Coverage of contraceptives for women and the availability of a religious or moral exemption (or an accommodation) has been hotly debated recently.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;"><a href="https://register.gotowebinar.com/register/8354714256140621827">Click HERE to Register!</a></p> <p class="bodytext" style="text-align: justify;">&bull; On March 14, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/832/transparency-a-building-block-of-self-funding" target="_blank">Transparency: A Building Block of Self-funding</a>,&rdquo; where we discussed some emerging and ongoing transparency issues, measures being taken to try to resolve them, and methods you can use to get the data you need in order to lower costs.</p> <p class="bodytext" style="text-align: justify;">&bull; On February 14, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/823/what-we-love-about-self-funding-in-2019" target="_blank">What We Love About Self-Funding in 2019</a>,&rdquo; where we discussed what makes self-funding such a great option for so many employers and employees, as well as the incredibly cool new innovations rolling out in 2019.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 16, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/811/the-affordable-care-act-in-2019-a-look-ahead" target="_blank">The Affordable Care Act in 2019: A Look Ahead</a>,&rdquo; where we discussed many legal and political battles that threaten the ACA&#39;s existence.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:Featuring Video Podcasts!</span></p> <p class="bodytext" style="text-align: justify;">&bull; On March 29, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/837/empowering-plans-p68-breaking-news-federal-judge-blocks-expansion-of-ahps" target="_blank">Breaking News - Federal Judge Blocks Expansion of AHPs</a>,&rdquo; where Adam and Brady discuss the Department of Labor&rsquo;s new rules that expanded the sale of association health plans (&ldquo;AHPs&rdquo;) violate existing law.</p> <p class="bodytext" style="text-align: justify;">&bull; On March 26, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/836/empowering-plans-p67-employee-takeover-self-funded-health-plans-from-the-members-pov" target="_blank">Employee Takeover: Self-Funded Health Plans from the Member&#39;s POV</a>,&rdquo; where Phia&rsquo;s Marketing &amp; Accounts Manager, Matthew Painten, and Compliance &amp; Regulatory Affairs Consultant, Philip Qualo, dissect Phia&rsquo;s very own Self-funded health plan.</p> <p class="bodytext" style="text-align: justify;">&bull; On February 28, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/829/empowering-plans-p66-bigger-in-texas" target="_blank">Bigger in Texas</a>,&rdquo; where Ron and Brady discuss Brady&rsquo;s recent trip to Austin and presentation at the Texas Association of Benefit Administrators.</p> <p class="bodytext" style="text-align: justify;">&bull; On February 15, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/824/empowering-plans-p65-hail-to-the-chief" target="_blank">Hail to the Chief!</a>,&rdquo; where our hosts, Brady and Ron, dissect the President&rsquo;s State of the Union Address.</p> <p class="bodytext" style="text-align: justify;">&bull; On February 5, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/819/empowering-plans-p64-hospital-transparency" target="_blank">Hospital Transparency!</a>,&rdquo; where out hosts, Ron and Brady discuss the new legal compliance and regulatory affairs team (&ldquo;LCARA&rdquo;) with team member Philip Qualo, and specifically address recent efforts to promote hospital transparency.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 25, 2019, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/816/empowering-plans-p63-touchdown" target="_blank">Touchdown!</a>,&rdquo; how providers &ndash; like plan sponsors &ndash; are concerned with the state of things and want to identify what&rsquo;s wrong, what&rsquo;s right, and how we can collaborate on a new approach that works for us all, as members of a single industry &ndash; healthcare.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 10, 2019, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/808/empowering-plans-p62-obamacare-is-still-the-law-right" target="_blank">Obamacare is Still the Law, Right?</a>,&rdquo; where Ron and Brady dissect the Texas decision that challenges the legality of the ACA.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 2, 2019, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/804/empowering-plans-p61-leather-patches-pipes" target="_blank">Leather Patches &amp; Pipes</a>,&rdquo; where our host, Ron Peck sits down with Andrew Silverio and Jon Jablon to discuss the forthcoming master&rsquo;s degree program in plan development they will be teaching.</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="heading1">&nbsp;</p> <p class="heading1">Face of Phia</p> <p class="bodytext" style="text-align: justify;">&bull; On February 19, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/826/faces-of-phia-episode-taking-account-with-lisa-t" target="_blank">Taking Account with Lisa T!</a>,&rdquo; where our hosts sit down with The Phia Group&rsquo;s Senior Controller, Lisa Tangney.</p> <p class="bodytext" style="text-align: justify;">&bull; On February 8, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/820/faces-of-phia-episode-8-its-tomasz-time" target="_blank">It&rsquo;s Tomasz Time!</a>,&rdquo; where our hosts sit down with The Phia Group&rsquo;s Senior Claim &amp; Case Support Analyst, Tomasz Olszewski.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 30, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/818/faces-of-phia-episode-7-ashley-turco-international-agent-of-security" target="_blank">Ashley Turco&hellip; International Agent of Security!</a>,&rdquo; where our hosts sit down with The Phia Group&rsquo;s Director of Compliance, Ashley Turco.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 17, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/813/faces-of-phia-episode-6-tech-talk-with-hemant" target="_blank">Tech Talk with Hemant</a>,&rdquo; where our hosts sit down with The Phia Group&rsquo;s Vice President of Technology, Hemant Dua.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 14, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/809/faces-of-phia-episode-5-setting-the-pace-with-tori-help-me-tori" target="_blank">Setting the Pace with Tori: Help me Tori!</a>,&rdquo; where our hosts sit down with a member of The Phia Group&rsquo;s Client Implementation Coordinator, Tori Pace.</p> <p class="bodytext" style="text-align: justify;">&bull; On January 7, 2019, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/806/faces-of-phia-episode-4-dishing-with-delaney" target="_blank">Dishing with Delaney</a>,&rdquo; where our hosts sit down with The Phia Group&rsquo;s Senior Training &amp; Development Specialist, Katie Delaney.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/itunes.png" style="width: 251px; height: 78px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2019 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2019 charity is the Boys &amp; Girls Club of Brockton.</p> <p><img src="/Portals/phiagroup/Newsletter%20Q1%202018/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton 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>&nbsp;</p> <p class="bodytext"><strong>A Special Delivery from the Phia Family</strong></p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/phiaemploy.jpg" style="width: 506px; height: 346px;" title="" /></p> <p>&nbsp;</p> <p class="bodytext" style="text-align: justify;">The Phia Family loves to show their Patriots Pride! In anticipation of the Super Bowl, we channeled our excitement to raise over 2,000 hygiene items and $1,400 for the Boys &amp; Girls Club of Brockton! As a thank you to the kind, thoughtful, giving members of the Phia Family, we decided to reward everyone at the office with a late opening the day after the Super Bowl.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Youth of the Year</strong></p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/youthofmonth.jpg" style="width: 483px; height: 356px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;">Our favorite time of the year has arrived and we get the opportunity to choose our Youth of the Year. A member of the Boys &amp; Girls Club of Brockton has been chosen by The Phia Group&rsquo;s CEO, Adam Russo, to receive the prestigious award of Youth of the Year. This member will receive a $5,000 college scholarship and a brand new laptop that will help them through the four years of college. We are proud to announce that Julieth Nwosu was chosen to receive this prestigious award! Congratulations, Julieth, and best of luck in college!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">The Self-Funded Case &ndash; Back To Basics</p> <p class="bodytext" style="font-weight: normal">By: Tim Callender, Esq. &ndash; March 2019 &ndash; <a href="https://www.sipconline.net/files/The Self-Funded Case-Back to Basics by Tim Callender.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Without a plan document, what is a self-funded plan, truly? It is a nebulous financial instrument, or bizarre oral contract slightly memorialized by HR emails and broker notes that exists without clear guidance or application. Yet this plan is still subject to incredible responsibility and liability. Needless to say, not only is having a plan document a good idea (if not required, depending on how you read the law) but it is an even better idea to have a well-written and understandable plan document. As discussed above, many plan sponsors become enamored with new and innovative solutions, ranging from specialty Rx cost control to a medical tourism program filled with plan member incentives. These are wonderful solutions that may yield outstanding results &ndash; but what if the plan document does not properly support and outline the specialty Rx program? What if the plan document fails to provide clear instruction to the plan member on how he/she can take advantage of the beneficial medical tourism program? Not only does the plan sponsor run the risk of implementing benefit structures that may cause legal problems, since they are not outlined in the plan document, but the plan sponsor will most surely lose out on gaining the benefit of these innovative solutions. Not to mention paying claims outside the terms of the plan&rsquo;s stop-loss policy. Without a well-written and understandable plan document, the it is pointless to pursue more complex solutions and the goals of cost containment and rich benefits will surely never be met.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.sipconline.net/files/The Self-Funded Case-Back to Basics by Tim Callender.pdf" target="_blank">Click here to read the rest of this article</a></p> <p><br /> <span class="bodytext"><strong>The Profit Motive &ndash; A Necessary Evil? </strong></span></p> <p>&nbsp;</p> <p class="bodytext" style="font-weight: normal">By: Andrew Silverio, Esq. &ndash; February 2019 &ndash; <a href="https://www.sipconline.net/files/The Profit Motive-A Necessary Evil_ by Andrew Silverio.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Working in the self-funded healthcare industry, it can be easy for us to develop tunnel vision and focus on cost containment and affordability at all costs, losing sight of other valid interests within and relating to the healthcare market. Quality of care is an obvious one &ndash; if not done properly, reductions in cost can come at the expense of quality (of course, this isn&rsquo;t always the case in healthcare, a product which so often has a great deal of inefficiency built in). But there are other, less directly related interests which we should keep in mind when we zoom out and look at the broader system, for example in forming policy decisions. The healthcare market is an ecosystem, and like in any ecosystem, one organism becoming too powerful can ultimately be a bad thing for everyone. A super-predator in an isolated system can quickly hunt its own prey out of existence and starve.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.sipconline.net/files/The Profit Motive-A Necessary Evil_ by Andrew Silverio.pdf" target="_blank">Click here to read the rest of this article</a></p> <p>&nbsp;</p> <p class="bodytext"><strong>A Texas Federal Judge Declares The Affordable Care Act Unconstitutional: What Next?</strong></p> <p class="bodytext">By: Brady Bizarro, Esq. &ndash; January 2019 &ndash; <a href="https://www.sipconline.net/files/A Texas Federal Judge Declares The Affordable Care Act Unconstitutional- What Next by Brady Bizarro%2C Esq.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</p> <p class="bodytext" style="text-align: justify;">On February 26, 2018, eighteen state attorneys general and two Republican governors filed suit in a Texas district court against the federal government over the constitutionality of the Affordable Care Act (&ldquo;ACA&rdquo;). While Texas v. United States is not the first serious legal challenge brought against the Obama administration&rsquo;s signature healthcare law (see, e.g., King v. Burwell, 135 S. Ct. 2480 (2015); see also National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012)), it is the first in which the executive branch broke with tradition and declared that it would not defend the ACA in court. The case has certainly represented the most serious threat to the ACA since the GOP&rsquo;s legislative efforts to repeal the healthcare law failed last summer. As it turns out, this threat should have been taken more seriously by industry analysts. On December 14, 2018, Judge Reed O&rsquo;Connor of the U.S. District Court for the Northern District of Texas found that the ACA was unconstitutional.</p> <p class="bodytext"><a href="https://www.sipconline.net/files/A Texas Federal Judge Declares The Affordable Care Act Unconstitutional- What Next by Brady Bizarro%2C Esq.pdf" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a>Phia&rsquo;s 2019 Speaking Events:</p> <p class="bodytext"><strong>Phia&rsquo;s Speaking Engagements:</strong><br /> <br /> &bull; 1/9/2019 &ndash; FMMA Conference &ndash; Austin, TX</p> <p class="bodytext">&bull; 2/27/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Denver, CO</p> <p class="bodytext">&bull; 3/8/2019 &ndash; UnitedAg Conference &ndash; Anaheim, CA</p> <p class="bodytext">&bull; 3/19/2019 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charlotte, NC</p> <p class="bodytext">&bull; 3/21/2019 &ndash; CGI Business Solutions Seminar &ndash; Woburn, MA</p> <p class="bodytext">&bull; 3/26/2019 &ndash; HFTA Broker Meeting &ndash; Tyler, TX</p> <p class="bodytext">&bull; 4/3/2019 &ndash; BenefitsPRO Broker Expo &ndash; Miami, FL</p> <p class="bodytext">&bull; 4/5/2019 &ndash; Pareto Conference &ndash; Nashville, TN</p> <p class="bodytext">&bull; 4/7/2019 &ndash; Captive Symposium &ndash; Cayman Islands</p> <p class="bodytext">&bull; 4/8/2019 &ndash; National Beer Wholesalers Association Legislative Conference &ndash; Washington DC</p> <p class="bodytext">&bull; 4/12/2019 &ndash; FMMA 2019 Annual Conference &ndash; Dallas, TX</p> <p class="bodytext">&bull; 4/23/2019 &ndash; Johns Hopkins Industry Education Series &ndash; Baltimore, MD</p> <p class="bodytext">&bull; 4/24/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 4/25/2019 &ndash; BevCap&rsquo;s Best Practices Workshop &ndash; Orlando, FL</p> <p class="bodytext">&bull; 4/26/2019 &ndash; Society of Professional Benefit Administrators Annual Conference &ndash; Washington, D.C.</p> <p class="bodytext">&bull; 5/2/2019 &ndash; MassAHU Benefest 2019 Conference &ndash; Westborough, MA</p> <p class="bodytext">&bull; 5/14/2019 &ndash; Cypress Unversity &ndash; Las Vegas, NV</p> <p class="bodytext">&bull; 5/30/2019 &ndash; Contrarian Captive &ndash; Austin, TX</p> <p class="bodytext">&bull; 6/11/2019 &ndash; Leavitt Conference &ndash; Big Sky, MT</p> <p class="bodytext">&bull; 7/15/2019 &ndash; HCAA TPA Summit &ndash; Dallas, TX</p> <p class="bodytext">&bull; 7/31/2019 &ndash; 2019 MVP Academy &ndash; Wellesley, MA</p> <p class="bodytext">&bull; 8/24/2019 &ndash; Well Health Workshop &ndash; Chicago, IL</p> <p class="bodytext">&bull; 10/27/2019 &ndash; 2019 Annual NASP Conference &ndash; Washington DC</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employee of the Quarter:<br /> Andrew Fine</span></p> <p class="bodytext" style="text-align: justify;">Congratulations to Andrew Fine, The Phia Group&rsquo;s Q2 2019 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;">When Andrew first started at The Phia Group in 2017 as an intake specialist, it was clear that he was a perfect fit for not only his role, but for The Phia Group. Andrew is currently the Lead Intake Specialist for Phia&rsquo;s Consulting department. Andrew has a great work ethic and maintains a positive attitude. The Consulting department can always rely on him to stay on top of client requests, as he is very efficient and organized.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/employ19.jpg" style="width: 273px; height: 412px;" title="" /></p> <p class="bodytext">Congratulations Andrew, and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a>Phia News</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Exceptional Business Award</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to announce that we have been presented with an Exceptional Business Award at the 11th Annual Mentor Recruitment Rally &amp; Celebration! We take tremendous pride in our community and the youths of the Boys &amp; Girls Club of Brockton - Allowing the young people of our community opportunities and platforms in which they can succeed has been rooted in our everyday business functions, leading to a promising future and a caring environment for all those involved.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/award01.jpg" style="width: 527px; height: 365px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Valentine&rsquo;s Day at Phia</strong></p> <p class="bodytext" style="text-align: justify;">The Phia family celebrated Valentines Day with a guessing game! Everyone in the office was tasked with guessing how many candy hearts were in the glass jar&hellip; But we didn&rsquo;t stop there&hellip; We challenged our followers on <a href="https://www.linkedin.com/company/1435480" target="_blank">LinkedIn</a> to join in on the fun. After an entire day of guesses being collected, we finally counted out the candy hearts. There were a total of 2,329 candy hearts in the glass jar! Congratulations to Jeff Hanna, of The Phia Group, who guessed 2,303. We would also like to congradulate Diana Denzin, who had the closest guess on our LinkedIn page, with a guess of 2,621.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/vday01.jpg" style="width: 542px; height: 295px;" title="" /></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p><span class="boldtext">Job Opportunities:</span></p> <p>&bull; Intake Specialist</p> <p>&bull; Attorney I</p> <p>&bull; Overpayments Recovery Assistant</p> <p>&bull; Health Benefit Plan Drafter</p> <p>&bull; Case Investigator I</p> <p>&bull; Provider Relations Client Concierge</p> <ul class="bodytext"> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Promotions </strong><br /> <br /> &bull; Ron Peck has been promoted from Sr. VP and General Counsel to Executive Vice President and General Counsel</p> <p class="bodytext">&bull; Julie Martin has been promoted from VP, Recovery Services to Sr. Vice President, Recovery Services</p> <p class="bodytext">&bull; Jen McCormick has been promoted from VP, Consulting to Sr. Vice President, Phia Group Consulting</p> <p class="bodytext">&bull; Chris Aquiar has been promoted from Director, Recovery Services to Vice President, Legal Recovery Services</p> <p class="bodytext">&bull; Hemant Dua has been promoted from Sr. Director of IT to Vice President of Technology</p> <p class="bodytext">&bull; Brady Bizarro has been promoted from Director, Healthcare Attorney to Director of Legal Compliance &amp; Regulatory Affairs (LCARA)</p> <p class="bodytext">&bull; Andrew Silverio has been promoted from Health Benefit Plan Admin - Attorney III to Compliance &amp; Oversight Counsel</p> <p class="bodytext">&bull; Philip Qualo has been promoted from HR Compliance Specialist to Compliance &amp; Regulatory Affairs Consultant</p> <p class="bodytext">&bull; Sean Donnelly has been promoted from Corporate Counsel to Associate General Counsel</p> <p class="bodytext">&bull; Cara Carll has been promoted from Senior Team Lead to Manager of Case Evaluation, Customer Service &amp; Claim Analysis</p> <p class="bodytext">&bull; Amanda Lima has been promoted from Provider Relations Team Lead to CEO Executive Assistant and Manager of Provider Relations</p> <p class="bodytext">&bull; Cindy Monfils has been promoted from Account Coordinator/Paralegal to COO Executive Assistant/Paralegal</p> <p class="bodytext">&bull; Jamie Johnson has been promoted from Team Lead, Sr. Recovery Team to Team Lead, Bodily Injury</p> <p class="bodytext">&bull; Rose Jardim has been promoted from Team Lead of Accounting to Supervisor of Accounting</p> <p class="bodytext">&bull; Ekta Gupta was promoted from Coordinator, Data Services Group to Manager, Data Services Group</p> <p class="bodytext">&bull; Erin Hussey has been promoted from Attorney I to Attorney II</p> <p class="bodytext">&bull; Andrew Fine has been promoted from Intake Specialist to Lead Intake Specialist.</p> <p class="bodytext"><br /> &nbsp;</p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> &bull; Robyn Sullivan was hired as an Executive Assistant</p> <p class="bodytext">&bull; Robert Martinez was hired as an Attorney in the Provider Relations Department</p> <p class="bodytext">&bull; Robyn Cleaves was hired at a Team Lead in Accounting</p> <p class="bodytext">&bull; Shawndell Dias was hired as a Case Investigator</p> <p class="bodytext">&bull; Scott Byerely was hired as the Vice President, Operations and Total Quality Management</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter%20Q1%202018/footerlogo.png" 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> 846The Stacks - 2nd Quarter 2019https://www.phiagroup.com/Media/Posts/PostId/845/the-stacks-2nd-quarter-2019NewslettersFri, 19 Apr 2019 19:57:42 GMT<h1><span style="font-size:130%;"><b style="mso-bidi-font-weight:normal"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">A Texas Federal Judge Declares The Affordable Care Act Unconstitutional: What Next?</span></b> </span></h1> <h2 style="text-align: justify;"><span style="font-size:larger;"><span style="color:#28166F;"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">By: Brady Bizarro, Esq. </span></span></span></h2> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">On February 26, 2018, eighteen state attorneys general and two Republican governors filed suit in a Texas district court against the federal government over the constitutionality of the Affordable Care Act (&ldquo;ACA&rdquo;). While <em>Texas v. </em></span><em><span style="color:#000000;">United</span></em><span style="color:#000000;"><em> States</em> is not the first serious legal challenge brought against the Obama administration&rsquo;s signature healthcare law (<i style="mso-bidi-font-style:normal">see, e.g., King v. Burwell</i>, 135 S. Ct. 2480 (2015); <i style="mso-bidi-font-style:normal">see also</i> <i style="mso-bidi-font-style:normal">National Federation of Independent Business v. Sebelius, </i>567 U.S. 519 (2012)), it is the first in which the executive branch broke with tradition and declared that it would not defend the ACA in court. The case has certainly represented the most serious threat to the ACA since the GOP&rsquo;s legislative efforts to repeal the healthcare law failed last summer. As it turns out, this threat should have been taken more seriously by industry analysts. On December 14, 2018, Judge Reed O&rsquo;Connor of the U.S. District Court for the Northern District of Texas found that the ACA was unconstitutional.</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">His decision has rattled the markets, Democratic political leaders, advocacy groups, and the broader healthcare industry. One prominent Democratic senator remarked, &ldquo;This is a </span><span style="color:#000000;">five alarm</span><span style="color:#000000;"> fire &ndash; Republicans just blew up our healthcare system.&rdquo; Senate Minority Leader Chuck Schumer (D-NY) called it an &ldquo;awful ruling . . . [which, if not reversed] will be a disaster for tens of millions of American families, especially for people with pre-existing conditions.&rdquo; After taking a closer look at this ruling, however, many legal experts have concluded that it is not nearly as </span><span style="color:#000000;">earth shattering</span><span style="color:#000000;"> as the headlines have made it appear.</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">First, Judge O&rsquo;Connor&rsquo;s ruling did not block enforcement of the ACA despite the fact that the plaintiffs had asked the court to issue a nationwide injunction on the federal government from implementing, regulating, or enforcing the ACA. Since the judge declined, all of the existing provisions of the ACA with which employers, fully insured plans, and self-funded plans must comply are still in effect. This decision has no effect whatsoever on plan design, on cost containment, on employee incentives, or on regulatory compliance. A quick check of Healthcare.gov post-ruling revealed that federal officials have even added this reassuring message: &ldquo;Court&rsquo;s decision does not affect 2019 enrollment coverage.&rdquo;</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">Second, a spokeswoman for the California attorney general has already confirmed that the sixteen states (and D.C.) that stepped in to defend the ACA will appeal this district court ruling to the United States Court of Appeals for the Fifth Circuit in New Orleans, Louisiana. That means there is a chance that this decision could be overturned before the case reaches the Supreme Court. That possibility brings me to my third point; that legal scholars across the ideological spectrum have found the legal arguments made by the plaintiffs </span><span style="color:#000000;">in this case</span><span style="color:#000000;"> to be remarkably unpersuasive. To understand </span><span style="color:#000000;">why,</span><span style="color:#000000;"> let us break down the court&rsquo;s opinion (which sided with those arguments).</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">Judge O&rsquo;Connor&rsquo;s opinion has two major elements. First, he contends that since Congress reduced the ACA&rsquo;s individual mandate penalty to $0, the mandate to purchase insurance must be invalidated. Then, he argues that since the individual mandate is essential to and inseverable from the remainder of the ACA, the entire </span><span style="color:#000000;">2,000 page</span><span style="color:#000000;"> healthcare law must be struck down. This issue of &ldquo;severability,&rdquo; or whether one provision of </span><span style="color:#000000;">a law</span><span style="color:#000000;"> can be severed without invalidating the entire law, is key. Prior to addressing severability, however, Judge O&rsquo;Connor explains his constitutional analysis for finding that the individual mandate is no longer fairly readable as an exercise of Congress&rsquo;s tax power.</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">Regarding his first contention, that the individual mandate could not be saved from the ACA, Judge O&rsquo;Connor has made a rather compelling case. When the ACA was passed in 2010, the bill contained a requirement that all Americans purchase health insurance or pay a penalty. In 2012, the Supreme Court ruled that this requirement, known as the individual mandate, was a legitimate exercise of Congress&rsquo;s constitutional authority to tax. <i style="mso-bidi-font-style:normal">See NFIB v. Sebelius</i> (2012). In late 2017, in the Tax Cuts and Jobs Act (&ldquo;TCJA&rdquo;), Congress zeroed out the penalty associated with the tax, meaning the individual mandate can no longer reasonably be considered a tax. As such, the constitutional foundation identified by the majority of the Supreme Court, on which the individual mandate was based, was invalidated (recall that the majority in <i style="mso-bidi-font-style:normal">NFIB v. Sebelius </i>also<i style="mso-bidi-font-style:normal"> </i>declined to sustain the individual mandate&rsquo;s constitutionality under the Commerce Clause).</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">With respect to Judge O&rsquo;Connor&rsquo;s second contention, that the entire ACA must fall, many legal experts strongly disagree. Nothing in the original 2010 bill spoke to the severability of the individual mandate. Typically, when lawmakers neglect to include a severability clause in a bill, courts look to discern the intent of Congress when considering whether finding a particular provision of a law unconstitutional would require the elimination of the entire law. In <i style="mso-bidi-font-style:normal">NFIB v. Sebelius</i>, the majority never addressed severability with respect to the individual mandate since the Court upheld the requirement. Four dissenting justices concluded that the individual mandate was unconstitutional and that Congress intended the entire ACA to be invalidated without the individual mandate. </span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">Judge O&rsquo;Connor assumes that the intent of the 2010 Congress controls the severability analysis in the case before his court; an intent only discerned by a minority of the Supreme Court. Indeed, he spends most of his 55-page opinion attempting to discern the intent of the 2010 Congress on his own. In doing so, however, he ignores the intent of a later Congress that did speak to the issue of severability in the </span><span style="color:#000000;">form</span><span style="color:#000000;"> a later legislative act. The 2017 Congress, in passing the TCJA, eliminated the individual mandate and preserved the rest of the ACA. This act presents strong evidence that Congress intended the ACA to function without the individual mandate. Judge O&rsquo;Connor&rsquo;s explanation for this fact is that the 2017 Congress was unable to repeal the individual mandate because of budget rules and it </span><span style="color:#000000;">therefore</span><span style="color:#000000;"> had no intent with respect to the individual mandate&rsquo;s severability. </span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">By assuming Congress had no intent because it was shackled by complicated legislative rules, Judge O&rsquo;Connor has drawn the ire of most of the legal community. If he had been so sure of his position, why would he neglect to issue a nationwide injunction on the ACA, as he could have done? True, throwing a wrench into the middle of the healthcare system, where $600 billion in federal funding and health insurance coverage for millions of Americans is on the line, would have been a drastic action; however, if Judge O&rsquo;Connor truly believed Congress intended this, he could have blocked enforcement of the ACA across the country.</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">I could go on at length about the consequences if this ruling were to stand; the impact on employer-sponsored plans, the effect on those with pre-existing conditions, the potential loss of health insurance coverage for millions of individuals, and the end of the Medicaid expansion. Yet, based on the response from the legal community of which I am a part, my position is that this decision rests on very shaky ground. This decision also goes much further than even the Trump administration had wanted (it wanted to preserve protections in the law for people with pre-existing medical conditions). I fully expect this case to be reversed by the United States Court of Appeals for the Fifth Circuit and to eventually be declined by the Supreme Court.</span><o:p></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p><span style="color:#000000;">&nbsp;</span></o:p></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><span style="color:#000000;">In short, we should all hold our collective horses and conduct business as usual for the time being.</span></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify"><o:p>__________________________________________________________________________________________</o:p></p> <h1><span style="font-size:130%;"><strong>The Profit Motive &ndash; A Necessary Evil?</strong></span></h1> <h2><span style="color:#28166F;"><span style="font-size:larger;"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">By: Andrew Silverio, Esq.</span></span></span></h2> <p style="text-align: justify;"><span style="color:#000000;">Working in the self-funded healthcare industry, it can be easy for us to develop tunnel vision and focus on cost containment and affordability at all costs, losing sight of other valid interests within and relating to the healthcare market.&nbsp; Quality of care is an obvious one &ndash; if not done properly, reductions in cost can come at the expense of quality (of course, this isn&rsquo;t always the case in healthcare, a product which so often has a great deal of inefficiency built in).&nbsp; But there are other, less directly related interests which we should keep in mind when we zoom out and look at the broader system, for example </span><span style="color:#000000;">in forming</span><span style="color:#000000;"> policy decisions.&nbsp; The healthcare market is an ecosystem, and like in any ecosystem, one organism becoming too powerful can ultimately be a bad thing for everyone.&nbsp; A super-predator in an isolated system can quickly hunt its own prey out of existence and starve.</span></p> <p style="text-align: justify;"><span style="color:#000000;">CNBC published an article recently about a disease called nonalcoholic steatohepatitis, or &ldquo;NASH.&rdquo; &nbsp;It develops from nonalcoholic fatty liver disease, which has been estimated by the Center for Disease Analysis to impact 89 million </span><span style="color:#000000;">Americans,</span><span style="color:#000000;"> and can lead to cirrhosis, cardiac and lung complications, liver cancer, and death.&nbsp; As a result of the obesity epidemic, particularly around the western world, the disease is becoming increasingly common, and the National Institute of Health now states that as many as 30 million Americans, or 12 percent of adults, have NASH.&nbsp;&nbsp; It&rsquo;s estimated that by 2020 NASH will surpass hepatitis C as the leading cause of liver transplants in the United States, as increasingly younger Americans, now often in their 20s and 30s, are developing the disease.</span></p> <p style="text-align: justify;"><span style="color:#000000;">As alarming as these numbers are, there is still no FDA approved treatment for NASH.&nbsp; Yet.</span></p> <p style="text-align: justify;"><span style="color:#000000;">With a global market for a cure estimated at $35 billion (with a b) dollars, pharmaceutical companies are quite literally racing to get new drugs approved and onto the market.&nbsp; There are currently 55 NASH drugs in various stages of clinical trials according to BioMedtracker, so new treatments are clearly on the horizon.</span></p> <p style="text-align: justify;"><span style="color:#000000;">That $35 billion pot of gold is the sole reason so many companies are sinking so much money into just having a shot at being first to market.&nbsp; The market may be months away from a cure, it may be a few years away &ndash; we&rsquo;re not doctors or medical researchers &ndash; but what we can say with confidence is that whatever the timeline is, it would be much longer without that mammoth payoff as motivation.&nbsp; Manufacturers of new specialty drugs are allowed to charge, and regularly receive payment of, absolutely absurd prices.&nbsp; But in some cases, as appears to be the case with NASH, it is </span><span style="color:#000000;">precisely</span><span style="color:#000000;"> because of this that we will soon have treatment for a disease which would otherwise continue taking lives unchecked.</span></p> <p style="text-align: justify;"><span style="color:#000000;">This ability of </span><span style="color:#000000;">manufacturers &nbsp;to</span><span style="color:#000000;"> charge and receive such high rates for new drugs has also given rise to an </span><span style="color:#000000;">entire</span><span style="color:#000000;"> new sub-industry based around medical tourism and drug importation. In attempting to get patients </span><span style="color:#000000;">access</span><span style="color:#000000;"> to new specialty drugs at a reduced cost to employers, numerous programs aimed at securing generic versions not yet available in the United States are enjoying success under several different models.&nbsp; These programs run the whole spectrum, from acting to facilitate shipment by a foreign pharmacy in Canada or Mexico to the American patient, or sending that patient to a border to cross over and pick up a drug themselves, all the way to a concierge service where a patient flies first class to the Caribbean, is put up in a hotel, and receives their treatment in a tropical paradise.&nbsp; The fact that this third option can actually still be significantly less expensive than the patient simply picking up the American version of a drug at the pharmacy down the street from his or her home is quite telling.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Other types of cost-containment efforts take aim at getting the amounts a plan has to actually pay for these drugs under control.&nbsp; Again, these programs vary greatly and can take the form of exclusions for certain specialty drugs, exclusions for <em>all </em>specialty drugs, or unique cost-sharing structures where copayment amounts change based on whether payment might be available from another source or based on the particular drug.&nbsp; Seemingly recognizing the impossibility of an individual without insurance paying for these drugs out of pocket, manufacturers implement assistance programs to help cover patient </span><span style="color:#000000;">copayments,</span><span style="color:#000000;"> or offer discounts or rebates for those who pay completely out of pocket.&nbsp; Other programs aim to identify when these programs might be available and steer that monetary benefit back toward the health plan.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The fact that all these different approaches are necessary illustrates an important principle which is often overlooked &ndash; the profit incentive to develop new drugs and therapies.&nbsp; America is a global leader in developing new therapies, and is by far the biggest healthcare spender per capita and arguably guilty of the greatest waste.&nbsp; Can the former continue to be true without the latter?&nbsp; If not, to what extent are we willing to sacrifice innovation and the development of new therapies for those few with no remedies available for their illnesses, in order to ensure that the masses can receive vital routine care in an affordable way?</span></p> <p style="text-align: justify;"><span style="color:#000000;">Food for thought.</span></p> <p style="text-align: justify;">______________________________________________________________________________________________</p> <h1><span style="font-size:130%;"><strong>The Self-Funded Case &ndash; Back To Basics</strong></span></h1> <h2><span style="color:#28166F;"><span style="font-size:larger;"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">By: Tim Callender, Esq.</span></span></span></h2> <p><span style="color:#000000;"><strong><u>Self-Funding &ndash; So Many Toys in the Sandbox</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Not to criticize our industry, in the least, but if we are being honest, we should all agree that it takes thousands of &ldquo;parts&rdquo; to make this &ldquo;car&rdquo; run, so to speak.&nbsp; This fact has its positives.&nbsp; An industry chock full of numerous stakeholders does lead to incredible innovation, teamwork, healthy competition, creative solutions, and the general strength that comes with an industry steeped in camaraderie.&nbsp; Likewise, this reality of many stakeholders can also create confusion and distraction unless we are paying close attention and working to block out the noise.&nbsp; The typical self-funded case will likely have a list of stakeholders that include (in no particular order &amp; I am sure to leave </span><span style="color:#000000;">something / someone</span><span style="color:#000000;"> out):</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">The </span><span style="color:#000000;">broker / consultant</span></li> <li style="text-align: justify;"><span style="color:#000000;">The employer, plan sponsor</span></li> <li style="text-align: justify;"><span style="color:#000000;">A benefits committee and/or benefits decisionmakers within the plan sponsor</span></li> <li style="text-align: justify;"><span style="color:#000000;">A third-party administrator or a carrier ASO platform</span></li> <li style="text-align: justify;"><span style="color:#000000;">A plan document solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A pharmacy benefits manager</span></li> <li style="text-align: justify;"><span style="color:#000000;">A specialty Rx cost containment solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A case </span><span style="color:#000000;">management / utilization</span><span style="color:#000000;"> management solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A concierge and/or centers of excellence solution</span></li> <li style="text-align: justify;"><span style="color:#000000;">A stop-loss </span><span style="color:#000000;">carrier / managing</span><span style="color:#000000;"> general underwriter</span></li> <li style="text-align: justify;"><span style="color:#000000;">Internal legal counsel</span></li> <li style="text-align: justify;"><span style="color:#000000;">External legal counsel</span></li> <li style="text-align: justify;"><span style="color:#000000;">Legal counsel for all the solution providers</span></li> <li style="text-align: justify;"><span style="color:#000000;">A dialysis cost-containment solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A claim re-pricing solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A network</span></li> <li style="text-align: justify;"><span style="color:#000000;">A wrap network or wrap network alternative</span></li> <li style="text-align: justify;"><span style="color:#000000;">A claim negotiation solution and/or patient advocacy solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A data analytics platform</span></li> <li style="text-align: justify;"><span style="color:#000000;">A claims auditing solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">A number of independent review organizations</span></li> <li style="text-align: justify;"><span style="color:#000000;">A subrogation and recovery solution provider</span></li> <li style="text-align: justify;"><span style="color:#000000;">And many, many, more&hellip;. (I felt the bullet points were becoming excessive &ndash; time to stop)</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;">In short &ndash; there are many, many toys in this sandbox of self-funding. </span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>So&hellip;. How About, Back to Basics?</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">As discussed, there </span><span style="color:#000000;">are</span><span style="color:#000000;"> an incredible number of stakeholders in the self-funding sandbox. To reiterate, this is not necessarily a bad thing, but it can steer us away from the fundamental basics and core needs of our industry, which can lead us astray from the root goal.&nbsp; What is that goal?&nbsp; In short, most self-funded plan sponsors are going to tell you that they entered into the self-funded space for two reasons: (1) to bring the costs associated with their health plan down; and (2) to have the creative control needed to deliver top-notch health benefits to their employees and their families.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Not to take away from the importance of the newest healthcare-related iPhone app, or the newest, innovative methodology behind case management, but sometimes it is important to step back and focus on the basics of this complex, self-funded system.&nbsp; Whether from the outside looking in, or deeply involved in the self-funded industry, all viewers should agree that this industry &ndash; this system &ndash; is definitely a complex one, as noted by the copious bullet points listed above.&nbsp; To wade through the complex and try to identify the key roots of a successful self-funded case is not only a noble pursuit but should be a point of pride for all in this space.&nbsp; With the roots in place, all of the other, more complex solutions can fall into place and will do so with a much higher likelihood of success.</span></p> <p style="text-align: justify;"><span style="color:#000000;">While like minds might rightly differ on the key elements that lead us toward the goals discussed above, I would list out the five most important roots that push the goals of driving down costs while delivering great benefits as follows:</span></p> <ol> <li style="text-align: justify;" value="NaN"><span style="color:#000000;">A well-written and understandable plan document.</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;">A vested &ldquo;benefits committee&rdquo; or other decision-making body housed within the employer Plan Sponsor.</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;">An educated and empowered consultant.</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;">A partner-focused third-party administrator.</span></li> <li style="text-align: justify;" value="NaN"><span style="color:#000000;">A well-oiled subrogation and recovery platform.</span></li> </ol> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>The </u></strong></span><strong><u><span style="color:#000000;">All Powerful</span></u></strong><span style="color:#000000;"><strong><u> and Governing Document</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Without a plan document, what is a self-funded plan, truly?&nbsp; It is a nebulous financial instrument, or bizarre oral contract slightly memorialized by HR emails and broker notes that </span><span style="color:#000000;">exists</span><span style="color:#000000;"> without clear guidance or application.&nbsp; Yet this plan is still subject to incredible responsibility and liability.&nbsp; Needless to say, not only is <em>having</em> a plan document a good idea (if not required, depending on how you read the law) but it is an even better idea to have a well-written and understandable plan document.&nbsp; As discussed above, many plan sponsors become enamored with new and innovative solutions, ranging from specialty Rx cost control to a medical tourism program filled with plan member incentives.&nbsp; These are wonderful solutions that may yield outstanding results &ndash; but what if the plan document does not properly support and outline the specialty Rx program?&nbsp; What if the plan document fails to provide clear instruction to the plan member on how he/she can take advantage of the beneficial medical tourism program?&nbsp; Not only does the plan sponsor run the risk of implementing benefit structures that may cause legal problems, since they are not outlined in the plan document, but the plan sponsor will most surely lose out on gaining the benefit of these innovative solutions.&nbsp; Not to mention paying claims outside the terms of the plan&rsquo;s stop-loss policy.&nbsp; Without a well-written and understandable plan document, </span><span style="color:#000000;">the it</span><span style="color:#000000;"> is pointless to pursue more complex solutions and the goals of cost containment and rich benefits will surely never be met.&nbsp; &nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>The Heart &amp; The Brain </u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Every employer plan sponsor should have a benefits committee in place, whether the committee is made up of 3 people or 15 people.&nbsp; Too many employers rely solely on the expertise of their consultant and &ldquo;pass the buck,&rdquo; so to speak, when it comes to truly understanding the ins and outs of their self-funded plan.&nbsp; Not to say that relying on a consultant is a bad thing &ndash; that&rsquo;s why they exist!&nbsp; However, as any expert will tell you, the expert&rsquo;s job is always easier when he/she is advising an educated consumer.&nbsp; An educated plan sponsor, backed by a benefits committee full of diverse knowledge and expertise, and advised by an industry expert consultant, is already leaps and bounds ahead of the rest when it comes to the ability to choose and implement solutions that will lead to cost savings and rich benefits.&nbsp; Not to mention, the committee can share the labor burdens associated with running a self-funded health plan.&nbsp; Like, working together to finalize that plan document!&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Additionally, a benefits committee increases the chances of a plan successfully implementing a complex solution.&nbsp; Let&rsquo;s use an out-of-network, reference-based pricing solution as a singular example.&nbsp; Such an innovative and disruptive program does not stand a chance if there is not </span><span class="gr-progress" style="color:#000000;">employee / member</span><span style="color:#000000;"> </span><span style="color:#000000;">buy in</span><span style="color:#000000;"> and understanding.&nbsp; There will likely be balance billing and &ldquo;scary&rdquo; situations which will lead plan members to bring the noise, so to speak, directly to HR.&nbsp; This noise can quickly cause enough pain that the plan sponsor will choose to abandon an otherwise legitimate and beneficial program.&nbsp; But.&nbsp; What if a savvy, vested, and educated benefits committee existed, at the employer, plan sponsor level?&nbsp; Imagine the education and communication opportunities that could exist &ndash; imagine the opportunities to work with the plan members, ask critical questions of the vendor, and course correct when needed.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">A benefits committee, whether small or large, will move a plan closer to its goals of containing costs and delivering rich benefits, every time.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Likewise, it takes the industry expert consultant to advise this bought in committee and bring them the solutions and ideas that they may not be aware of, that they can then interpret and execute, on their own terms.</span></p> <p style="text-align: justify;"><span style="color:#000000;">To </span><span style="color:#000000;">repeat:</span><span style="color:#000000;"> the vested benefits committee plus the expert consultant = reduced plan costs and the implementation of solutions to drive rich benefit delivery.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>The Partner</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">A sophisticated plan sponsor, governed by a benefits committee and advised by an expert consultant, should next seek a true partner in its third-party administrator.&nbsp; Plan sponsors can sometimes fall victim to regionalism or sticker attraction (seeking out the lowest administrative fee), which may not always lead to the best payor partner for that particular plan.&nbsp; Instead, plan sponsors and their consultants should begin by clearly understanding and defining their own needs and their own goals.&nbsp; They must do this first before trying to find the right payor partner.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Is the plan focused on a strong network?&nbsp; An in-house dialysis solution?&nbsp; Is a domestic call center presence important?&nbsp; What about reporting capabilities?&nbsp; What does the account management model look like and how involved will they be with enrollment meetings and finalizing the plan document?&nbsp; Will the payor listen to the plan&rsquo;s recommendations and needs regarding stop-loss?&nbsp; The list goes on.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Needless to say, combining a thoughtful benefits committee, with an expert consultant, and a true partner-oriented </span><span style="color:#000000;">payor,</span><span style="color:#000000;"> will allow for a plan to truly innovate and successfully put solutions in place that will meet the plan&rsquo;s goals.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>The Money at The End of The Chain</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">In thinking on the goals of driving costs down while delivering great benefits, there is one area that provides a clear &ldquo;win.&rdquo;&nbsp; Subrogation and recovery efforts.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Why is this the case?&nbsp; In efforts to contain costs, many plans go straight to the overly advertised, upfront, disruptive solutions that may drive costs down before costs are incurred.&nbsp; Many of these solutions have merit and bear fruit! But plan sponsors should not lose sight of the big recovery win that is available through a robust subrogation and recovery platform.&nbsp; Especially now, where copious opportunities exist to seek the recovery of plan dollars on so many fronts.&nbsp; Traditionally, most plans would focus their recovery efforts on the routine motor vehicle accident &ndash; the benchmark example of third-party liability.&nbsp; Anymore though, alongside these benchmark </span><span style="color:#000000;">MVAs</span><span style="color:#000000;">, plans should be considering other sources of third-party liability, such as torts, product recalls, and class actions.&nbsp; The list, and </span><span style="color:#000000;">opportunities,</span><span style="color:#000000;"> go on.&nbsp; &nbsp;&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Additionally, whether governed by ERISA or state law, or a combination of both, all self-funded plans are bound by some level of fiduciary duty.&nbsp; Instead of quoting federal or state law, the gist is this: plan fiduciaries must behave prudently with plan assets, which includes how the fiduciaries spend plan assets, don&rsquo;t spend plan assets, or get plan assets back!</span></p> <p style="text-align: justify;"><span style="color:#000000;">To this end, it is easy for a plan sponsor to focus on asset expenditure and upfront plan </span><span style="color:#000000;">savings,</span><span style="color:#000000;"> while forgetting about recovering dollars from a third party.&nbsp; This is understandable!&nbsp; Upfront expenses and upfront plan savings are exactly that, &ldquo;upfront!&rdquo;&nbsp; But, the concept of chasing around a third party, sometimes for years, in an effort to return plan funds back to the plan &ndash; well, it is easy to see how this concept can fall by the wayside and become easily forgotten.&nbsp; Yet, maximizing recovery efforts should be just as important to a plan fiduciary as the more routine, upfront savings and expenses that usually take priority.&nbsp; Seeking to assure that subrogation and recovery efforts are maximized is an important obligation of every plan fiduciary.&nbsp; Not to mention, returning plan assets into the plan&rsquo;s coffers means costs can be kept down and the plan can reinvest those dollars in other areas that might lead to that richer, more robust health plan.&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">Goals met.</span></p> <p style="margin:0in;margin-bottom:.0001pt;text-align:justify">&nbsp;</p> 845 Faces of Phia: Episode 11 - Reminiscing with Andrewhttps://www.phiagroup.com/Media/Posts/PostId/844/faces-of-phia-episode-11-reminiscing-with-andrewPodcastsWed, 17 Apr 2019 17:17:47 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/iOc-8TLW898" width="560"></iframe></p> <div class="style-scope ytd-video-secondary-info-renderer" slot="content" style="text-align: justify;">&nbsp;</div> <div class="style-scope ytd-video-secondary-info-renderer" slot="content"> <p style="text-align: justify;">In the latest episode of Faces of Phia, Adam and Ron reminisce on Andrew Silverio&#39;s Undergraduate adventure. Tune in for an episode filled with trips down memory lane, international drug importation, and predictions about the future of prescription drugs!</p> <p style="text-align: justify;"><a href="https://youtu.be/iOc-8TLW898">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/iOc-8TLW898">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> </div> 844Empowering Plans: P69 – A Healthcare Free-for-Allhttps://www.phiagroup.com/Media/Posts/PostId/843/empowering-plans-p69-a-healthcare-free-for-allPodcastsFri, 12 Apr 2019 13:21:14 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yea-tTjVVnc" width="560"></iframe></p> <p style="text-align: justify;">Join Adam, Ron, and Brady for a healthcare free for all where they tackle the most pressing issues facing our industry, including surprise emergency room bills, drug pricing, medical necessity, and employee incentive programs.</p> <p style="text-align: justify;"><a href="https://youtu.be/yea-tTjVVnc">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/yea-tTjVVnc">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 843Faces of Phia: Episode 10 - Tales From The Lost Filing Roomhttps://www.phiagroup.com/Media/Posts/PostId/840/faces-of-phia-episode-10-tales-from-the-lost-filing-roomPodcastsFri, 05 Apr 2019 17:50:42 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/B6V3v-txl0U" width="560"></iframe></p> <div class="style-scope ytd-expander" id="content"> <div class="style-scope ytd-video-secondary-info-renderer" id="description" slot="content"><yt-formatted-string class="content style-scope ytd-video-secondary-info-renderer" force-default-style="" split-lines="">In the latest episode of Faces of Phia, Adam and Ron dig up tales from the days of old with future industry leader and veteran employee, Amanda Grogan. Tune in for an episode filled with trips down memory lane, tests of knowledge, and a Rumspringa?</yt-formatted-string></div> <div class="style-scope ytd-video-secondary-info-renderer" slot="content">&nbsp;</div> <div class="style-scope ytd-video-secondary-info-renderer" slot="content"> <p style="text-align: justify;"><a href="https://www.youtube.com/watch?v=B6V3v-txl0U">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/GR6q157rdVM">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> </div> </div> 840Empowering Plans: P68 – Breaking News - Federal Judge Blocks Expansion of AHPshttps://www.phiagroup.com/Media/Posts/PostId/837/empowering-plans-p68-breaking-news-federal-judge-blocks-expansion-of-ahpsPodcastsFri, 29 Mar 2019 17:25:16 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/wImOWZ5ohTk" width="560"></iframe></p> <p style="text-align: justify;"><span class="pre_wrap">Last night, a federal judge in Washington, D.C. ruled that the Department of Labor&rsquo;s new rules that expanded the sale of association health plans (&ldquo;AHPs&rdquo;) violate existing law. Those rules applied to fully-insured AHPs in September 2018, to existing self-funded AHPs in January 2019, and would have permitted new self-funded AHPs on April 1, 2019. If this ruling stands, it will have a significant impact on the self-funded industry. The Phia Group will have extensive analysis of this decision in the coming days. For now, join Adam and Brady as they unpack this 43-page order and discuss what it all means for employers, TPAs, brokers, and the broader industry.</span></p> <p style="text-align: justify;"><a href="https://youtu.be/wImOWZ5ohTk">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/wImOWZ5ohTk">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 837Empowering Plans: P67 – Employee Takeover: Self-Funded Health Plans from the Member's POVhttps://www.phiagroup.com/Media/Posts/PostId/836/empowering-plans-p67-employee-takeover-self-funded-health-plans-from-the-members-povPodcastsTue, 26 Mar 2019 16:29:13 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/vVzQEZi8XWk" width="560"></iframe></p> <p style="text-align: justify;">Listen in as The Phia Group&rsquo;s Marketing &amp; Accounts Manager, Matthew Painten, and Compliance &amp; Regulatory Affairs Consultant, Philip Qualo, dissect Phia&rsquo;s very own Self-funded health plan. These guys aren&rsquo;t holding back and you don&rsquo;t want to miss out on this podcast!</p> <p style="text-align: justify;"><a href="https://youtu.be/vVzQEZi8XWk">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/vVzQEZi8XWk">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 836Transparency: A Building Block of Self-fundinghttps://www.phiagroup.com/Media/Posts/PostId/832/transparency-a-building-block-of-self-fundingWebinarsThu, 14 Mar 2019 14:17:09 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/OTu6cGViG6M" width="560"></iframe></p> <p style="text-align: justify;">Whether from unpredictable provider charges, “black box” claims repricing, mysterious PBM rebates, or unobtainable claims data, entities operating in the self-funded space such as employers, TPAs, brokers, and stop-loss carriers have been forced to deal with a systemic lack of transparency.<br />  <br /> Join The Phia Group’s legal team as they discuss some emerging and ongoing transparency issues, measures being taken to try to resolve them, and methods you can use to get the data you need in order to lower costs.</p> <p><a href="https://youtu.be/OTu6cGViG6M">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 832 Empowering Plans: P66 - Bigger in Texashttps://www.phiagroup.com/Media/Posts/PostId/829/empowering-plans-p66-bigger-in-texasPodcastsThu, 28 Feb 2019 19:15:32 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/d5WoKwksO6U" width="560"></iframe></p> <p style="text-align: justify;">Join The Phia Group&rsquo;s Ron Peck and Brady Bizarro as they discuss Brady&rsquo;s recent trip to Austin and presentation at the Texas Association of Benefit Administrators; with a focus on employee engagement, new ideas for cost containment, and an in depth analysis of pending litigation challenging the legality of ObamaCare.&nbsp; Yeah&hellip; You&rsquo;ll want to tune in for this one.</p> <p style="text-align: justify;"><a href="https://youtu.be/d5WoKwksO6U">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/d5WoKwksO6U">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 829Faces of Phia: Episode 9 - Taking Account with Lisa T!https://www.phiagroup.com/Media/Posts/PostId/826/faces-of-phia-episode-taking-account-with-lisa-tPodcastsTue, 19 Feb 2019 18:54:32 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/BPZfIcke8L8" width="560"></iframe></p> <p style="text-align: justify;">In this episode of Faces of Phia, Adam and Brady interview the superpowered controller of The Phia Group.&nbsp; From adventures in the Steel City to conquering &ldquo;nice problems to have,&rdquo; the team covers it all in this candid discussion.</p> <p style="text-align: justify;"><a href="https://youtu.be/BPZfIcke8L8">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/BPZfIcke8L8">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 826Empowering Plans: P65 - Hail to the Chief!https://www.phiagroup.com/Media/Posts/PostId/824/empowering-plans-p65-hail-to-the-chiefPodcastsFri, 15 Feb 2019 18:26:10 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/2GhWm5RYljg" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> <p><span class="pre_wrap">In this can&rsquo;t miss episode of Empowering Plans, Brady and Ron dissect the President&rsquo;s State of the Union Address, and focus in on how it will impact those of us servicing health benefit plans &ndash; and the entire healthcare industry. This one is going to be huge.</span></p> <p><a href="https://youtu.be/2GhWm5RYljg">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/2GhWm5RYljg">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 824What We Love About Self-Funding in 2019https://www.phiagroup.com/Media/Posts/PostId/823/what-we-love-about-self-funding-in-2019WebinarsThu, 14 Feb 2019 14:39:48 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/WvfFYgFFj6g" width="560"></iframe></p> <p style="text-align: justify;">Valentine’s Day is upon us, and we’re feeling the love.  Too often we, as an industry, spend our time discussing issues, problems, and concerns, and don’t dedicate enough time to the features and opportunities that make self-funding great.  We focus so much on “how we save” self-funding, that we forget to celebrate the reasons why self-funding is worth saving in the first place.  Join the team as they discuss what makes self-funding such a great option for so many employers and employees, as well as the incredibly cool new innovations rolling out in 2019, that will be sure to make self-funding a sweetheart for even more employers this year and beyond.</p> <p><a href="https://youtu.be/WvfFYgFFj6g">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 823Faces of Phia: Episode 8 - It’s Tomasz Time!https://www.phiagroup.com/Media/Posts/PostId/820/faces-of-phia-episode-8-its-tomasz-timePodcastsFri, 08 Feb 2019 17:39:49 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/1PABxaM2ubs" width="560"></iframe></p> <div class="style-scope ytd-expander" id="content"> <div class="style-scope ytd-video-secondary-info-renderer" id="description" slot="content"><yt-formatted-string class="content style-scope ytd-video-secondary-info-renderer" split-lines="">Live from Polska &ndash; a journey around the world leads to&hellip; The Phia Group. Join Adam and Brady as they take a journey through history and across oceans, to share the story of this unsung hero.</yt-formatted-string></div> </div> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><a href="https://youtu.be/1PABxaM2ubs">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/1PABxaM2ubs">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 820Empowering Plans: P64 - Hospital Transparency!https://www.phiagroup.com/Media/Posts/PostId/819/empowering-plans-p64-hospital-transparencyPodcastsTue, 05 Feb 2019 16:42:52 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/ll0zpBoGcgg" width="560"></iframe></p> <p style="text-align: justify;">Let&rsquo;s Escargot &amp; Meet LCARA: In this episode Ron and Brady discuss the new legal compliance and regulatory affairs team (&ldquo;LCARA&rdquo;) with team member Philip Qualo, and specifically address recent efforts to promote hospital transparency.</p> <p style="text-align: justify;"><a href="https://youtu.be/ll0zpBoGcgg">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/ll0zpBoGcgg">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 819Faces of Phia: Episode 7 - Ashley Turco… International Agent of Security!https://www.phiagroup.com/Media/Posts/PostId/818/faces-of-phia-episode-7-ashley-turco-international-agent-of-securityPodcastsWed, 30 Jan 2019 15:05:49 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/VKN8UDdWqFA" width="560"></iframe></p> <div class="style-scope ytd-video-secondary-info-renderer" slot="content"> <p style="text-align: justify;">In this episode, the crew once again sits down with a valued team member, whose role sits at the crossroads between technology and healthcare.&nbsp; Ensuring that the privacy and security issues hounding all businesses don&rsquo;t threaten The Phia Group as it leverages technology to better serve its clients, Ashley is unique not only at the company &ndash; but industrywide.&nbsp; Listen in to find out why, and what you need to do to get her seal of approval.</p> <p style="text-align: justify;"><a href="https://youtu.be/VKN8UDdWqFA">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/VKN8UDdWqFA">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> </div> 818Empowering Plans: P63 - Touchdown!https://www.phiagroup.com/Media/Posts/PostId/816/empowering-plans-p63-touchdownPodcastsFri, 25 Jan 2019 16:37:10 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/d0CH4RyKa34" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> <p style="text-align: justify;">How payers, providers, and those of us who serve them, can work together as a team and achieve a winning plan for the future of healthcare.&nbsp; In this episode, Adam, Ron and Brady, talk about how providers &ndash; like plan sponsors &ndash; are concerned with the state of things and want to identify what&rsquo;s wrong, what&rsquo;s right, and how we can collaborate on a new approach that works for us all, as members of a single industry &ndash; healthcare.</p> <p style="text-align: justify;"><a href="https://youtu.be/d0CH4RyKa34">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/d0CH4RyKa34">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 816Faces of Phia: Episode 6 - Tech Talk with Hemanthttps://www.phiagroup.com/Media/Posts/PostId/813/faces-of-phia-episode-6-tech-talk-with-hemantPodcastsThu, 17 Jan 2019 18:18:46 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/r4D2kOLvxto" width="560"></iframe></p> <div class="style-scope ytd-expander" id="content"> <div class="style-scope ytd-video-secondary-info-renderer" slot="content">&nbsp;</div> <div class="style-scope ytd-video-secondary-info-renderer" id="description" slot="content"><yt-formatted-string class="content style-scope ytd-video-secondary-info-renderer" split-lines="">Sit down, turn the volume up, and enjoy as Ron and Brady discuss with our latest Face of Phia &ndash; Hemant Dua &ndash; data, robots, and how technology is impacting healthcare, health plans, and The Phia Group&rsquo;s own efforts to empower plans. Tune in, or you&rsquo;ll be stuck in the stone age!</yt-formatted-string></div> <div class="style-scope ytd-video-secondary-info-renderer" slot="content">&nbsp;</div> <div class="style-scope ytd-video-secondary-info-renderer" slot="content"> <p style="text-align: justify;"><a href="https://www.youtube.com/watch?v=r4D2kOLvxto&amp;feature=youtu.be">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/IDSTJ0ZaEDQ">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> </div> </div> 813The Affordable Care Act in 2019: A Look Aheadhttps://www.phiagroup.com/Media/Posts/PostId/811/the-affordable-care-act-in-2019-a-look-aheadWebinarsWed, 16 Jan 2019 16:56:43 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/KZd0xKlYSJw" width="560"></iframe></p> <p style="text-align: justify;">This year, we mark the ninth anniversary of the healthcare law that transformed our industry. The Affordable Care Act has been under assault from the White House, from Congress, and now, it has been declared unconstitutional by a federal court. Despite the embattled state of the ACA, the Trump administration has set an agenda for the ACA's implementation this year, and it remains the law of the land. In this webinar, The Phia Group's legal team will explore the many legal and political battles that threaten the ACA's existence while covering those key provisions that have changed, those that have remained the same, and everything in between.</p> <p><a href="https://youtu.be/KZd0xKlYSJw">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 811Faces of Phia: Episode 5 – Setting the Pace with Tori: Help me Tori!https://www.phiagroup.com/Media/Posts/PostId/809/faces-of-phia-episode-5-setting-the-pace-with-tori-help-me-toriPodcastsMon, 14 Jan 2019 15:39:04 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/IDSTJ0ZaEDQ" width="560"></iframe></p> <p style="text-align: justify;">In this most recent episode, Tori Pace &ndash; another Phia superstar &ndash; shares experiences working with each department, what she&rsquo;s learned from these experiences, and campaigns for a regular seat on the show.</p> <p style="text-align: justify;"><a href="https://youtu.be/IDSTJ0ZaEDQ">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/IDSTJ0ZaEDQ">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 809Empowering Plans: P62 - Obamacare is Still the Law, Right?https://www.phiagroup.com/Media/Posts/PostId/808/empowering-plans-p62-obamacare-is-still-the-law-rightPodcastsThu, 10 Jan 2019 14:39:11 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/TztFzldPhAw" width="560"></iframe></p> <p>Ron and Brady dissect the Texas decision that challenges the legality of the ACA, what it actually means, and what is next &ndash; as well as what you could (should?) be doing now.</p> <p><a href="https://youtu.be/TztFzldPhAw">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/TztFzldPhAw">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 808The Phia Group's 1st Quarter 2019 Newsletter https://www.phiagroup.com/Media/Posts/PostId/807/the-phia-groups-1st-quarter-2019-newsletterNewslettersWed, 09 Jan 2019 16:02:51 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/Newsletter%202019%20Q1/header2019.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/icons5.jpg" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p1"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b14qtr18.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Newsletter%202019%20Q1/b24qtr19.png" 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="53%"><br /> <img height="304" src="/Portals/phiagroup/Newsletter%202018%20Q2/adam.jpg" width="300" /></td> <td valign="top" width="47%"> <p class="bodytext"><br /> <span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">With 2018 in the rear view, it&#39;s important that we look back at such a historical year, while also moving forward to fine-tune our focus here at The Phia Group. In 2019, we will hone in on the highest priorities on behalf of our industry, to make certain that the momentum of innovation continues on. All of you must begin to empower your benefit plans. Healthcare has been, and continues to be the number one issue when discussing politics, law, and the economy. It is important to stay aware of change and the most cutting edge options, while also addressing each employer&rsquo;s unique attributes and specific needs. We must create an understanding of what the best administrators are offering, so that we can in turn identify the best options for your benefit plan and all parties involved. Make it your resolution to understand the various types of plan components that are needed to stay competitive, while maximizing benefits and minimizing costs. I truly believe, we here at The Phia Group, have the tools to empower you to take control of your plan. Happy reading!</p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </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%202018%20Q2/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: Independent Consultation &amp; Evaluation (ICE)</a><br /> <a href="#p3">Phia Group Case Study: Subrogation</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2019 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p11">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a name="p1"></a> <p>&nbsp;</p> <p class="heading1"><strong><span style="font-size:12px;">Service Focus of the Quarter: Independent Consultation &amp; Evaluation (ICE)</span></strong></p> <p class="bodytext" style="text-align: justify;">Here at The Phia Group, we are not a TPA, but we know TPAs like the back of our hand. That is 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 potential 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 involved in 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 cannot?</p> <p class="bodytext" style="text-align: justify;">Enter The Phia Group&rsquo;s ICE service. We are experts in the law related to health benefit offerings, and we know plan documents like Tom Brady knows a pigskin. ICE was created to ensure that health plans and the TPAs that work with them have a resource to tap when things get hairy &ndash; and since it is billed on a predictable PEPM rate, rather than on an hourly basis, it is affordable and accessible, and there are no surprises.</p> <p class="bodytext" style="text-align: justify;">Contact our Vice President of Sales &amp; Marketing Tim Callender, to learn more. Tim can be reached at 781-535-5631 or tcallender@phiagroup.com.</p> <p class="bodytext">&nbsp;</p> <a id="p3" name="p3"></a> <p class="bodytext"><strong>Phia Case Study: Subrogation</strong></p> <p class="bodytext" style="text-align: justify;">A TPA client of The Phia Group had been unable to resolve a $62,000 lien with the patient&rsquo;s attorney. The patient was in a motor vehicle accident, and subsequently retained an attorney to pursue the other driver for damages. The Plan Administrator attempted to place the attorney on notice of the plan&rsquo;s right to reimbursement, but received no response whatsoever from the attorney, despite numerous letters and phone calls. The TPA had given up, and mentioned this failed recovery to one of The Phia Group&rsquo;s attorneys in passing, who promptly volunteered that we would revive this file for them and attempt a recovery.</p> <p class="bodytext" style="text-align: justify;">The Phia Group essentially started over by sending letters and calling the attorney, which again garnered no responses, as expected. The Phia Group&rsquo;s legal team elected to take a different approach: after researching state law and decisions rendered by the state&rsquo;s bar association, The Phia Group&rsquo;s next correspondence focused on the attorney&rsquo;s own ethical obligations, rather than only the patient&rsquo;s reimbursement obligations.</p> <p class="bodytext" style="text-align: justify;">The Phia Group not only received a prompt (and somewhat repentant) response from the attorney, but secured an agreement signed by the attorney to hold all settlement proceeds in trust and to honor the health plan&rsquo;s rights in full. About two years later, the TPA recovered 90% of its lien.</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> _ <p>&nbsp;</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Whether You Are A Fiduciary! </strong></p> <a id="p12" name="p12"></a> <p class="bodytext" style="text-align: justify;">Simply put, federal law provides that with very limited exceptions, entities acting as fiduciaries may not disclaim such a designation. The law is fairly straightforward when it provides that &ldquo;&hellip;any provision in an agreement or instrument which purports to relieve a fiduciary from responsibility or liability for any responsibility, obligation, or duty under this part shall be void as against public policy.&rdquo; To elaborate on that, the U.S. Supreme Court has stated that, &ldquo;not only the persons named as fiduciaries by a benefit plan&hellip;but also anyone else who exercises discretionary control or authority over the plan&#39;s management, administration, or assets, is an ERISA fiduciary.&rdquo;</p> <p class="bodytext" style="text-align: justify;">Keep in mind, however, that the fact that an entity such as a TPA may be a fiduciary, under the reasoning spelled out above, does not necessarily mean that the TPA has breached a fiduciary duty when/if a breach occurs.</p> <p class="bodytext" style="text-align: justify;">Fiduciary status is determined on a case-by-case basis; the courts have been clear that fiduciary status is triggered by the exercise of any discretionary authority over the management of a plan&rsquo;s disposition of its assets. Practically speaking, the main purpose of fiduciary duties is money; the U.S. Court of Appeals for the Sixth Circuit has summed it up very well by noting that &ldquo;[a]n entity such as a third-party administrator becomes an ERISA fiduciary when it exercises practical control over an ERISA plan&rsquo;s money.&rdquo;</p> <p class="bodytext" style="text-align: justify;">If you control money, you owe fiduciary duties to the beneficiaries or potential beneficiaries of that money. So&hellip;be careful! Consult a neutral third-party expert when you face difficult claims or benefits decisions.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Success Story of the Quarter: Independent Consulting &amp; Evaluation (ICE)</strong></p> <p class="bodytext" style="text-align: justify;">A third-party administrator presented The Phia Group with the facts of a situation wherein one of their incoming groups, previously serviced by another administrator, had a great deal of antiquated and weak language in its Plan Document. Erin Hussey, an attorney at The Phia Group, reviewed the Plan and noticed particular issues within its &ldquo;eligibility&rdquo; section.</p> <p class="bodytext" style="text-align: justify;">The first issue Erin spotted was language that incentivized Medicare-eligible employees to not enroll in their group health plan, and to enroll in Medicare instead. Erin noted that this provision was in violation of the Medicare Secondary Payer Act (&ldquo;MSP&rdquo;), which explicitly prohibits such incentives.</p> <p class="bodytext" style="text-align: justify;">Second, the Plan Document explained that retiree coverage was not offered to non-executive employees. Erin noticed that this may run afoul of &sect;105(h) non-discrimination rules; these rules prohibit group health plans from treating highly-compensated individuals (&ldquo;HCIs&rdquo;) more favorably than non-HCIs. Therefore, by providing retiree coverage to only executives (who are far more likely to be HCIs), this language seemed to violate the 105(h) rules.</p> <p class="bodytext" style="text-align: justify;">Erin communicated these findings to The Phia Group&rsquo;s client, who was understandably concerned with the language issues. Erin explained the applicable law, the TPA&rsquo;s responsibilities, and potential issues and penalties that could arise, and she provided a set of best practices for the TPA to follow in such circumstances. Based on the information Erin imparted, The Phia Group&rsquo;s client was able to work with the employer group to correct the language and avoid likely MSP and 105(h) penalties in the face of a federal government that has been cracking down on violations of federal law such as these.</p> <p class="bodytext" style="text-align: justify;">This is a perfect example of a way that health plans can avoid problems before they arise! The Phia Group&rsquo;s ICE service helps TPAs, plans, and brokers with issues with claims, appeals, and other concrete issues &ndash; but where ICE can help the most is by preventing tough problems before they arise!<br /> &nbsp;</p> <p>&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; A Conflict of Intent: Why We Can&rsquo;t Achieve a Meeting of the Minds on Healthcare &ndash; December 12, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/The Modernization of Health Savings Accounts by Krista J_ Maschinot.pdf" target="_blank">The Modernization of Health Savings Accounts</a> &ndash; December 3, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Free Market Healthcare Solutions &ndash; <a href="https://issuu.com/fidelispublish/docs/solutions_11_18_final?e=13880229/66092603" target="_blank">Prescription Drug Prices Bridge a Divided Electorate in Election Season</a> &ndash; November 28, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; <a href="http://www2.philly.com/philly/health/health-cents/turn-breech-baby-sweet-olive-oil-charge-medical-bill-20181119.html">Dialysis Providers Withstand Regulatory Haymaker</a> &ndash; November 26, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; The Inquirer: <a href="https://moneyinc.com/dialysis-providers-withstand-regulatory-haymaker" target="_blank">Daily Philly News &ndash; Main Line Hospital Charges $63 for Olive Oil Used to Turn a Breech Baby</a> &ndash; November 20, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Don't Let Your Loas Leave You DOA_ PART II - States Speak Up! by Kelly E_ Dempsey.pdf" target="_blank">Don&#39;t Let Your Loss Leave You DOA: Part II - States Speak Up!</a> &ndash; November 2, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Explanations That Benefit.pdf" target="_blank">Explanations That Benefit</a> &ndash; October 4, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; <a href="https://moneyinc.com/why-does-reform-always-seem-to-favor-the-wrongdoer">Why Does Reform Always Seem to Favor the Wrongdoer?</a> &ndash; October 1, 2018</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/801/a-texas-judge-rules-aca-unconstitutional-our-take" target="_blank">A Texas Judge Strikes Down Obamacare &ndash; Our Take</a>. Don&rsquo;t miss out on this great blog post!</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/794/you-down-with-rbp-you-may-already-be" target="_blank">You Down with RBP? (You May Already Be!)</a> Reference-based pricing is one of the most mysterious self-funding structures out there.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/786/osha-publishes-guidance-on-post-accident-drug-testing" target="_blank">OSHA Publishes Guidance on Post-Accident Drug Testing.</a> Here&rsquo;s an explanation to these requirements and how they apply to particular circumstances.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/784/healthcare-on-the-ballot-and-a-free-side-of-fries" target="_blank">Healthcare on the Ballot, and a Free Side of Fries!</a> Let&rsquo;s take a step back and assess the big picture.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/772/is-your-life-insurance-policy-subject-to-erisa" target="_blank">Is Your Life Insurance Policy Subject to ERISA?</a> You may think this is a ridiculous question; however, Plan Sponsors and employers may want to reconsider this inquiry in light of a recent Seventh Circuit ruling...</p> <p class="bodytext" style="text-align: justify;">&nbsp;</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">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;"><a href="https://register.gotowebinar.com/register/8354714256140621827">Click HERE to Register!</a></p> <p class="bodytext" style="text-align: justify;">&bull; On December 12, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/799/what-to-expect-in-2019-part-2" target="_blank">What to Expect in 2019 &ndash; Part 2</a>,&rdquo; where we discussed current industry happenings and our predictions to help you look forward to the coming year.</p> <p class="bodytext" style="text-align: justify;">&bull; On November 13, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/785/what-to-expect-in-2019-part-1" target="_blank">What to Expect in 2019 - Part 1</a>,&rdquo; where we discussed current industry happenings and our predictions to help you look forward to the coming year.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 18, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/778/specialty-drugs-trends-and-issues-affecting-self-funded-plans" target="_blank">Specialty Drugs: Trends and Issues Affecting Self-Funded Plans</a>,&rdquo; where we discussed the rising costs of specialty drugs.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:Featuring Video Podcasts!</span></p> <p class="bodytext" style="text-align: justify;">&bull; On November 20, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/789/empowering-plans-p60-politics-with-brady" target="_blank">Politics With Brady</a>,&rdquo; where Brady and Ron analyze the recent election results, and determine how they will impact the health benefits and health care industries.</p> <p class="bodytext" style="text-align: justify;">&bull; On November 16, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/788/empowering-plans-p59-talkin-with-tpac" target="_blank">Talkin&rsquo; with TPAC</a>,&rdquo; where our hosts, Ron and Brady, enjoy chatting with Michael Meloch, President of TPAC Underwriters and valued member of The Phia Group&rsquo;s own advisory board</p> <p class="bodytext" style="text-align: justify;">&bull; On November 1, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/783/empowering-plans-p58-special-edition-talking-politics-elections-and-healthcare" target="_blank">Special Edition: Talking Politics, Elections, and Healthcare</a>,&rdquo; where our hosts discuss healthcare on the ballot.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 22, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/779/empowering-plans-p57-ahps-will-they-live-up-to-the-hype" target="_blank">AHPs: Will They Live Up to the Hype</a>,&rdquo; where our hosts discuss the benefits and hurdles the final rules have created for these new AHPs.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 15, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/775/empowering-plans-p56-2019-fly-ball-or-home-run" target="_blank">2019 - Fly Ball or Home Run</a>,&rdquo; where Ron and Adam discuss the many issues, changes and challenges 2018 has lined up for 2019.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 1, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/771/empowering-plans-p55-learn-from-the-past-to-shape-the-future" target="_blank">Learn from the Past to Shape the Future</a>,&rdquo; where our hosts sit down with industry legend and innovative leader, Jerry Castelloe of Castelloe Partners.</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="heading1">&nbsp;</p> <p class="heading1">Face of Phia</p> <p class="bodytext" style="text-align: justify;">&bull; On November 29, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/795/faces-of-phia-episode-3-flying-high-with-judy" target="_blank">Flying High with Judy</a>,&rdquo; where Ron and Adam sit down with a member of The Phia Group&rsquo;s Customer Service team, Judith McNeil.</p> <p class="bodytext" style="text-align: justify;">&bull; On November 16, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/787/faces-of-phia-episode-2-not-your-norma-l-employee" target="_blank">Not Your &ldquo;Norma-l&rdquo; Employee</a>,&rdquo; where our hosts, Adam Russo and Ron Peck, sit down with a member of The Phia Group&rsquo;s Accounting team, Norma Phillips.</p> <p class="bodytext" style="text-align: justify;">&bull; On October 24, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/780/faces-of-phia-episode-1-a-chat-with-matt" target="_blank">A Chat With Matt</a>,&rdquo; where Adam Russo and Ron Peck sit down with The Phia Group&rsquo;s Marketing &amp; Accounts Manager, Matthew Painten.</p> <p class="bodytext" style="text-align: center;"><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/itunes.png" style="width: 251px; height: 78px;" title="" /></a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2019 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2019 charity is the Boys &amp; Girls Club of Brockton.</p> <p><img src="/Portals/phiagroup/Newsletter%202018%20Q2/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.</p> <p>&nbsp;</p> <p class="bodytext"><strong>Thanksgiving &ndash; A Special Delivery</strong></p> <p><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/Thanksgiving%202018.jpg" style="width: 400px; height: 250px;" title="" /></p> <p class="bodytext" style="text-align: justify;">On Wednesday, November 21st, the Phia family went out to our local grocery store and purchased a total of 20 Thanksgiving dinners for the families of The Boys &amp; Girls Club of Brockton. Once we loaded them up in our cars, we personally delivered them to the families. Words cannot express the feeling we got when we saw the looks on those families&rsquo; faces.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Christmas Tree Angel</strong></p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/xmass.jpg" style="width: 500px; height: 450px;" title="" /></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 Boys &amp; Girls Club of Brockton. This year we had over 100 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> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Unwrapping Christmas</strong></p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/xmass2.jpg" style="width: 600px; height: 450px;" title="" /></p> <p class="bodytext" style="text-align: justify;">Santa and his elves made a surprise visit to the Boys &amp; Girls Club of Brockton, one week before Christmas. Santa had sent a special elf to the Boys &amp; Girls Club a couple of weeks prior to their visit to ask each child what they wanted most for Christmas. Santa and his elves gave out over 100 gifts to these amazing and talented children. We love giving gifts, but we really love receiving those smiles in return. &nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">The Modernization of Health Savings Accounts</p> <p class="bodytext" style="font-weight: normal">By: Krista J. Maschinot, Esq. &ndash; December 2018 &ndash; <a href="https://www.sipconline.net/files/The%20Modernization%20of%20Health%20Savings%20Accounts%20by%20Krista%20J_%20Maschinot.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">HSAs are highly regulated, tax-exempt savings accounts that both individuals and employers may contribute to on behalf of individuals covered by certain high-deductible health plans (HDHPs). These accounts are designed to help individuals set aside funds to be used for the qualified medical expenses of the individuals, their spouses, and their tax dependents. Unlike flexible spending accounts (FSAs), HSAs are not subject to mandatory &ldquo;use it or lose it rules&rdquo; and while FSAs are not portable, HSAs are portable as they are owned by the individual, not the employer, and can follow the individual as he or she changes jobs similar to a 401(k) or an individual retirement account (IRA). HSAs can be invested similar to a retirement account and have the ability to grow over time making them a valuable retirement vehicle. They are funded on a pretax basis through a cafeteria plan and result in a triple tax savings for the individual as they are funded with pretax dollars, grow tax-free, and are not taxed upon withdrawal so long as they are used to pay for qualified medical expenses.</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/805/the-stacks-1st-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p><br /> <span class="bodytext"><strong>Don&#39;t Let Your Loss Leave You DOA: Part II - States Speak Up! </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Kelly E.Dempsey, Esq. &ndash; November 2018 &ndash; <a href="https://www.sipconline.net/files/Don't%20Let%20Your%20Loas%20Leave%20You%20DOA_%20PART%20II%20-%20States%20Speak%20Up!%20by%20Kelly%20E_%20Dempsey.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Remember that scenario from Spring of 2017 where an employer was attempting to do right by an employee and offered a continuation of coverage during an employer-approved leave of absence? If not, let&rsquo;s quickly refresh our memories.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">An employer&rsquo;s long-time trusted employee had a stroke of bad luck and was diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. As the employee&rsquo;s treatment plan became more aggressive, the employee ultimately needed to take a leave of absence &ndash; but leave under The Family and Medical Leave Act (FMLA) was exhausted due to the employee&rsquo;s recent addition of a new baby. The employer subsequently continued to provide coverage, pursuant to 2016 guidance issued by the United States Equal Employment Opportunity Commission regarding employer-provided leave in accordance with The Americans with Disabilities Act (ADA).</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/805/the-stacks-1st-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p>&nbsp;</p> <p class="bodytext"><strong>Explanations That Benefit</strong></p> <p class="bodytext">By: Jon Jablon, Esq. &ndash; October 2018 &ndash; <a href="https://www.sipconline.net/files/Explanations%20That%20Benefit.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="text-align: justify;">In the course of working with many different third-party administrators, it has become clear that every TPA operates differently. Claims processes are no exception; although federal law prescribes certain rules and regulations for the basics of what must be done and how, TPAs and health plans are left to their own devices to figure out the nuts and bolts of their particular processes. The only real requirement is that those processes fit in with the regulators&rsquo; rules and vision for how the industry should operate.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/805/the-stacks-1st-quarter-2019" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a>Phia&rsquo;s Q4 Speaking Events:</p> <p class="bodytext"><strong>Phia&rsquo;s Speaking Engagements:</strong><br /> <br /> &bull; 1/9/2019 &ndash; FMMA Conference &ndash; Austin, TX</p> <p class="bodytext">&bull; 2/27/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Denver, CO</p> <p class="bodytext">&bull; 3/8/2019 &ndash; UnitedAg Conference &ndash; Anaheim, CA</p> <p class="bodytext">&bull; 3/21/2019 &ndash; CGI Business Solutions Seminar &ndash; Woburn, MA</p> <p class="bodytext">&bull; 3/26/2019 &ndash; HFTA Broker Meeting &ndash; Tyler, TX</p> <p class="bodytext">&bull; 4/3/2019 &ndash; BenefitsPRO Broker Expo &ndash; Miami, FL</p> <p class="bodytext">&bull; 4/5/2019 &ndash; Pareto Conference &ndash; Nashville, TN</p> <p class="bodytext">&bull; 4/7/2019 &ndash; Captive Symposium &ndash; Cayman Islands</p> <p class="bodytext">&bull; 4/11/2019 &ndash; FMMA Conference &ndash; Dallas, TX</p> <p class="bodytext">&bull; 4/24/2019 &ndash; Sunlife 2019 MVP Academy &ndash; Kansas City, MO</p> <p class="bodytext">&bull; 4/25/2019 &ndash; Best Practices Workshop &ndash; Orlando, FL</p> <p class="bodytext">&bull; 5/30/2019 &ndash; Contrarian Captive &ndash; Austin, TX</p> <p class="bodytext">&bull; 6/11/2019 &ndash; Leavitt Conference &ndash; Big Sky, MT</p> <p class="bodytext">&bull; 7/31/2019 &ndash; 2019 MVP Academy &ndash; Wellesley, MA</p> <p class="bodytext">&bull; 8/24/2019 &ndash; Well Health Workshop &ndash; Chicago, IL</p> <p class="bodytext">&bull; 10/27/2019 &ndash; 2019 Annual NASP Conference &ndash; Washington DC</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employee of the Quarter:<br /> Philip Qualo</span></p> <p class="bodytext">Congratulations to Philip Qualo, The Phia Group&rsquo;s Q4 2018 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;">Since he started just over 6 months ago, Philip has proven himself instrumental to our compliance team. He has shown a passion for and commitment to ensuring that our company remains compliant with state and federal laws as we have continued to grow and thus become subject to new and increasingly complex regulations. In particular, he played a lead role in updating and revising our Employee Handbook, even tackling the rather arduous process of researching state law and creating supplements for each of the 11 states in which we now have remote employees. In addition to internal compliance efforts, Philip has produced high-quality consulting work for our clients. Successfully functioning in a dual-role is never easy for a new employee, especially when those roles involve sensitive human resources and compliance matters. Philip has performed admirably, and for that, he has earned our trust, and earned my Passion Award nomination.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/empyear.jpg" style="width: 400px; height: 250px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">Congratulations Philip and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employee of the Year:<br /> Brady Bizarro</span></p> <p class="bodytext" style="text-align: justify;">Congratulations to Brady Bizarro, The Phia Group&rsquo;s 2018 Employee of the Year!</p> <p class="bodytext" style="text-align: justify;">Brady has made his mark here at The Phia Group. Between traveling, speaking on our webinars and gracing industry leaders with his knowledge of politics and D.C. happenings at conferences around the United States, we would like to thank him for all that he has done. You truly exemplify what Phia employees should strive to be.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/1500.jpg" style="width: 381px; height: 264px;" title="" /></p> &nbsp; <p class="bodytext">Congratulations Brady and thank you for your many current and future contributions.&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a>Phia News</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Announcement of SIIA&rsquo;s Next Chairman</strong></p> <p class="bodytext" style="text-align: justify;">Adam V. Russo, CEO of The Phia Group, will serve as the chairman of SIIA&rsquo;s board of directors. Adam has been a long-time active SIIA member and will be concluding five years of service as a director. Congratulations to Adam and thank you for all fo the hard you and dedication.</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/adam9.jpg" style="width: 379px; height: 358px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>A Phia Halloween</strong></p> <p class="bodytext" style="text-align: justify;">How great are these costumes? This year, the Phia Halloween Costume Contest was truly a nail-biter. Who would win? Rafiki? The clown? The fan favorite &ldquo;Gambina the Unicorn riding Sprinkles the Unicorn,&rdquo; bravely worn by Gambit Hunt, ultimately took home the gold. Thank you to all who participated, you truly made it a stellar Halloween!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/costume6.jpg" style="width: 500px; height: 333px;" title="" /></p> <a id="pcert" name="pcert"></a> <p class="bodytext"><strong>Ugly Sweater Contest</strong></p> <p class="bodytext" style="text-align: justify;">Our Phia Family is so festive! Our &ldquo;Ugly Sweater Day&rdquo; was a hit and we thank all those who participated; congratulations to Norma (pictured below sporting a green and red number, with gold shoulders) for winning &ldquo;Ugliest Sweater&rdquo;!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202019%20Q1/costume7.jpg" style="width: 403px; height: 284px;" title="" /></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p><span class="boldtext">Job Opportunities:</span></p> <p>&bull; Accounting Manager</p> <p>&bull; Staff Attorney, Provider Relations</p> <p>&bull; Case Investigator I</p> <p>&bull; Claims Analyst</p> <p>&bull; Health Benefit Plan Drafter</p> <ul class="bodytext"> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Promotions </strong><br /> <br /> &bull; Ekta Gupta was promoted from ETL Specialist to Manager, Data Services Group</p> <p class="bodytext">&bull; Gambit Hunt was promoted from Sales Coordinator to Sales Executive</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> &bull; Tammy Tran was hired as an Accounts Payable Coordinator</p> <p class="bodytext">&bull; Christina Veneto was hired as a Talent Acquisition Specialist</p> <p class="bodytext">&bull; Brittany Grueter was hired as a Case Investigator I</p> <p class="bodytext">&bull; Elise Mulready was hired as a Claim and Case Support Analyst</p> <p class="bodytext">&bull; Nicholas Bonds was hired as a Health Benefit Plan Admin - Attorney I</p> <p class="bodytext">&bull; Danijela Stanic was hired as a Health Benefit Plan Consultant I</p> <p class="bodytext">&bull; Michael Vaz was hired as a Sales and Accounts Coordinator</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/footerlogo.png" 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> 807Faces of Phia: Episode 4 – Dishing with Delaneyhttps://www.phiagroup.com/Media/Posts/PostId/806/faces-of-phia-episode-4-dishing-with-delaneyPodcastsMon, 07 Jan 2019 18:58:51 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/GR6q157rdVM" width="560"></iframe></p> <p style="text-align: justify;">Take a moment to meet Katie Delaney, Phia&#39;s Senior Training &amp; Development Specialist who has been with the company since 2007.&nbsp; Responsible for training employees, you can thank Katie anytime a team member succeeds.&nbsp; Really?&nbsp; Listen to learn how we got to this point!</p> <p style="text-align: justify;"><a href="https://youtu.be/GR6q157rdVM">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/GR6q157rdVM">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 806The Stacks - 1st Quarter 2019https://www.phiagroup.com/Media/Posts/PostId/805/the-stacks-1st-quarter-2019NewslettersMon, 07 Jan 2019 16:32:44 GMT<h1 style="text-align: justify;">The Modernization of Health Savings Accounts</h1> <h3 style="text-align: justify;"><span style="color:#28166F;"><em>By: Krista Maschinot, Esq.</em></span></h3> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;">Health Savings Accounts (HSAs) were originally introduced as part of the Medicare Prescription Drug, Improvement, and Modernization Act that was signed into law by President George W. Bush on December 8, 2003.&nbsp; While the contribution amounts have increased gradually since this time, no other significant changes have occurred.&nbsp; Congress is addressing this issue and attempting to help individuals and families afford the ever increasing medical expenses plaguing the United States.</p> <p style="text-align: justify;">HSAs are highly regulated, tax-exempt savings accounts that both individuals and employers may contribute to on behalf of individuals covered by certain high-deductible health plans (HDHPs).&nbsp; &nbsp;These accounts are designed to help individuals set aside funds to be used for the qualified medical expenses of the individuals, their spouses, and their tax dependents. &nbsp;Unlike flexible spending accounts (FSAs), HSAs are not subject to mandatory &ldquo;use it or lose it rules&rdquo; and while FSAs are not portable, HSAs are portable as they are owned by the individual, not the employer, and can follow the individual as he or she changes jobs similar to a 401(k) or an individual retirement account (IRA).&nbsp; HSAs can be invested similar to a retirement account and have the ability to grow over time making them a valuable retirement vehicle. &nbsp;They are funded on a pretax basis through a cafeteria plan and result in a triple tax savings for the individual as they are funded with pretax dollars, grow tax-free, and are not taxed upon withdrawal so long as they are used to pay for qualified medical expenses.</p> <p style="text-align: justify;">The House of Representatives passed <a href="https://www.congress.gov/bill/115th-congress/house-bill/6199">the Restoring Access to Medication and Modernizing Health Savings Account Act of 2018 (HR 6199)</a> and the <a href="https://www.congress.gov/bill/115th-congress/house-bill/6311">Increasing Access to Lower Premium Plans and Expanding Health Savings Accounts Act of 2018 (HR 6311)</a> on July 25, 2018.&nbsp;&nbsp; As the names imply, the bills focus on updating and modernizing the current laws surrounding the use of Health Savings Accounts (HSAs).&nbsp; These updates include increasing the contribution limits for both individuals and families, expanding coverage to include qualified medical expenses that were previously omitted, and allowing for direct primary care physician arrangements to be accessed by individuals covered under an HDHP.</p> <p style="text-align: justify;"><em>Contribution limits increased</em></p> <p style="text-align: justify;">For 2018, the contribution limit (for employer and employee combined) for an individual is $3,450, while the limit for a family is $6,900 (increased from the original $2,600 for individuals and $5,150 for families).&nbsp; One modernization that HR 6311 will make is to increase to the contribution limits for individuals and families to $6,900 and $13,300 respectively.&nbsp; These amounts are the current annual limits on deductibles and out-of-pocket expenses for HSA-eligible HDHPs.&nbsp; In addition, individuals with HSA-qualifying family coverage who were previously deemed ineligible due to their spouse being enrolled in a medical FSA will now be permitted to contribute to an HSA.</p> <p style="text-align: justify;"><em>Coverage expanded</em></p> <p style="text-align: justify;">Under the current law, the funds in an HSA may only be used to pay for qualified medical expenses pursuant to <a href="https://www.law.cornell.edu/uscode/text/26/213">IRC Section 213(d)</a>, which include amounts paid:</p> <p style="margin-left: 0.5in; text-align: justify;">&ldquo;(A) for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body, <a name="d_1_B"></a></p> <p style="margin-left: 0.5in; text-align: justify;">(B) for transportation primarily for and essential to <a href="https://www.law.cornell.edu/definitions/uscode.php?width=840&amp;height=800&amp;iframe=true&amp;def_id=26-USC-858604352-1572829759&amp;term_occur=4&amp;term_src=title:26:subtitle:A:chapter:1:subchapter:B:part:VII:section:213" title="medical care">medical care</a> referred to in subparagraph (A), <a name="d_1_C"></a></p> <p style="margin-left: 0.5in; text-align: justify;">(C) for <a href="https://www.law.cornell.edu/definitions/uscode.php?width=840&amp;height=800&amp;iframe=true&amp;def_id=26-USC-787077958-1368498130&amp;term_occur=5&amp;term_src=title:26:subtitle:A:chapter:1:subchapter:B:part:VII:section:213" title="qualified long-term care services">qualified long-term care services</a> (as defined in <a href="https://www.law.cornell.edu/uscode/text/26/7702B#c" title="section 7702B(c)">section 7702B(c)</a>), or <a name="d_1_D"></a></p> <p style="margin-left: 0.5in; text-align: justify;">(D) for insurance (including amounts paid as premiums under part B of title XVIII of the Social <a href="https://www.law.cornell.edu/definitions/uscode.php?width=840&amp;height=800&amp;iframe=true&amp;def_id=26-USC-949122880-1979629537&amp;term_occur=56&amp;term_src=title:26:subtitle:A:chapter:1:subchapter:B:part:VII:section:213" title="Security">Security</a> Act, relating to supplementary medical insurance for the aged) covering <a href="https://www.law.cornell.edu/definitions/uscode.php?width=840&amp;height=800&amp;iframe=true&amp;def_id=26-USC-858604352-1572829759&amp;term_occur=5&amp;term_src=title:26:subtitle:A:chapter:1:subchapter:B:part:VII:section:213" title="medical care">medical care</a> referred to in subparagraphs (A) and (B) or for any qualified long-term care insurance contract (as defined in <a href="https://www.law.cornell.edu/uscode/text/26/7702B#b" title="section 7702B(b)">section 7702B(b)</a>).</p> <p style="margin-left: 0.5in; text-align: justify;">In the case of a <a href="https://www.law.cornell.edu/definitions/uscode.php?width=840&amp;height=800&amp;iframe=true&amp;def_id=26-USC-1032824960-1164215541&amp;term_occur=3&amp;term_src=title:26:subtitle:A:chapter:1:subchapter:B:part:VII:section:213" title="qualified long-term care insurance contract">qualified long-term care insurance contract</a> (as defined in <a href="https://www.law.cornell.edu/uscode/text/26/7702B#b" title="section 7702B(b)">section 7702B(b)</a>), only eligible long-term care premiums (as defined in paragraph (10)) shall be taken into account under subparagraph (D).&rdquo;</p> <p style="text-align: justify;"><a name="d_2"></a>HR 6199 further expands the permissible eligible expenditures to also include gym memberships and certain physical exercise programs (up to $500 for individual and $1,000 for family) along with feminine care products and other over-the-counter medical products.</p> <p style="text-align: justify;"><em>Direct Primary Care permitted</em></p> <p style="text-align: justify;">A Direct Primary Care service arrangement (DPC) is an alternative to a tradition health care plan wherein individuals pay a flat fee each month, similar to a membership fee, to a primary care physician that covers all of the individual&rsquo;s primary care service needs.&nbsp; For services that are outside the realm of primary care, additional fees will apply.&nbsp; At the current time, individuals cannot use their HSA funds to pay for the DPC monthly fee as they do not qualify as medical expenses under IRC Section 213(d).</p> <p style="text-align: justify;">Other issues surrounding DPC arrangements include the fact that when a DPC is offered outside of the employer&rsquo;s health plan it is considered to be a second health plan and impermissible other coverage as Section 223(c) of the Internal Revenue Code (IRC) states:</p> <p style="margin-left: 0.5in; text-align: justify;">&ldquo;[S]uch individual is not, while covered under a high deductible health plan, covered under any health plan-</p> <ul> <li style="text-align: justify;">which is not a high deductible health plan, and</li> <li style="text-align: justify;">which provides coverage for any benefit which is covered under the high deductible health plan.&rdquo;</li> </ul> <p style="text-align: justify;">As a result of this Code section, individuals are not permitted to be covered under an HDHP and to also be offered other coverage, include a DPC, outside of the employer&rsquo;s self-funded health plan as (1) a DPC is not an HDHP and (2) a DPC offers benefits that are already covered under the employer&rsquo;s HDHP. &nbsp;Further, individuals are not permitted to use their HSA funds for services related to DPCs, as DPCs are considered to be health plans and use of such funds would be deemed impermissible other coverage.</p> <p style="text-align: justify;">If the DPC is a benefit under the employer&rsquo;s self-funded health plan, the following consideration applies. An HDHP is not permitted to provide any first dollar coverage for benefits until a minimum deductible has been satisfied with the exception of preventive care services. Since the services provided by DPCs and other primary care physicians are not always considered preventive care, there will be times where the patient&#39;s care is still subject to the deductible. As a DPC does not typically include a fee for service, there is no fee to apply to the deductible which is problematic.</p> <p style="text-align: justify;">If enacted, HR 6311 will help solve the issues surrounding the ability of DPCs to be used along with HSA-eligible HDHPs.&nbsp; Specifically, it would permit DPC service arrangements to no longer be treated as health plans, thus no longer disqualifying an individual from contributing to an HSA.&nbsp; Additionally, the monthly DPC fees would qualify as medical expenses, meaning individuals would be permitted to use their HSA funds to pay for such fees (with a cap of $150 per individual and $300 per family per month).&nbsp;</p> <p style="text-align: justify;"><em>Other changes</em></p> <p style="text-align: justify;">The bills, again, if enacted, would also:</p> <ul> <li style="text-align: justify;">Allow up to $250 for individuals and $500 for families to be covered for non-preventive services under HDHPs;</li> <li style="text-align: justify;">Permit the use of employment-related health services and employer sponsored onsite medical clinics for limited use without violating HSA eligibility restrictions;</li> <li style="text-align: justify;">Allow for rollovers of health FSA balances from year to you (up to three times the contribution limit);</li> <li style="text-align: justify;">Allow for transfers of up to $2,650 for individuals and $5,300 for families from FSAs and HRAs to HSAs when enrolling in a qualifying high-deductible health plan with an HSA;</li> <li style="text-align: justify;">Allow spouses to make annual catch-up contributions of up to $1,000 to an HSA; and</li> <li style="text-align: justify;">Permit working seniors currently enrolled in Medicare Part A to contribute to an HAS when covered by a qualifying HDHP.</li> </ul> <p style="text-align: justify;">While these bills passed the House in July of this year, there has been no action on either in the Senate and December is quickly approaching.&nbsp; As the tax advantages offered in each are beneficial to both employees and employers, employers should monitor the bills as the year comes to a close.</p> <p>_________________________________________________________________________________________________________</p> <h1 style="text-align: justify;">Don&rsquo;t Let Your LOAs Leave You DOA (Part II): States Speak Up!</h1> <h3 style="text-align: justify;"><span style="color:#28166F;"><em>By: Krista Maschinot, Esq. </em></span></h3> <p style="text-align: justify;">Remember that scenario from Spring of 2017 where an employer was attempting to do right by an employee and offered a continuation of coverage during an employer-approved leave of absence? If not, let&rsquo;s quickly refresh our memories.</p> <p style="text-align: justify;">An employer&rsquo;s long-time trusted employee had a stroke of bad luck and was diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. As the employee&rsquo;s treatment plan became more aggressive, the employee ultimately needed to take a leave of absence &ndash; but leave under The Family and Medical Leave Act (FMLA) was exhausted due to the employee&rsquo;s recent addition of a new baby. The employer subsequently continued to provide coverage, pursuant to 2016 guidance issued by the United States Equal Employment Opportunity Commission regarding employer-provided leave in accordance with The Americans with Disabilities Act (ADA)<sup>1</sup>.</p> <p style="text-align: justify;">Although the employee ended up making a miraculous recovery, the claims poured in, and the employer soon realized there was a &ldquo;gap&rdquo; between the plan document and the employer&rsquo;s decision to provide ADA leave, such that the plan document did not actually allow this continued coverage. Of course, the employer was free to provide whatever leave it saw fit &ndash; but the employer&rsquo;s stop-loss carrier was not keen on reimbursing these claims, since this continued coverage was not contemplated when the carrier underwrote the policy. The employer was facing stop-loss reimbursement denials and potentially skyrocketing renewal rates for the upcoming plan year.</p> <p style="text-align: justify;">Part I of the story ended as a cliffhanger: the employer&rsquo;s bank account looked bleak, and the employer was scrambling to figure out how to continue offering benefits to its employees without going bankrupt. &ldquo;How did I end up here? All I wanted was to take care of my employees and give them the best benefits possible. Where did I go wrong?&rdquo;&nbsp;</p> <p style="text-align: justify;">As you may recall, we put ourselves in the shoes of employers. It&rsquo;s intuitive to think that a health-related leave of absence from employment is coupled with a continuation of health plan coverage. Unfortunately, though, plan documents and employee handbooks are as prone to &ldquo;gaps&rdquo; as any other two documents, if not more; you&rsquo;d be amazed at how antiquated some employee handbooks can be, and even when they&rsquo;re updated, it occurs to alarmingly few employers that the two documents must be harmonized.</p> <p style="text-align: justify;">Similar to &ldquo;surprise billing&rdquo; legislation, the last year or so has seen a boom in state legislation that is designed to protect employees, and much of the legislation focuses on &ndash; you guessed it &ndash; leaves of absence and continuation of coverage. Some state laws address whether or not leave must be paid, others address whether benefits must be continued while on leave, and others still address both issues. Two interesting recent examples are California and New York.</p> <p style="text-align: justify;">California&rsquo;s leave laws have been in place for decades, but have undergone various changes, including revisions in 1999, 2004, 2011, 2012, and most recently, 2017. California Senate Bill No. 63 implemented the New Parent Leave Act (NPLA) as of January 1, 2018. Affording protected leave to employees of employers with 20 or more employees, this marked a significant change from the state&rsquo;s previous requirement laws that applied only to employers with 50 or more employees. Employers subject to California law must consider the interaction of all state and federal leave laws, including the NPLA, FMLA, California Family Rights Act (bonding leave), and Pregnancy Disability Leave (PDL).&nbsp;</p> <p style="text-align: justify;">Unlike California&rsquo;s law, which expanded an existing law, New York passed a brand new leave law, and it happens to be the most generous paid leave law in the United States to date. Effective January 1, 2018, New York&rsquo;s Paid Family Leave Benefits Law (PFLBL) is being phased in over four years with full implementation in 2021. The law requires privately-owned employers to provide paid leave to employees in three situations: (1) for a father or mother to bond with a new child (birth, adoption, or foster); (2) to care for a close relative with a serious health condition; or (3) to care for a close relative when another close relative has been called to active military service. The length of leave in 2018 has been limited to eight weeks, but will increase over time to become 12 weeks upon full implementation in 2021. Interestingly, in addition to creating the requirements, the law requires employee handbook modifications, conspicuous posting of specific information (similar to FMLA), the need to coordinate with paid time off and FMLA, and of course the tax treatment of the benefits.</p> <p style="text-align: justify;">I don&rsquo;t know about you, but my head is spinning. For employers subject to a myriad of laws such as FMLA, the various state leave laws, and ERISA, it&rsquo;s no surprise that complying with all of them simultaneously is a serious headache, and sometimes details are overlooked.</p> <p style="text-align: justify;">Now, wait a minute. If a self-funded ERISA plan is protected by ERISA, aren&rsquo;t state laws like these inapplicable? The short answer is <em>no</em>. The longer answer is <em>no way</em>. At a high level, ERISA protects a health plan from being subject to state insurance laws &ndash; but laws such as paid leave and continuation of coverage laws have been found to not actually <em>be</em> insurance laws, but employment laws, and therefore ERISA can&rsquo;t shield anyone from compliance with such laws.</p> <p style="text-align: justify;">As an attorney, I can tell you that following state and federal laws is crucial to the viability of a health plan and the employer&rsquo;s business. As a health care professional, I can tell you that full compliance is not an easy task. Laws that protect employees tend to have intricate details and nuances; we&rsquo;ve picked on California and New York, but five other states and the District of Columbia have introduced legislation to offer or expand leave laws. Those states include Washington, New Jersey, Rhode Island, New Hampshire, and Maryland. Although most federal and state laws do not currently require a continuation of coverage, we may soon see an upheaval in the status quo.</p> <p style="text-align: justify;">In the absence of applicable state laws, employers can choose whether or not to provide the benefit of continued coverage &ndash; but of course an employer&rsquo;s generosity must be spelled out in the plan document, not just the employee handbook, in order to avoid stop-loss denials. Ultimately, the interaction of applicable state laws, FMLA, and any other type of employer-sponsored leave of absence will need to be assessed on case-by-case basis to determine the rights of an individual employee in any particular circumstance. As with everything else in the self-funded world, if the relevant documents aren&rsquo;t kept up-to-date and compliant, how can an employer expect to be able to solve the compliance Rubik&rsquo;s Cube?</p> <p style="text-align: justify;">The alarming reality is that many gaps between plan documents and employee handbooks are only discovered once a disaster has already ensued. All it takes is one catastrophic event to discover that the various documents aren&rsquo;t airtight, and may not even align with the employer&rsquo;s intent. &nbsp;</p> <p style="text-align: justify;">In sum, employers need to do their homework on a regular basis. As we enter renewal season, now is the perfect time for employers to look at their plan documents and the employee handbooks. Do the two documents reference the same types of leave? Do the documents clearly indicate under what circumstances, and for how long, coverage under the health plan is maintained during a leave? Has the employer assessed the need to comply with a new or revised state law? Are the employer and employee obligations and coverage options laid out clearly? Do the terms of these documents meet the intent of the employer? What does the stop-loss policy say about eligibility determinations? Can the handbook be used to document eligibility in the health plan? Do changes need to be made to minimize or eliminate gaps?</p> <p style="text-align: justify;">Don&rsquo;t let your LOAs leave you DOA. Do the leg work now, and figure out what needs to be done to avoid being caught by surprise.</p> <p style="text-align: justify;"><em>Kelly E. Dempsey is an attorney with The Phia Group. She is the Director of Independent Consultation and Evaluation (ICE) Services. 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. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.</em></p> <div> <div id="ftn1"> <p style="text-align: justify;"><sup>1</sup><a href="https://www.eeoc.gov/eeoc/publications/ada-leave.cfm"><sup> </sup>https://www.eeoc.gov/eeoc/publications/ada-leave.cfm</a></p> </div> </div> <p>_________________________________________________________________________________________________________</p> <h1 style="text-align: justify;">Explanations that Benefit</h1> <h3 style="text-align: justify;"><span style="color:#28166F;"><em>By: Jon Jablon, Esq.&nbsp;</em></span><span style="color:#28166F;"><em> </em></span></h3> <p style="text-align: justify;">In the course of working with many different third-party administrators, it has become clear that every TPA operates differently. Claims processes are no exception; although federal law prescribes certain rules and regulations for the basics of what must be done and how, TPAs and health plans are left to their own devices to figure out the nuts and bolts of their particular processes. The only real requirement is that those processes fit in with the regulators&rsquo; rules and vision for how the industry should operate.</p> <p style="text-align: justify;">As a form that is given to a claimant along with payment (or, perhaps more relevantly, <em>without</em> payment), the Explanation of Benefits (or EOB) form is often the first,&nbsp; and sometimes the only, document a claimant sees that explains why the claim was adjudicated as it has been. For that reason, although it would probably not be accurate to suggest that the regulators treat EOBs as &ldquo;special&rdquo; compared to any other regulations, in practical matters the EOB can be considered to be perhaps more important to get right than certain other things. That&rsquo;s because it&rsquo;s the first line of defense when denying or partially denying a claim, and the primary vehicle for a health plan&rsquo;s justification of its denial.</p> <p style="text-align: justify;">29 USC &sect; 1133 and accompanying regulations address a plan&rsquo;s internal appeals procedures and require that claimants must be notified of the reasons why a claim has been denied and must be given a reasonable opportunity for a full and fair internal review of a claim<sup>1</sup>. The regulations go on to require that a group health plan provide &ndash; among other things &ndash; the specific reason for the denial, reference to the specific plan provisions upon which it has been based, a description of the plan&rsquo;s appeals procedures, and a way to connect an applicable clinical judgment to the plan&rsquo;s provisions.</p> <p style="text-align: justify;">Those rules seem fairly straightforward &ndash; but due to the numerous situations that courts and regulators have encountered through the years, there are some nuances in this language that are perhaps not quite clear, and which TPAs should be acutely aware of when addressing matters such as EOB compliance. As usual, the black-letter law leaves room for interpretation.</p> <p style="text-align: justify;">In one particular case, for instance, a health plan required arbitration as a mandatory stage of plan appeal, after the initial written appeal was denied. The EOB, however, was silent on that requirement. The court in that case applied the normal doctrine that courts use to rectify cases of inadequate notice: the health plan was directed to allow the claimant to file a late appeal, despite the timeframes stated within the applicable plan document and the fact that those timeframes had run out. Known as &ldquo;tolling,&rdquo; this remedy effectively stops the &ldquo;countdown&rdquo; of the appeal time requirement due to inadequate notice from the plan. In this case, then, the timeframes for appeal stated in the plan document were deemed inapplicable, since the plan did not adequately communicate them.</p> <p style="text-align: justify;">One can argue that the plan document&rsquo;s inclusion of the relevant information should be sufficient to convey the information to a claimant &ndash; but according to courts, plan members can only reasonably be expected to know what is shown to them with respect to a specific case, rather than in the Plan Document in general. As one court put it, &ldquo;[j]ust as a fiduciary must give written notice to a plan participant or beneficiary of the steps to be taken to obtain internal review when it denies a claim, so also, we believe, should a fiduciary give written notice of steps to be taken to obtain external review through mandatory arbitration when it denies an internal appeal<sup>2</sup>.&rdquo; Even though the arbitration itself is not explicitly governed by ERISA, once it was made a part of the plan&rsquo;s claim procedures, it became a provision that must be brought to the claimant&rsquo;s attention. This case and others like it demonstrate that simply including a provision in the Plan Document is sometimes not enough to adequately inform a claimant of that provision.</p> <p style="text-align: justify;">That&rsquo;s an example of a situation where plan provisions (timelines, specifically) were actually ignored by a court, because the plan and TPA failed to adequately disclose certain plan requirements on the EOB.</p> <p style="text-align: justify;">Where does it end, though? Surely the regulations can&rsquo;t list <em>every</em> conceivable item that must be present on the EOB; even if a very long list were created, there would always be some new situation not previously contemplated. Hence, there is case law like this, that is designed to both give guidance in this specific instance, but also help inform future interpretations of these same rules. For instance, if a health plan required mediation rather than arbitration, surely the case law described above would still apply, even though it&rsquo;s not an identical situation. It&rsquo;s close enough, though, that the required &ldquo;good faith, reasonable interpretation&rdquo; of unclear regulations can be colored by this example.</p> <p style="text-align: justify;">In a longstanding series<sup>3</sup> of somewhat more egregious examples of deficient EOBs, courts have opined that the regulations explaining the EOB requirements are not designed to invite &ldquo;conclusions,&rdquo; but instead &ldquo;reasons&rdquo; or &ldquo;explanations.&rdquo; So, rather than state that a claim is denied because pre-authorization was not given, the EOB should state <em>why</em> pre-authorization was not given, and <em>therefore</em> the conclusion<sup>4</sup>. Put simply, and again parroting the established regulations, &ldquo;[a]n ERISA fiduciary must provide the beneficiary with the <em>specific reasons</em> for the denial of benefits<sup>5</sup>.&rdquo;</p> <p style="text-align: justify;">Noncompliance, or an instance of a questionable nature, is somewhat common with reference-based pricing. The prevailing attitude seems to be that since reference-based pricing is such a fundamental change to the plan itself, there&rsquo;s so much else going on that an EOB note such as &ldquo;claim denied due to reference-based pricing&rdquo; is somehow sufficient. Based on courts&rsquo; interpretations of the prevailing regulations, a remark this generic would neither be literally compliant with the text of the regulations, nor satisfy the intent of the regulations (which is to provide the claimant with information sufficient to file a meaningful appeal on the merits, or ultimately file suit to enforce benefits pursuant to ERISA)<sup>6</sup>.</p> <p style="text-align: justify;">My mention of the intent of the regulations was deliberate. In the legal system, intent is not <em>always</em> necessary to be held liable; at the risk of going on a tangent, there&rsquo;s something called &ldquo;strict liability&rdquo; which imposes legal liability even without intent or even knowledge of wrongdoing. In the process of interpreting ERISA, this country&rsquo;s courts have in some situations refused to apply a comparable doctrine of strict liability to violations of ERISA. In other words, sometimes a violation occurs, but the offending fiduciary is <em>not</em> held liable, due to other actions of that fiduciary.</p> <p style="text-align: justify;">To illustrate this, consider a situation where a claimant is given a compliant EOB containing one denial reason, the claimant appeals, and the health plan or its TPA denies the appeal, and also cites additional reasons for the denial that were not provided on the original EOB. For some context, it isn&rsquo;t compliant with ERISA to provide additional denial reasons after the claimant has already exhausted or &ldquo;used up&rdquo; the available appeals, since that wouldn&rsquo;t afford the claimant the opportunity to actually appeal the newly-given denials reasons<sup>7</sup>.</p> <p style="text-align: justify;">In some situations, though &ndash; when the claimant is given the opportunity to appeal the other denial reasons, despite already having exhausted appeals for the initial denial reason &ndash; compliance with one provision of ERISA has actually saved the fiduciary from noncompliance in another area. In a situation like this, the health plan is not in compliance when it issues a separate denial reason after already denying appeals for the initial denial reason &ndash; but the fiduciary was able to &ldquo;cure&rdquo; its noncompliance by providing the claimant ample opportunity to appeal the new denial reasons. Sometimes referred to as &ldquo;substantial compliance<sup>8</sup>,&rdquo; courts have noted that certain instances of technical noncompliance can be excused as long as the purpose of the regulations<sup>9</sup> is not frustrated. In this case, that purpose is ensuring that claimants receive adequate recourse to appeal claims denials, which has been done.</p> <p style="text-align: justify;">As a final note, although the majority of this article discusses procedural matters related to EOBs, it&rsquo;s worth taking a brief look into the substance of denials. Although the relevant regulations provide that the claimant must be given the &ldquo;specific reasons&rdquo; for the denial of benefits, an interesting nuance of this rule apparently involves a sort of meta-reasoning: as one court put it, &ldquo;The administrator must give the &lsquo;specific reasons&rsquo; for the denial, but that is not the same thing as the reasoning behind the reasons...<sup>10</sup>&rdquo;</p> <p style="text-align: justify;">Admittedly, that sounds very odd. The nuance is that although the Plan Administrator must provide a reason for denial, the Plan Administrator, oddly, isn&rsquo;t required to provide a <em>good</em> reason. The fiduciary duty extends to providing <em>a</em> reason, and then the law places the burden on the claimant to refute that reason. Of course, the regulations explaining what must be present on an EOB are designed to give the claimant the tools it needs to refute the denial &ndash; but the fact remains that the Plan Administrator may provide a nonsensical reason for denial, and the Plan Administrator has then literally satisfied its duty to compliantly notify the claimant of the specific reason for the denial. After all, the law does not assume that Plan Administrators are perfect, or even logical; only that they explain themselves.</p> <p style="text-align: justify;">According to one particular court, requiring the Plan Administrator to explain its &lsquo;reasoning behind the reasons&rsquo; &ldquo;would turn plan administrators not just into arbitrators, for arbitrators are not usually required to justify their decisions, but into judges, who are.<sup>11</sup>&rdquo; Interestingly, despite the doctrine of &ldquo;substantial compliance&rdquo; noted above, perhaps courts should adopt a doctrine of &ldquo;substantial <em>noncompliance</em>,&rdquo; which can place a fiduciary out of compliance for providing an egregiously poor reason for denial, and thus violating the spirit of the law, despite following the black letter of the law.</p> <p style="text-align: justify;">Regardless, the regulations are neither clear nor all-inclusive &ndash; but there is case law designed to educate Plan Administrators regarding things that must be on an EOB, and what doesn&rsquo;t need to be. The rules are not as intuitive as the regulations make them out to be&hellip;but then again, in this industry, what is?</p> <div> <div id="ftn1"> <p style="text-align: justify;"><em><sup>1</sup>Chappel v. Lab. Corp. of Am.</em>, 232 F.3d 719, 726 (9th Cir. 2000).</p> </div> <div id="ftn2"> <p style="text-align: justify;"><em><sup>2</sup>Id.</em></p> </div> <div id="ftn3"> <p style="text-align: justify;"><em><sup>3</sup>Accord VanderKlok v. Provident Life and Accident Ins. Co.</em>, 956 F.2d 610 (6th Cir. 1992); <em>Wolfe v. J.C. Penney Co.</em>, 710 F.2d 388 (7th Cir. 1983);<em> Richardson v. Central States, Southeast and Southwest Areas Pension Fund</em>, 645 F.2d 660, 665 (8th Cir. 1981)</p> </div> <div id="ftn4"> <p style="text-align: justify;"><em><sup>4</sup><u>Weaver v. Phx. Home Life Mut. Ins. Co.</u></em><u>, 990 F.2d 154, 158 (4th Cir. 1993)</u></p> </div> <div id="ftn5"> <p style="text-align: justify;"><em><sup>5</sup>Makar v. Health Care Corp. of Mid-Atlantic (CareFirst)</em>, 872 F.2d 80, 83 (4th Cir. 1989) (dicta), <em>emphasis preserved</em>.</p> </div> <div id="ftn6"> <p style="text-align: justify;"><sup>6</sup>See <em>Halpin v. W.W. Grainger, Inc.</em> 962 F2d 685 (CA7 Ill, 1992)</p> </div> <div id="ftn7"> <p style="text-align: justify;"><em><sup>7</sup>Urbania v Cent. States, Southeast &amp; Southwest Areas Pension Fund</em>, 421 F3d 580 (CA7 Ill 2005).</p> </div> <div id="ftn8"> <p style="text-align: justify;"><em><sup>8</sup>Lacy v. Fulbright &amp; Jaworski,</em> 405 F.3d 254, 256-257 &amp; n.5 (5th Cir. 2005).</p> </div> <div id="ftn9"> <p style="text-align: justify;"><em><sup>9</sup>Robinson v. Aetna Life Ins.</em>, 443 F.3d 389, 393 (5th Cir. 2006).</p> </div> <div id="ftn10"> <p style="text-align: justify;"><em><sup>10</sup>Gallo v. Amoco Corp.</em>, 102 F.3d 918, 923 (7th Cir. 1996), <em>internal citations omitted</em>.</p> </div> <div id="ftn11"> <p style="text-align: justify;"><em><sup>11</sup>Id.</em></p> </div> </div> <p style="text-align: justify;">&nbsp;</p> 805Empowering Plans: P61 - Leather Patches & Pipeshttps://www.phiagroup.com/Media/Posts/PostId/804/empowering-plans-p61-leather-patches-pipesPodcastsWed, 02 Jan 2019 21:11:32 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/GKln4TlQTWQ" width="560"></iframe></p> <p>The Phia Group&rsquo;s foray into higher learning!&nbsp; Ron discusses with professors Silverio and Jablon the forthcoming master&rsquo;s degree program in plan development they will be teaching.&nbsp; If you&rsquo;re up for the challenge, prepare to learn!</p> <p><a href="https://youtu.be/GKln4TlQTWQ">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/GKln4TlQTWQ">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 804The Phia Group Announces the Formation of Legal Compliance & Regulatory Affairs Team https://www.phiagroup.com/Media/Posts/PostId/800/the-phia-group-announces-the-formation-of-legal-compliance-regulatory-affairs-teamPress ReleasesMon, 17 Dec 2018 15:11:19 GMT<p><strong>December 14, 2018 - For Immediate Release </strong></p> <p>Braintree, MA -- The Phia Group LLC, one of the health benefit industry&rsquo;s leading cost-containment service providers, announced that it has completed the formal creation of its internal Legal Compliance and Regulatory Affairs (&ldquo;LCARA&rdquo;) team.</p> <p>The members of this Phia Group Consulting (&ldquo;PGC&rdquo;) subdivision will handle the most complex Independent Consultation and Evaluation (&ldquo;ICE&rdquo;) queries while performing in-depth research meant to benefit both The Phia Group, and its partners. Led by its Director of Legal Compliance &amp; Regulatory Affairs, <strong>Brady Bizarro, Esq.</strong>, as well as Compliance &amp; Oversight Counsel, <strong>Andrew Silverio, Esq.</strong> and Compliance &amp; Regulatory Affairs Consultant, <strong>Philip Qualo, J.D.</strong>, the LCARA team will diligently track statutory and regulatory changes, to ensure both the continued compliance of The Phia Group as well as its clientele. By focusing both on the company&rsquo;s own internal needs as well as the needs of its clients, the LCARA team represents a new stage in &ldquo;crowd sourcing&rdquo; information and experience.<br /> <br /> &ldquo;There are certainly a few individuals here or there who include this type of work in their list of responsibilities,&rdquo; The Phia Group&rsquo;s CEO <strong>Adam Russo</strong> remarked, &ldquo;But we are confident that no team has ever been so focused on remaining ahead of legal challenges, and ensuring that both The Phia Group and its allies learn &ndash; and benefit &ndash; from each other&rsquo;s growth, wins, and losses.&rdquo;<br /> <br /> To learn more about The Phia Group, its regulatory compliance services, or any of its offerings, please contact The Phia Group&rsquo;s Sales Executive, <strong>Garrick Hunt</strong>, at 781-535-5644 or <a href="mailto:Info@PhiaGroup.com">Info@PhiaGroup.com</a>.</p> <p><strong>About The Phia Group</strong><br /> <br /> The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit <a href="https://linkprotect.cudasvc.com/url?a=https%3a%2f%2ft.e2ma.net%2fclick%2fdh9p9e%2f1zbnr9%2fhk2hm7b&amp;c=E,1,nmxa2NG9Dj_NhB9bXGB5E9NlT1jh_fTldqi0iLMejD5m1IWxFpHHwV8EhPhlCC42XEzCecKv2nBUuV1tvGNCAYcjFyloDCBfiNOGnGtKNF8,&amp;typo=1">www.PhiaGroup.com.</a></p> 800What to Expect in 2019 – Part 2https://www.phiagroup.com/Media/Posts/PostId/799/what-to-expect-in-2019-part-2WebinarsWed, 12 Dec 2018 17:12:00 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/hI7atWUv3jI" width="560"></iframe></p> <p>To build on last month’s webinar (Part 1), join The Phia Group’s legal team for an hour on December 12, 2018, as they present the second part of this two-part series on What to Expect in 2019. Touching on topics such as appeals, stop-loss trends, reference-based pricing, and much more, this webinar will highlight current industry happenings and our predictions to help you look forward to the coming year. Just like last month: miss this one, and you’ll be left behind.</p> <p><a href="https://youtu.be/hI7atWUv3jI">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 799Faces of Phia: Episode 3 – Flying High with Judyhttps://www.phiagroup.com/Media/Posts/PostId/795/faces-of-phia-episode-3-flying-high-with-judyPodcastsThu, 29 Nov 2018 15:59:34 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/4HMC8OkfJLk" width="560"></iframe></p> <p style="text-align: justify;">In this episode, Ron and Adam sit down with Judith McNeil. Judith is the most recent winner of our &ldquo;Employee of the Quarter&rdquo; award, as well as our second Face of Phia. Judith&rsquo;s story goes from inspiring to hilarious, and is one you certainly won&rsquo;t want to miss. Expect to see things differently by the time you&rsquo;re done with this episode.</p> <p><a href="https://youtu.be/4HMC8OkfJLk">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/4HMC8OkfJLk">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 795The Phia Group, LLC Announces Expansion of Exclusive U.S. Relationship with Jason C. Davis Consulting (“JCDC”)https://www.phiagroup.com/Media/Posts/PostId/792/the-phia-group-llc-announces-expansion-of-exclusive-us-relationship-with-jason-c-davis-consulting-jcdcPress ReleasesTue, 20 Nov 2018 19:25:41 GMT<p style="text-align: justify;">November 20, 2018 &ndash; For Immediate Release</p> <p style="text-align: justify;">The Phia Group, LLC Announces Expansion of Exclusive U.S. Relationship with Jason C. Davis Consulting (&ldquo;JCDC&rdquo;) and the Onboarding of Nick Fitzsimmons.</p> <p style="text-align: justify;">Braintree, MA.&nbsp; The Phia Group LLC, one of the health benefit industry&rsquo;s leading cost-containment service providers, announced today that it has agreed to expand upon its existing exclusive consulting agreement with JCDC through the addition of Nick Fitzsimmons.&nbsp; Mr. Davis and Mr. Fitzsimmons will assist The Phia Group with sales and product development as it relates to its suite of Provider Relations services, including but not limited to Claim Negotiation &amp; Signoff and &ldquo;Phia Unwrapped.&rdquo;</p> <p style="text-align: justify;">&ldquo;How plans process claims, apply new pricing methodologies, and interact with healthcare providers will determine who thrives in the years to come,&rdquo; remarked Adam Russo, CEO of The Phia Group, &ldquo;Jason and Nick are here to help us and our partners reach the next level as it relates to this increasingly important topic.&rdquo;</p> <p style="text-align: justify;">Prior to becoming independent consultants, Jason Davis and Nick Fitzsimmons helped manage the U.S. Markets for Global Excel Management and have a combined provider relations experience of over 35 years.</p> <p style="text-align: justify;">&ldquo;Though we consult in other markets, we wanted one exclusive, long-term strategic partnership in the United States; and The Phia Group&rsquo;s innovative, forward thinking attorneys and industry specialists &ndash; with their energy, market presence, and industry know-how &ndash; just seemed like a good fit for us,&rdquo; stated Jason Davis.&nbsp; Nick Fitzsimmons explained, &ldquo;I look forward to further enhancing the already incredible collaboration between JCDC and The Phia Group. &nbsp;Together we will continue to positively impact the viability of the benefit plans they service, and improve the lives of their plan members, by building products and services that are uniquely valuable, and distinctly Phia.&rdquo;</p> <p style="text-align: justify;">To learn more about The Phia Group, its Provider Relations services, or any of its offerings, please contact The Phia Group&rsquo;s Sales Executive, Garrick Hunt, at 781-535-5644 or <a href="mailto:Info@PhiaGroup.com">Info@PhiaGroup.com</a>.</p> 792Empowering Plans: P60 - Politics With Bradyhttps://www.phiagroup.com/Media/Posts/PostId/789/empowering-plans-p60-politics-with-bradyPodcastsTue, 20 Nov 2018 15:39:05 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/s9usDUCUZlQ" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> <p>This Podcast is HUUUUGE &ndash; Brady and Ron will dig deep, analyze the recent election results, and determine how they will impact the health benefits and health care industries.&nbsp; Bottom line?&nbsp; If you listen to this episode, you will definitely impress everyone at the Thanksgiving dinner table. You&rsquo;re Welcome.</p> <p><a href="https://youtu.be/s9usDUCUZlQ">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/Zkxyh-U9w0I">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 789Empowering Plans: P59 - Talkin’ with TPAChttps://www.phiagroup.com/Media/Posts/PostId/788/empowering-plans-p59-talkin-with-tpacPodcastsFri, 16 Nov 2018 19:27:56 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/Zkxyh-U9w0I" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> <p style="text-align: justify;">In this &ldquo;Partners in Empowerment&rdquo; episode, Ron and Brady enjoy chatting with Michael Meloch, President of TPAC Underwriters and valued member of The Phia Group&rsquo;s own advisory board.&nbsp; Michael isn&rsquo;t shy when it comes to diagnosing the issues, boiling healthcare cost containment down to simple basics we can all appreciate, and telling it like it is.&nbsp; His employer based perspective and focus on the bottom line (a/k/a &ldquo;risk&rdquo;) is as refreshing as it is informative.&nbsp; Don&rsquo;t miss this one!</p> <p><a href="https://youtu.be/Zkxyh-U9w0I">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/Zkxyh-U9w0I">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 788Faces of Phia: Episode 2 – Not Your “Norma-l” Employeehttps://www.phiagroup.com/Media/Posts/PostId/787/faces-of-phia-episode-2-not-your-norma-l-employeePodcastsFri, 16 Nov 2018 18:59:05 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/IxD1OpXQLdk" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> <p><span class="pre_wrap">In today&rsquo;s episode, our hosts chat with Norma Phillips&hellip; our first official &ldquo;Face of Phia;&rdquo; (sorry Matt). Norma explains what makes her different (and special) as well as what makes The Phia Group so unique. From Friday night films, to saving the American workers&rsquo; job&hellip; Norma and the team touch all the bases.</span></p> <p><a href="https://youtu.be/IxD1OpXQLdk">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/IxD1OpXQLdk">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 787What to Expect in 2019 - Part 1https://www.phiagroup.com/Media/Posts/PostId/785/what-to-expect-in-2019-part-1WebinarsTue, 13 Nov 2018 15:09:00 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/1PjVzxg0jI8" width="560"></iframe></p> <p style="text-align: justify;">The future is here! As we’re about to enter 2019, the undercurrents of the self-funded industry are as exciting as they are dynamic, and changes are happening at an unbelievable pace. Join The Phia Group’s legal team as they present Part 1 of this two-part series on What to Expect in 2019, which will highlight current industry happenings and our predictions to help you look forward to the coming year.  Miss this one, and you’ll be left behind.</p> <p><a href="https://youtu.be/1PjVzxg0jI8">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 785Empowering Plans: P58 - Special Edition: Talking Politics, Elections, and Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/783/empowering-plans-p58-special-edition-talking-politics-elections-and-healthcarePodcastsThu, 01 Nov 2018 20:08:00 GMT<p><iframe allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/8n5T78tLgeI" width="560"></iframe></p> <p><span class="pre_wrap">Like it or not, healthcare is on the ballot &ndash; nationally, statewide, and locally. The questions asked and people we elect will have an impact on how we receive and pay for healthcare &ndash; and for those of us in the benefits industry &ndash; failing to identify the trends, issues, and opportunities is tantamount to waving the white flag. Stay in the know and get ready to go; don&rsquo;t miss this episode of Empowering Plans.</span></p> <p><a href="https://www.youtube.com/watch?v=8n5T78tLgeI">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=8n5T78tLgeI">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 783Faces of Phia: Episode 1 – A Chat With Matthttps://www.phiagroup.com/Media/Posts/PostId/780/faces-of-phia-episode-1-a-chat-with-mattPodcastsWed, 24 Oct 2018 14:49:32 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/dQEvNom4AFs" width="560"></iframe></p> <p><span class="pre_wrap">In this episode we sit down with The Phia Group&rsquo;s Marketing &amp; Accounts Manager, Matthew Painten. Matt tells about how his time with the organization has changed him, and educated him regarding healthcare and what everyone can do to reduce their expense. Matt will give us insight into his transformation as well as how he accomplishes his work for the betterment of all.</span></p> <p><a href="https://youtu.be/dQEvNom4AFs">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/dQEvNom4AFs">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 780Empowering Plans: P57 - AHPs: Will They Live Up to the Hype?https://www.phiagroup.com/Media/Posts/PostId/779/empowering-plans-p57-ahps-will-they-live-up-to-the-hypePodcastsMon, 22 Oct 2018 13:54:00 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/4oL_YnrRods" width="560"></iframe></p> <p>Have you heard?&nbsp; In 2019 it will be easier than ever to form a self-funded &ldquo;Association Health Plan&rdquo; (AHPs) &hellip; So what?&nbsp; In the words of&nbsp; Jurassic Park&rsquo;s Dr. Ian Malcolm (a/k/a Jeff Goldblum), we have been so preoccupied with whether or not we could, we didn&rsquo;t stop to think if we should.&nbsp; This podcast discusses the pros and cons, as well as benefits and hurdles the final rules have created for these new AHPs.&nbsp; From compliance with State MEWA laws to obeying federal laws such as ERISA&rsquo;s consumer protections (including the Mental Health Parity and Addiction Equity Act [MHPAEA]), we dissect why we must slow our run towards AHPs to a measured walk.</p> <p><a href="https://youtu.be/4oL_YnrRods">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/4oL_YnrRods">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 779Specialty Drugs: Trends and Issues Affecting Self-Funded Planshttps://www.phiagroup.com/Media/Posts/PostId/778/specialty-drugs-trends-and-issues-affecting-self-funded-plansWebinarsThu, 18 Oct 2018 14:53:00 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/aPRiUJyaJZg" width="560"></iframe></p> <p>No matter what corner of the industry you’re in, you know that health plans have had a constant need to contain costs as a result of skyrocketing medical bills. The rising cost of Rx drugs has certainly been an issue as well – and specialty drugs are a hot-button issue as health plans struggle to find ways to manage them.<br /> <br /> Join The Phia Group’s legal team for an hour as they discuss the latest trends and issues relating to specialty drugs – including plan design, international sourcing, copay programs, and more.<br /> <br /> <a href="https://youtu.be/aPRiUJyaJZg">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 778The Phia Group's 4th Quarter 2018 Newsletter https://www.phiagroup.com/Media/Posts/PostId/776/the-phia-groups-4th-quarter-2018-newsletterNewslettersMon, 15 Oct 2018 21:01:22 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/Newsletter%202018%20Q2/header2018.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/icons5.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p1"><img src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/b14qtr18.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p12"><img src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/b24qtr18.png" 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="53%"> <p>&nbsp;</p> <p><img height="305" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/adam.jpg" width="300" /></p> </td> <td valign="top" width="47%"> <p class="bodytext"><br /> <span style="color:#000000;"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></span></p> <p class="bodytext" style="text-align: justify;">It&rsquo;s hard to believe that another three months have gone by. The leaves are turning here in Boston and my beloved Indians are out of the playoffs, but at least the Browns have won two games. Anyways, it&rsquo;s busy season for all of us here at The Phia Group, and for all of you as well, so I want to keep this short and sweet. The focus for the next three months of our webinars, podcasts and articles will be around what to expect in 2019. We see it as a transition year with big changes in effect for 2020, so stay tuned my friends. Happy reading to all of you!</p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </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/Q4%202017%20Newsletter/Newsletter%202018%20Q4/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: PACE &amp; Pre-Service Appeals</a><br /> <a href="#p2">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2018 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a name="p1"></a> <p>&nbsp;</p> <p class="heading1" style="text-align: justify;">Service Focus of the Quarter: PACE and Pre-Service Appeals</p> <p class="bodytext" style="text-align: justify;">Not all appeals are created equal. While there are always regulations to follow when handling claims and appeals, obeying the rules with respect to pre-service appeals can be far more difficult than their post-service.</p> <p class="bodytext" style="text-align: justify;">Pre-service appeals bring with them more intensive time-restrictive requirements than post-service appeals. Plan Administrators and TPAs have a hard enough time making determinations in the time allotted for post-service appeals; when faced with far quicker turnaround times on pre-service appeals, it&rsquo;s even easier to make a claim administration or adjudication error.</p> <p class="bodytext" style="text-align: justify;">You&rsquo;ve heard about The Phia Group&rsquo;s Plan Appointed Claim Evaluator (&ldquo;PACE&rdquo;) service, whereby we assume fiduciary duties on final-level, internal appeals; but did you know that PACE can now also include pre-service second-level appeals? Now you do!</p> <p class="bodytext" style="text-align: justify;">Many of you already trust The Phia Group&rsquo;s consultative team as it relates to claims processing, and rely upon our PACE service to protect you as it relates to your post-service claim appeals; second level pre-service appeal review is a logical extension of that, and helps protect the plan and TPA in situations where the plan and TPA are even more crunched for time than usual.</p> <p class="bodytext" style="text-align: justify;">To learn more about PACE, including pre-service options, contact Tim Callender at 781-535-5631 or tcallender@phiagroup.com.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><a id="p2" name="p2"></a></p> <p class="bodytext" style="text-align: justify;"><strong>Phia Case Study: Phia to the Rescue!</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group&rsquo;s consulting team received an interesting consulting request (via PGCReferral@phiagroup.com) from the broker of a self-funded health plan administered by an Administrative Services Only (&ldquo;ASO&rdquo;) carrier. The broker had identified what was believed to be a billing error made by the ASO carrier, and had engaged The Phia Group to help determine what type of recourse, if any, the health plan had against the ASO.</p> <p class="bodytext" style="text-align: justify;">In particular, The Phia Group was tasked with review the plan&rsquo;s Administrative Services Agreement (ASA) to determine its audit/indemnification rights if it were ultimately determined that the ASO truly had made the suspected errors.</p> <p class="bodytext" style="text-align: justify;">The Phia Group outlined several provisions that the client could invoke in its favor against the ASO, including audit rights and the obligation to correct an erroneous overpayment if the ASO committed negligence, fraud, or misconduct; quality assurance requirements and penalties for non-compliance; and indemnification in certain circumstances, including negligence.</p> <p class="bodytext" style="text-align: justify;">With those provisions in-hand, the health plan and broker were able to put pressure on the plan&rsquo;s claims administrator to perform the audit necessary to discover its errors.</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> _ <p>&nbsp;</p> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: </strong> <b><span style="font-size:12.0pt;line-height:115%; font-family:&quot;Calibri&quot;,sans-serif;mso-ascii-theme-font:minor-latin;mso-fareast-font-family: Calibri;mso-fareast-theme-font:minor-latin;mso-hansi-theme-font:minor-latin; mso-bidi-theme-font:minor-latin;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA">Abiding by the Terms of the Plan Document!</span></b> <strong> </strong></p> <p style="text-align: justify;"><a id="p2a" name="p2a"></a></p> <p class="bodytext" style="text-align: justify;">Reference-based pricing can be complicated and daunting, but it doesn&rsquo;t have to be. There are certain techniques for doing it correctly, but even more techniques for doing it incorrectly. One such incorrect technique is to put language into the Plan Document that describes the reference-based pricing methodology, and then subsequently ignoring it.</p> <p class="bodytext" style="text-align: justify;">Some plans utilizing reference-based pricing contain language in the Plan Document that limits payment at a percentage of Medicare, without account for negotiated rates or settlements. We certainly don&rsquo;t mean to say that the Plan Document should contain two percentages &ndash; one &ldquo;initial&rdquo; percent and one &ldquo;settlement&rdquo; percent &ndash; but the language needs to be written such that the Plan Administrator is not violating the terms of the Plan Document if a given claim needs to be settled. Violating the terms of the Plan Document, after all, is a breach of the Plan Administrator&rsquo;s most basic fiduciary duty.</p> <p class="bodytext" style="text-align: justify;">An example of this is when a Plan Document provides that &ldquo;This plan will pay all claims at 150% of Medicare.&rdquo; Well, if a claim needs to be settled at 200% of Medicare, what then? The Plan Administrator has no authority from the Plan Document to make a settlement payment, resulting in (a) the negotiated rate being taxable to the employee, since it&rsquo;s not a plan benefit, and (b) the Plan Administrator being technically prohibited from making a settlement payment from plan assets.</p> <p class="bodytext" style="text-align: justify;">The Phia Group&rsquo;s standard reference-based pricing language specifically notes that if there is a negotiated rate (which can be an ongoing contract, case-by-case agreement, or settlement agreement on the back-end of a balance-bill), that negotiated rate is the payable amount. If and only if there is no negotiated rate, then the Medicare-based payment comes into play. That accounts for the possibility of a contract or negotiation of any given claim if necessary, without giving away the farm by promising that there will be negotiations.</p> <p class="bodytext" style="text-align: justify;">At its core, reference-based pricing is nothing more than a method of redefining traditional U&amp;C. All other plan processes remain the same, and fiduciary duties are still intact &ndash; which means the Plan Administrator needs to continue to be acutely aware of them, even while navigating reference-based pricing.</p> <p class="bodytext" style="text-align: justify;">The nuances of reference-based pricing are no excuse for violating fiduciary duties; as regulators and lawmakers continue to push back on reference-based pricing, let&rsquo;s not give them an excuse to condemn it.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>Success Story of the Quarter: Unwrapping the OON Claim</strong></p> <p class="bodytext" style="text-align: justify;">A health plan utilizing The Phia Group&rsquo;s Phia Unwrapped service incurred an out-of-network claim billed at $72,000. The health plan paid its Medicare-based benefits, and the patient was subsequently balance-billed for the entire balance, which was right around $60,000. After the initial patient advocacy layer of Phia Unwrapped, the provider continued to bill the patient, and The Phia Group then engaged the provide</p> <p class="bodytext" style="text-align: justify;">r to negotiate the balance. This particular provider felt that it was unconstrained by any notions of fair market value, even stating that &ndash; and we quote &ndash; &ldquo;if there is no law that limits the billing, we can bill however we please.&rdquo;</p> <p class="bodytext" style="text-align: justify;">We ultimately went above the billing department and found contact information for the hospital&rsquo;s CFO, whom we contacted and implored him to be reasonable. We pointed to benchmarks, fair market value, other area providers&rsquo; bills, cost-to-charge ratios, and more.</p> <p class="bodytext" style="text-align: justify;">Ultimately, without a word, and without knowing what exactly tipped the scales, we received a signed copy of our proposed agreement. We are now in the process, with the client&rsquo;s approval, of securing a direct contract with this facility at a rate that our client can accept as reasonable.</p> <p class="bodytext" style="text-align: justify;"><br /> &nbsp;</p> <p class="bodytext" style="text-align: justify;"><strong>A Case to Remember</strong></p> <p class="bodytext" style="text-align: justify;">Edward Brice Brimacombe v. OptumInsight, Inc. d/b/a Optum; Bank of America; et. al., Sup. Ct. AZ County of Maricopa, Case No. CV2018-055781, September 19, 2018</p> <p class="bodytext" style="text-align: justify;">Delays, miscommunication, and a lack of preparation will eliminate subrogation rights every time. The case of Edward Brice Brimacombe v. OptumInsight, Inc. d/b/a Optum; Bank of America; et. al., Sup. Ct. AZ, Case No. CV2018-055781, was filed on September 19, 2018 in Maricopa County, by an attorney representing a plan participant. He has done so in an effort to have the court void the Bank of America Benefit Plan&rsquo;s subrogation lien. We learn many important lessons from this case, as we seek to protect plan rights and strengthen subrogation efforts.</p> <p class="bodytext" style="text-align: justify;">First, in this case, the attorney representing the plan participant contacted neither the employer (the plan sponsor, Bank of America) nor the benefit plan&rsquo;s subrogation vendor (OptumInsight). Rather, they contacted the carrier whose administrative services only (ASO) and network were utilized by the plan; United Healthcare. As part of The Phia Group&rsquo;s subrogation implementation, we issue notification to all employees regarding who we are, and what we do, and we take active steps to identify opportunities to recover &ndash; and put all parties on notice &ndash; before they even have a chance to contact (the wrong) entities.</p> <p class="bodytext" style="text-align: justify;">Second, it&rsquo;s been alleged that the representative at the United Healthcare ASO did not understand what was being asked, or what subrogation is. It&rsquo;s a reminder that we all have a duty to make sure anyone who may take such calls either understands this part of the plan&rsquo;s administration, or knows to whom they should refer the inquiry. It is an integral part of The Phia Group&rsquo;s implementation process.</p> <p class="bodytext" style="text-align: justify;">Third, the attorney says that months later (in July of 2017), OptumInsight (the subrogation partner of the plan in question) did reach out to the attorney, seeking details about the case, but showing no knowledge of what the attorney claims had transpired previously. We, as an industry, need to ensure we always communicate &ndash; or appear to have communicated &ndash; avoiding any suggestion that there is no communication between the ASO/TPA, plan sponsor, and subrogation vendor. That&rsquo;s why The Phia Group makes it a priority to obtain access to our clients&rsquo; claims management systems&hellip; so that we can have read-only access to the notes, and be aware of such calls and correspondence prior to talking to the applicable parties.</p> <p class="bodytext" style="text-align: justify;">Fourth, the participant&rsquo;s attorney claims that he responded and offered an opportunity to reassert the previously waived lien, but (he says) he did not receive a response to that offer for months. This shows us that delays will result in the right to lien recoupment being lost, in light of new case law and common sense. The bottom line is that we&rsquo;re operating against the clock, and personal injury attorneys know that delays on our part put the recovery at risk. That&rsquo;s why The Phia Group sticks to firm deadlines.</p> <p class="bodytext" style="text-align: justify;">Fifth, OptumInsight advised the attorney that the carrier lacked authority to waive the plan&rsquo;s rights, however, the participant&rsquo;s attorney advised that by &ldquo;acting&rdquo; as if they did have the authority, they exercised legally binding implied authority. This teaches us that ASOs and TPAs must not speak for the plan or act as if they have authority in instances where they do not have such authority. This is why The Phia Group&rsquo;s subrogation clients are also provided with preferred access to such other services as Independent Consultation and Evaluation (&ldquo;ICE&rdquo;) and Plan Appointed Claim Evaluator (&ldquo;PACE&rdquo;) services; to ensure we identify such issues and nip them in the bud before they cause any harm, as well as protect TPAs and ASOs from unwanted fiduciary liability.</p> <p>&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; <a href="https://moneyinc.com/how-proposed-hsa-legislation-would-afford-new-employer-and-employee-freedoms/">How Proposed HSA Legislation Would Afford New Employer and Employee Freedoms</a> &ndash; September 1, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance By Corrie Cripps.pdf" target="_blank">Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance</a> &ndash; September 1, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; Patient Assistance Programs: <a href="https://moneyinc.com/patient-assistance-programs/" target="_blank">Why Many Drive Up Costs for Health Plans and Now, Patients</a> &ndash; August 9, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Much Needed Correction in the Second Circuit_ Is Relief (Equitable%2C That Is) Around the Corner_ by Christopher Aquiar.pdf" target="_blank">Much Needed Correction in the Second Circuit...Is Relief (Equitable, That Is) Around the Corner?</a> &ndash; August 2, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Free Market Healthcare Solutions &ndash; <a href="https://issuu.com/fidelispublish/docs/fmhsolutions_06_18?e=13880229/63096980" target="_blank">How Imperfect Regulatory Action May Still Create Opportunities for Self-Funding</a> &ndash; July 14, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements by Erin M_ Hussey%2C Esq.pdf" target="_blank">When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements</a> &ndash; July 12, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Free Market Healthcare Solutions &ndash; <a href="https://issuu.com/fidelispublish/docs/fmhsolutions_06_18?e=13880229/63096980" target="_blank">How Imperfect Regulatory Action May Still Create opportunities for Self-Funding</a> &ndash; July 11, 2018</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; <a href="https://moneyinc.com/state-reactions-and-their-power-over-association-health-plans/" target="_blank">State Reactions and their Power over Association Health Plans</a> &ndash; July 1, 2018</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/770/communication-breakdown-more-lessons-learned-from-my-wifes-battle-against-lymphoma" target="_blank">Communication Breakdown &ndash; More Lessons Learned from My Wife&rsquo;s Battle Against Lymphoma</a>. An important lesson from the Senior Vice President and General Counsel.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/762/a-contract-by-any-other-name" target="_blank">A Contract By Any Other Name</a>. The regulators have been impressively sparse in their opinions of reference-based pricing.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/757/has-the-life-expectancy-of-drug-rebates-been-reduced" target="_blank">Has the Life Expectancy of Drug Rebates Been Reduced?</a> The U.S. health secretary (Azar) is making some moves and has indicated that eliminating drug rebates may help reduce costs.</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/749/know-when-to-fold-em" target="_blank">Know when to fold &lsquo;em!</a> A blog post you can&rsquo;t afford to pass up!</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/745/trump-administration-halts-billions-in-aca-payments" target="_blank">Trump Administration Halts Billions in ACA Payments</a>. The Trump Administration has taken quite a beating from the Affordable Care Act..</p> <p class="bodytext" style="text-align: justify;">&nbsp;</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">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="text-align: justify;"><br /> &bull; On September 18, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/761/back-to-school-renewal-time" target="_blank">Back to School: Renewal Time</a>,&rdquo; where we discussed a laundry list of what employers, TPAs, brokers, and stop-loss carriers should look for this time of the year &ndash; and provide some guidance on how the industry&rsquo;s players can stay ahead of the curve.</p> <p class="bodytext" style="text-align: justify;">&bull; On August 14, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/753/breaking-the-mold-creative-solutions-for-everyday-problems" target="_blank">Breaking the Mold: Creative Solutions for Everyday Problems</a>,&rdquo; where we discussed complications that self-funded health plans and their partners need to be able to successfully navigate.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 12, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/742/hottest-industry-trends-and-topics-this-is-what-you-asked-for" target="_blank">Hottest Industry Trends and Topics &ndash; This is What You Asked For</a>,&rdquo; where we discussed specialty drugs, association health plans, the &ldquo;right to try&rdquo; law and more.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:Featuring Video Podcasts!</span></p> <p class="bodytext" style="text-align: justify;">&bull; On September 24, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/766/empowering-plans-p54-crossing-bridges" target="_blank">Crossing Bridges</a>,&rdquo; where Adam, Ron and Brady chat with friend and industry ally, Mark Stadler &ndash; President and CEO of BridgeHealth.</p> <p class="bodytext" style="text-align: justify;">&bull; On September 5, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/758/empowering-plans-p53-the-view-from-nova-healthcare" target="_blank">The View from Nova Healthcare</a>,&rdquo; where our hosts interview Laura Hirsch, President of Nova Healthcare Administrators.</p> <p class="bodytext" style="text-align: justify;">&bull; On August 15, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/755/empowering-plans-p52-the-view-from-siias-political-perch" target="_blank">The View from SIIA&rsquo;s Political Perch</a>,&rdquo; where our hosts, Adam Russo and Brady Bizarro, speak with Ryan C. Work &ndash; Vice President of Government Affairs at the Self-Insurance Institute of America (&ldquo;SIIA&rdquo;).</p> <p class="bodytext" style="text-align: justify;">&bull; On August 8, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/751/empowering-plans-p51-a-healthcare-homerun" target="_blank">A Healthcare Homerun</a>,&rdquo; where our hosts, Adam Russo, Brady Bizarro, and Ron Peck, chat with Mark S. Gaunya &ndash; Chief Innovation Officer and Principal of Borislow Insurance.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 26, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/748/empowering-plans-p50-where-is-ron-a-very-personal-podcast-from-the-svp" target="_blank">Where is Ron? A Very Personal Podcast from the SVP</a>,&rdquo; where Phia&rsquo;s Senior Vice President &amp; General Counsel dials in to describe where he&#39;s been, what major health issue is impacting his family, and what he hopes we can all learn from their experiences thus far - as members of the industry, potential patients, and human beings.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 23, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/746/empowering-plans-p49-issues-with-inaction-balance-billing-and-wellness-programs" target="_blank">Issues with Inaction: Balance Billing and Wellness Programs</a>,&rdquo; where Jennifer McCormick, Brady Bizarro and Erin Hussey discuss issues with inaction.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 17, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/744/empowering-plans-p48-make-cost-containment-great-again" target="_blank">Make Cost Containment Great Again</a>,&rdquo; where Brady Bizarro and Adam Russo discuss the hot topics impacting the insurance industry.</p> <p class="bodytext" style="text-align: justify;">&bull; On July 11, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/740/empowering-plans-p47-coaching-the-self-funded-industry" target="_blank">Coaching the Self-Funded Industry</a>,&rdquo; where Adam and Brady interview Rick Koven, President of Koven Consulting &amp; Coaching.</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"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/itunes.png" style="width: 251px; height: 78px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2018 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2018 charity is the Boys &amp; Girls Club of Brockton.</p> <p style="text-align: justify;"><img src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.</p> <p>&nbsp;</p> <p><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/bgc18.jpg" style="width: 600px; height: 400px;" title="" /></p> <p class="bodytext" style="text-align: justify;">With the upcoming school year arriving, The Phia Group wanted to make sure that the kids from the Boys &amp; Girls Club of Brockton were fully stocked up on school supplies. Our goal was to fill 210 backpacks with all of the supplies that they would need for a successful year. We are happy to announce we have surpassed our fundraising goal and successfully collected 13,754 items. We are so excited to pass these educational tools on to the children of the Boys &amp; Girls Club of Brockton, in hopes of a successful school year!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance</p> <p class="bodytext" style="font-weight: normal">By: Corrie Cripps &ndash; September 2018 &ndash; <a href="https://www.sipconline.net/files/Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance By Corrie Cripps.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Plan sponsors of self-insured group health plans have to balance the need for cost-containment strategies while ensuring compliance with federal health benefit mandates. Mental health parity compliance is particularly challenging to navigate as case law is still being developed in this area.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Mental Health Parity and Addiction Equity Act (MHPAEA), as amended by the Affordable Care Act (ACA), generally requires that group health plans ensure that the financial requirements and treatment limitations on mental health or substance use disorder (MH/SUD) benefits they provide are no more restrictive than those on medical or surgical benefits. Click here to read the rest of this article</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/763/the-stacks-4th-quarter-2018" target="_blank">Click here to read the rest of this article</a></p> <p><br /> <span class="bodytext"><strong>Much Needed Correction in the Second Circuit...Is Relief (Equitable, That Is) Around the Corner? </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Christopher Aguiar, Esq. &ndash; August 2018 &ndash; <a href="https://www.sipconline.net/files/Much Needed Correction in the Second Circuit_ Is Relief (Equitable%2C That Is) Around the Corner_ by Christopher Aquiar.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Third party subrogation and reimbursement rights and the State of New York have always had a bit of a contentious relationship. At every turn it seems New York is tinkering with its state laws in a way that weakens the rights of insurance companies and (they think) benefit plans of all kinds. Many arguments are available both for and against the viability of a benefit plan&rsquo;s rights in New York. As you can expect, Private Self-Funded ERISA Plans enjoy the benefit of preemption and surely do not have to be concerned with these changes in New York State Law &hellip; Or do they?</p> <p class="bodytext" style="font-weight: normal"><a href="https://www.phiagroup.com/Media/Posts/PostId/763/the-stacks-4th-quarter-2018" target="_blank">Click here to read the rest of this article</a></p> <p>&nbsp;</p> <p class="bodytext"><strong>When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements</strong></p> <p class="bodytext">By: Erin M. Hussey, Esq. &ndash; July 2018 &ndash; <a href="https://www.sipconline.net/files/When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements by Erin M_ Hussey%2C Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="text-align: justify;">Plan Administrators of self-funded plans are able to customize their benefit offerings to meet the needs of the employer group, as long as that customization is compliant. Compliance for self-funded plans subject to the Employee Retirement Income Security Act (&ldquo;ERISA&rdquo;) includes federal health-related regulations such as the Patient Protection and Affordable Care Act (&ldquo;PPACA&rdquo; or &ldquo;ACA&rdquo;) and the Mental Health Parity and Addiction Equity Act (&ldquo;MHPAEA&rdquo;). The lurking problem exposing employers, who sponsor those self-funded plans, to unexpected liability are the federal employer-related regulations. The Equal Employment Opportunity Commission (&ldquo;EEOC&rdquo;) and the Department of Justice (&ldquo;DOJ&rdquo;) have taken action to enforce compliance with certain employer-related regulations such as the Americans with Disabilities Act (&ldquo;ADA&rdquo;) and Title VII of the Civil Rights Act of 1964 (&ldquo;Title VII&rdquo;).</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/763/the-stacks-4th-quarter-2018" target="_blank">Click here to read the rest of this article</a></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a>Phia&rsquo;s Q4 Speaking Events:</p> <p class="bodytext"><strong>Phia&rsquo;s Speaking Engagements:</strong></p> <p class="bodytext">Adam Russo&rsquo;s 2018 Speaking Engagements:<br /> <br /> &bull; 1/23/18 &ndash; Q4 Intelligence Conference &ndash; Tampa, FL<br /> &bull; 2/2/2018 &ndash; Benefit Intelligence School District Conference &ndash; Phoenix, AZ<br /> &bull; 3/7/2018 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charleston, NC<br /> &bull; 3/9/2018 &ndash; CGI Business Solutions Seminar &ndash; Manchester, NH<br /> &bull; 3/14/2018 &ndash; Pareto Structure Meeting &ndash; Park City, UT<br /> &bull; 4/12/2018 &ndash; Caprock Health Care Forum &ndash; Dallas, TX<br /> &bull; 4/25/2018 &ndash; Berkley Captive Symposium &ndash; Grand Cayman Islands<br /> &bull; 4/26/2018 &ndash; Innovative Risk &ndash; Grand Cayman Islands<br /> &bull; 4/30/2018 &ndash; World Health Care Congress &ndash; Washington, DC<br /> &bull; 5/17/2018 &ndash; Prairie States Broker Event &ndash; Chicago, IL<br /> &bull; 6/21/2018 &ndash; GBSI Conference &ndash; Springfield, MO<br /> &bull; 6/26/2018 &ndash; Leavitt Annual Event &ndash; Big Sky, MT<br /> &bull; 8/24/2018 &ndash; WellHealth Workshop &ndash; Berkley Captive Program &ndash; Itasca, IL<br /> &bull; 8/29/2018 &ndash; Gus Bates Insurance &ndash; Fort Worth, TX<br /> &bull; 9/24/2018 &ndash; SIIA&rsquo;s Annual National Educational Conference &amp; Expo &ndash; Austin, TX<br /> <br /> Ron Peck&rsquo;s 2018 Speaking Engagements: &bull; 1/25/2018 &ndash; HealthFirst TPA Client Conference &ndash; Tyler, TX<br /> &bull; 3/6/2018 &ndash; SIIA National Conference &ndash; Charleston, SC<br /> &bull; 3/7/2018 &ndash; CGI Business Solutions Seminar &ndash; Manchester, NH<br /> &bull; 3/23/18 &ndash; Health Rosetta - Module 5: Next-Gen Plan Design &ndash; Boston, MA<br /> <br /> Tim Callender&rsquo;s 2018 Speaking Engagements:<br /> <br /> &bull; 2/14/2018 &ndash; BevCap Captive Group, 10th Anniversary Meeting &ndash; Kona, HI<br /> &bull; 4/25/2018 &ndash; Cypress University &ndash; Las Vegas, NV<br /> &bull; 5/7/2018 &ndash; UBA Spring Conference &ndash; Chicago, IL<br /> &bull; 5/16/2018 &ndash; Sun Life MVP Forum &ndash; Kansas City, KS<br /> &bull; 5/24/2018 &ndash; Pareto Captive Services, Contrarian Re Captive Meeting &ndash; Nashville, TN<br /> &bull; 6/25/2018 &ndash; Leavitt Conference &ndash; Big Sky, MT &bull; 7/17/2018 &ndash; HCAA TPA Summit &ndash; Minneapolis, MN<br /> &bull; 9/17/2018 &ndash; United Benefit Advisors, Fall Conference &ndash; Cincinnati, OH<br /> <br /> Jen McCormick&rsquo;s 2018 Speaking Engagements:<br /> <br /> &bull; 4/17/2018 &ndash; Texas Association of Benefit Advisors &ndash; Dallas, TX<br /> &bull; 5/16/2018 &ndash; IOA RE &ndash; Indianapolis, IN</p> <p class="bodytext">&nbsp;</p> <p>&nbsp;</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employee of the Quarter:<br /> Judith McNeil</span></p> <p class="bodytext" style="text-align: justify;">Congratulations to Judith McNeil, The Phia Group&rsquo;s Q3 2018 Employee of the Quarter! In addition to her great customer service skills, Judy is an extremely reliable employee who goes above and beyond to ensure that there is always adequate coverage in the Customer Service Department &amp; that all tasks are completed in a timely manner. She is one of the first to volunteer to come in early or stay late &amp; will do so with a smile on her face. Judy&rsquo;s passion for her job has been recognized and acknowledged by both coworkers and Plan members. Her work ethic has left an impression on coworkers to the point where when they think of Customer Service, they think of Judy.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/judith.jpg" style="width: 310px; height: 320px;" title="" /></p> <p class="bodytext">Congratulations Judith and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a>Phia News</span></p> <p class="bodytext"><strong>Phia on the Front Cover! </strong></p> <p class="bodytext" style="text-align: justify;">Check it out! <a href="https://www.linkedin.com/in/ACoAAADyqCsBI2mG3ZxzBFQhEhVdqVQYKVwKDi0/" target="_blank">Adam Russo</a> and <a href="https://www.linkedin.com/in/ACoAAAAdiyMB0LbVRzP5VS5fZ4FX8Ic3lykY2B0/" target="_blank">Ron E. Peck</a> represent The Phia Group on the cover of the Free Market Healthcare Solutions magazine! In their modeling debut, Phia&#39;s classic Dynamic Duo explain what we do at Phia and how we are helping you take control of your health plan!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/frontcover.jpg" style="width: 355px; height: 425px;" title="" /></p> <p class="bodytext"><br /> <a href="https://issuu.com/fidelispublish/docs/fmhsolutions_06_18?e=13880229/63096980" target="_blank">Click here to check out the magazine!</a></p> <a id="pcert" name="pcert"></a> <p class="bodytext"><strong>The American Red Cross Visits Phia!</strong></p> <p class="bodytext" style="text-align: justify;">The <a href="https://www.linkedin.com/company/157239/" target="_blank">American Red Cross</a> came to visit The Phia Group and 13 of our employees successfully donated a pint of blood. With those 13 donations, we were able to save 39 lives. We take great pride in knowing the impact this can have. To learn more about the American Red Cross and how you can help save a life, make sure you check out <a href="http://www.redcross.org/?scode=RSG00000E017&amp;cid=generic&amp;med=cpc&amp;source=google&amp;ds_lpt_start&amp;ds_lpt_end&amp;gclid=CjwKCAjwhcjVBRBHEiwAoDe5x1juxCAUJ2v-p39shpHFJM1eWZINWzoVe3UA9es5ggwEjFzW7QJ_uhoC5B4QAvD_BwE&amp;gclsrc=aw.ds&amp;dclid=COOh-Nv3_dkCFYO3yAodewAJFQ" target="_blank">The American Red Cross website</a>.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/redcross18.jpg" style="width: 370px; height: 343px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Phia Welcome Video</strong></p> <p class="bodytext" style="text-align: justify;">We are pleased to announce our new Phia Welcome video! This video was designed to ensure that our vision, mission and purpose was made clear to not only our clients, but to the general population. Here at Phia we would like to urge any and every one to take a look &ndash; it concerns us all. Not only do hardworking Americans deserve access to quality and affordable healthcare, we want to secure and maintain that this is a possibility for all. The Phia Group drives success through passion and we hope you can see the root of our fervent efforts through this presentation of our enterprise.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="350" src="https://www.youtube.com/embed/flTqct1Ne_I" width="600"></iframe> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>New Client Account Manager &ndash; Matthew Painten</strong></p> <p class="bodytext" style="text-align: justify;">As you may know, Matthew Painten has recently been promoted to Client Account Manager at The Phia Group, in addition to his Marketing Management role. Although you may already have a direct point of contact at Phia, please feel free to start communicating with Matthew directly for any and all of your requests. You may email him personally at MPainten@phiagroup.com or send an email to CAM@phiagroup.com.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/matthew.jpg" style="width: 481px; height: 600px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p><span class="boldtext">Job Opportunities:</span></p> <p>&bull; Health Benefit Plan Drafter, Consulting<br /> &bull; Health Benefit Plan Attorney I<br /> &bull; Staff Attorney, Provider Relations<br /> &bull; Accounts Payable Coordinator, Accounting<br /> &bull; Claim Recovery Specialist &ndash; WC, Recovery<br /> &bull; Claim and Case Support Analyst, Recovery<br /> &bull; Sales Administrative Assistant, Sales<br /> &bull; Claims Specialist, Provider Relations<br /> &bull; Sales and Marketing Internship<br /> &bull; Information Technology Internship</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Promotions </strong><br /> <br /> &bull; Ekta Gupta was promoted from ETL Specialist to Manager, Data Services Group<br /> &bull; Zack Mclaren was promoted from Case investigator to Senior Claims Recovery Specialist<br /> &bull; Catina Griffiths was promoted from Case Investigator to Case Handler</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>New Hires</strong><br /> <br /> &bull; Carlos Alvarez was hired as a Case Investigator<br /> &bull; Neal Wang was hired as an ETL Specialist<br /> &bull; Megan Colter was hired as a Health Benefit Plan Consultant<br /> &bull; Michael Litman was hired as an Intake Specialist<br /> &bull; Diana Newburg was hired as a Health Benefit Plan Consultant &ndash; PACE<br /> &bull; Nicole Russo was hired as a Case Investigator<br /> &bull; Catherine DeQuinzio was hired as a Case Investigator<br /> &bull; Derek Gorini was hired as an IT Systems Administrator</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong>Phia Fun Day:</strong></p> <p class="bodytext" style="text-align: justify;">The Phia Group&#39;s annual Phia Fun Day was nothing short of a success. The Phia Family spent the day at George&#39;s Island off Boston Harbor; there they explored Fort Warren, played beach games, and swam! Our employees more than deserve a fun day in the sun and we were happy to provide for them the best! We can&#39;t wait for next year!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/phiafun.jpg" style="width: 600px; height: 426px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Q4%202017%20Newsletter/Newsletter%202018%20Q4/footerlogo.png" 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> 776 Empowering Plans: P56 - 2019 - Fly Ball or Home Run?https://www.phiagroup.com/Media/Posts/PostId/775/empowering-plans-p56-2019-fly-ball-or-home-runPodcastsMon, 15 Oct 2018 16:36:59 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Kz0Qf0rx4Vc" width="560"></iframe></p> <p>&nbsp;</p> <p>In this episode, Ron and Adam discuss the many issues, changes and challenges 2018 has lined up for 2019, and how the outcomes we witness in 2019 are certain to change everything by 2020.&nbsp; Tune in, or suffer the consequences!</p> <p><a href="https://youtu.be/Kz0Qf0rx4Vc">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/Kz0Qf0rx4Vc">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 775Empowering Plans: P55 - Learn from the Past to Shape the Future https://www.phiagroup.com/Media/Posts/PostId/771/empowering-plans-p55-learn-from-the-past-to-shape-the-futurePodcastsMon, 01 Oct 2018 14:03:43 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/DHoSqqV4uUM" width="560"></iframe></p> <p>In this episode, our hosts sit down with industry legend and innovative leader, Jerry Castelloe of Castelloe Partners, to dissect the state of the health benefits universe, identify new issues, repeat offenders, and determine what trends, risks &ndash; and victories &ndash; from the past are shaping the future.</p> <p><a href="https://youtu.be/DHoSqqV4uUM">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/DHoSqqV4uUM">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 771Empowering Plans: P54 - Crossing Bridgeshttps://www.phiagroup.com/Media/Posts/PostId/766/empowering-plans-p54-crossing-bridgesPodcastsMon, 24 Sep 2018 14:14:52 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Qbhe6tAH0LE" width="560"></iframe></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;">In this episode, Ron, Brady, and Adam chat with friend and industry ally, Mark Stadler &ndash; President and CEO of BridgeHealth.&nbsp; As the leader of an organization whose purpose is to connect patients with the best providers &ndash; offering the highest quality care for the lowest price &ndash; regardless of geographic location, Mark and his team need to build bridges and interact with all three &ldquo;Ps&rdquo; of healthcare &ndash; the &ldquo;P&rdquo;atient, &ldquo;P&rdquo;ayer, and &ldquo;P&rdquo;rovider.&nbsp; This gives Mark unique insight that he now shares with our listeners.</p> <p><a href="https://youtu.be/Qbhe6tAH0LE">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/Qbhe6tAH0LE">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 766WestView Capital Partners Completes Growth Investment in The Phia Grouphttps://www.phiagroup.com/Media/Posts/PostId/764/westview-capital-partners-completes-growth-investment-in-the-phia-groupPress ReleasesThu, 20 Sep 2018 15:38:13 GMT<p style="text-align: justify;"><span style="color:#000000;"><strong>September 17, 2018<br /> Braintree, MA and Boston, MA</strong></span><br /> <br /> <span style="color:#000000;">The Phia Group, LLC (&ldquo;Phia&rdquo; or the &ldquo;Company&rdquo;), a provider of outsourced cost containment and payment integrity solutions to healthcare payers, today announced that it has received a growth investment from WestView Capital Partners.<br /> <br /> Headquartered in Braintree, MA, the Company&rsquo;s comprehensive suite of outsourced tech-enabled services enables healthcare payers to maximize health benefits while offsetting the rising cost of healthcare, making healthcare more affordable for their beneficiaries. As one of the leading experts in the self-funded health plan industry, Phia provides plan administrators and their groups with on-demand, knowledge expert services and support, spanning the clinical, regulatory compliance, and reimbursement aspects of the claims and benefits administration process. Phia&rsquo;s tech-enabled, data driven subrogation and claim recoupment platform has been proven to drive the highest recovery and savings rates in the industry, while its consultative and cost containment services are universally recognized as industry leaders in both innovation and outcomes.<br /> <br /> &ldquo;Phia is committed to being on the forefront of the rapid changes occurring every day in healthcare, and specifically in the self-insured market, ensuring our clients have the right tools and information to control costs and protect their plan assets,&rdquo; said Adam Russo, CEO of Phia. &ldquo;We are firm believers that the self-funded market will continue to rapidly grow and evolve and are thrilled to have partnered with WestView, whose longstanding focus not only on healthcare technology and outsourcing but specifically the reimbursement and claims payment ecosystem will help us capitalize on the numerous opportunities we see out in front of us.&rdquo;<br /> <br /> &ldquo;Through years of hard work and dedication, Phia has positioned itself as a thought leader and knowledge expert in the healthcare cost containment market,&rdquo; said Matt Carroll, General Partner at WestView, who will join Phia&rsquo;s Board of Directors along with WestView colleagues Jeff Clark and Kevin Twomey.&nbsp; &ldquo;Adam Russo and his team epitomize the type of passionate and creative entrepreneurs we have built WestView around, so it is only fitting that Phia is the first investment in our latest fund,&rdquo; added Carroll.<br /> <br /> WestView was represented by Latham &amp; Watkins with senior debt financing provided by Abacus Finance Group while Phia was represented by Covington Associates and McLane Middleton.<br /> <br /> About The Phia Group:<br /> <br /> The Phia Group is a provider of outsourced cost containment and payment integrity solutions for healthcare payers and the entities that service them. Through innovative technologies, legal expertise, and focused, flexible customer service the Company strives to maximize health benefits while reducing healthcare costs for plan administers and their beneficiaries. The Company&rsquo;s tech-enabled, knowledgeable experts and service offering span the clinical, regulatory compliance, and reimbursement aspects of the claims and benefit administration process, including plan document drafting, subrogation and overpayment recovery, claim negotiation, plan defense and consulting services, all of which are designed to control costs and protect plan assets.<br /> <br /> About WestView Capital Partners:<br /> <br /> WestView Capital Partners, a Boston-based private equity firm focused exclusively on middle market growth companies, manages approximately $1.7 billion in capital across four funds. WestView partners with existing management teams to sponsor minority and majority recapitalizations, growth, and consolidation transactions in industries such as healthcare technology and outsourcing, business services, software and IT services, consumer, and growth industrial. WestView invests in companies with operating profits between $3 million and $20 million with investment sizes ranging from $10 million to $60 million. For more information, please visit www.wvcapital.com.</span></p> <p style="text-align: justify;">&nbsp;</p> 764The Stacks - 4th Quarter 2018https://www.phiagroup.com/Media/Posts/PostId/763/the-stacks-4th-quarter-2018NewslettersWed, 19 Sep 2018 14:04:00 GMT<h1 style="text-align: justify;"><strong>Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance</strong></h1> <h3 style="text-align: justify;"><span style="color:null;"><em>By: Corrie Cripps</em></span></h3> <p style="text-align: justify;">Plan sponsors of self-insured group health plans have to balance the need for cost-containment strategies while ensuring compliance with federal health benefit mandates. Mental health parity compliance is particularly challenging to navigate as case law is still being developed in this area.</p> <p style="text-align: justify;"><strong>Background</strong></p> <p style="text-align: justify;">The Mental Health Parity and Addiction Equity Act (MHPAEA), as amended by the Affordable Care Act (ACA), generally requires that group health plans ensure that the financial requirements and treatment limitations on mental health or substance use disorder (MH/SUD) benefits they provide are no more restrictive than those on medical or surgical benefits.</p> <p style="text-align: justify;">MHPAEA generally applies to group health plans that provide coverage for mental health or substance use disorder benefits in addition to medical/surgical benefits. Some self-insured plans are exempt from MHPAEA, such as those with 50 or fewer employees.</p> <p style="text-align: justify;">The Department of Labor (DOL) has primary enforcement authority with regard to MHPAEA over private sector employment-based group health plans.<sup>1</sup></p> <p style="text-align: justify;"><strong>DOL Actions</strong></p> <p style="text-align: justify;">In April 2018, the Departments of Labor, Health and Human Services and the Internal Revenue Service issued a package of guidance on MHPAEA. Among the items was the “FY 2017 MHPAEA Enforcement Fact Sheet”, which states that in fiscal year (FY) 2017, the DOL conducted 187 MHPAEA-related investigations and cited 92 violations of MHPAEA noncompliance.<sup>2</sup></p> <p style="text-align: justify;">The Employee Benefits Security Administration (EBSA) branch of the DOL authored publications and compliance assistance materials to assist plans with MHPAEA compliance. One of these publications, “Warning Signs” is an extremely useful tool to refer to when doing a quick review of a plan document/summary plan description.<sup>3</sup> This document was published in May 2016, but the DOL is expected to publish a “Warning Signs 2.0” document in fiscal year 2018 to focus on non-quantitative treatment limitations (NQTLs), since this appears to be a problem compliance area for plans. NQTLs are generally limits on the scope or duration of benefits for treatment that are not expressed numerically, such as medical management techniques, provider network admission criteria, or fail-first policies. In terms of MHPAEA compliance, plans should ensure that any NQTLs with respect to MH/SUD benefits are comparable to the limitations that apply to the medical/surgical benefits in the same classification.</p> <p style="text-align: justify;"><strong>Current Mental Health Parity Cases</strong></p> <p style="text-align: justify;">MHPAEA does not require that self-insured group health plans cover MH/SUD benefits; it only requires that if a plan does cover MH/SUD benefits that the benefits are in parity with the medical/surgical benefits.</p> <p style="text-align: justify;">One of the challenges for plans is determining the scope of benefit types that are compared for parity purposes. Since case law is still being developed in this area, these matters continue to be unsettled.</p> <p style="text-align: justify;">The following are some recent cases that highlight this area of concern.</p> <p style="text-align: justify;"><em><u>Vorpahl v. Harvard Pilgrim Health Care Ins. Co.</u></em><u> <em>(D. Mass. July 20, 2018)</em></u><sup>4</sup></p> <p style="text-align: justify;">This focus of this case is on coverage of a “wilderness treatment program”. The plan at issue is a fully-insured plan that denied coverage for an employee’s dependent children who received treatment at a state-licensed outdoor youth treatment program that was authorized to provide mental health services. The children’s parents claim the plan’s exclusion for “health resorts, recreational programs, camps, wilderness programs, outdoor skills programs, relaxation or lifestyle programs, and services provided in conjunction with (or as part of) those programs” violates the MHPAEA and the ACA. The US District Court for the District of Massachusetts dismissed the ACA claim but denied the insurer’s motion to dismiss the MHPAEA claim, so this portion of the lawsuit will proceed.</p> <p style="text-align: justify;">What is interesting about this case is how the plan participants determined the medical/surgical equivalent of the wilderness treatment program, which is different than how the plan viewed the benefits and exclusions.</p> <p style="text-align: justify;">The plan argued that its exclusion is a categorical exclusion that applies to both medical/surgical benefits and MH/SUD benefits provided at this type of facility. The example the plan gave for the medical/surgical equivalent is a “diabetes camp”, which the plan would also exclude.</p> <p style="text-align: justify;">The plan participants argued that because the plan covers medical/surgical benefits provided at other inpatient treatment settings it should cover this wilderness treatment program setting as well since it is an equivalent type of treatment setting.  In support of their position, they cited the <em>Joseph F. v. Sinclair Servs. Co.</em> case from 2016, in which the court ruled that the plan violated MHPAEA by covering skilled nursing facilities but not covering residential treatment facilities.</p> <p style="text-align: justify;">So which comparison is correct—the more specific setting comparison, or the broader category comparison? There is currently no direct guidance on this issue.</p> <p style="text-align: justify;">While this case is still at its early stages procedurally, we will be watching to see how it develops.</p> <p style="text-align: justify;"><em><u>Bushell v. Unitedhealth Group Inc., 2018 WL 1578167 (S.D.N.Y. 2018)</u></em><sup>5</sup></p> <p style="text-align: justify;">The question in this case is how to determine the MH/SUD equivalent of the plan’s “nutritional counseling” benefit.</p> <p style="text-align: justify;">In this case, the plan participant who has anorexia nervosa sued the insurer after it denied her claim for nutritional counseling to treat her condition. The insurer asserted that nutritional counseling was not covered under the plan.</p> <p style="text-align: justify;">The plan participant argued that the plan covered such counseling for non-mental health conditions, such as diabetes, and therefore was in violation of MHPAEA. The insurer asked the court to dismiss the claim, arguing that the counseling services that were requested were not in the same classification as the counseling services that were covered under the plan. The court refused to dismiss the claim, therefore allowing the case to proceed.</p> <p style="text-align: justify;">The parity rules under MHPAEA are applied on a classification basis. Therefore, if a plan provides mental health or substance use disorder benefits in any “classification”, then mental health and substance use disorder benefits must be provided in every classification in which medical/surgical benefits are provided. Those classification requirements apply to the following:</p> <ul> <li style="text-align: justify;">Inpatient, in-network</li> <li style="text-align: justify;">Inpatient, out-of-network</li> <li style="text-align: justify;">Outpatient, in-network</li> <li style="text-align: justify;">Outpatient, out-of-network</li> <li style="text-align: justify;">Emergency care; and</li> <li style="text-align: justify;">Prescription drugs</li> </ul> <p style="text-align: justify;">In this particular case, the medical/surgical benefit of diabetes nutritional counseling was covered within the “outpatient, out-of-network” classification (as noted by the court in this case), but the mental health benefit for anorexia nutritional counseling, which may also fall into that classification, was not. Therefore, if mental health is covered under the plan, and the medical/surgical benefit of nutritional counseling for diabetes is covered in any of the classifications listed above, then the mental health benefit of nutritional counseling must be provided in parity in that same classification(s).</p> <p style="text-align: justify;">The plan participant makes a good argument for parity here. Plans that cover both (1) mental health benefits and (2) the medical/surgical benefit of diabetes nutritional counseling should take the conservative approach and cover mental health nutritional counseling as an additional benefit. Another option would be for the plan to provide a “Nutritional Counseling” benefit that is more general, and not specific to just diabetes.</p> <p style="text-align: justify;">The results are pending in this case but we will be tracking the outcome. Plans should be aware that eating disorder treatments are considered mental health benefits. Congress addressed this in section 13007 of the 21<sup>st</sup> Century Cures Act and this subject was also addressed in the FAQs that the Departments issued on June 16, 2017.<sup>6,7</sup> Plans should be cautious when reviewing plan exclusions to ensure they cannot be interpreted as applying a limit on an eating disorder treatment.</p> <p style="text-align: justify;"><strong>Conclusion</strong></p> <p style="text-align: justify;">The DOL’s published enforcement reports suggest that the DOL is continuing to investigate compliance with MHPAEA. In addition, based on current litigation, it appears there is a fairly low burden to state a claim under MHPAEA that survives a motion to dismiss. Plan sponsors should review cost-containment techniques with counsel to ensure they are designed to mitigate risk in this area while ensuring compliance.</p> <p style="text-align: justify;"><em>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.  </em></p> <p style="text-align: justify;"> </p> <div> <div id="ftn1"> <p style="text-align: justify;"><em><sup>1</sup> The Mental Health Parity and Addiction Equity Act (MHPAEA),</em> <a href="https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html">https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html</a>, (last visited August 8, 2018).</p> </div> <div id="ftn2"> <p style="text-align: justify;"><em><sup>2</sup> FY 2017 MHPAEA Enforcement Fact Sheet,</em> <a href="https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/mhpaea-enforcement-2017.pdf">https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/mhpaea-enforcement-2017.pdf</a>, (last visited August 8, 2018).</p> </div> <div id="ftn3"> <p style="text-align: justify;"><em><sup>3</sup> Warning Signs – Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) that Require Additional Analysis to Determine Mental Health Parity Compliance,</em> May 2016, <a href="https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/mental-health-parity/warning-signs-plan-or-policy-nqtls-that-require-additional-analysis-to-determine-mhpaea-compliance.pdf">https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/mental-health-parity/warning-signs-plan-or-policy-nqtls-that-require-additional-analysis-to-determine-mhpaea-compliance.pdf</a>, (last visited August 8, 2018).</p> </div> <div id="ftn4"> <p style="text-align: justify;"><em><sup>4</sup> Vorpahl v. Harvard Pilgrim Health Care Ins. Co.</em> <em>(D. Mass. July 20, 2018), </em><a href="https://www.bloomberglaw.com/public/desktop/document/Vorpahl_v_Harvard_Pilgrim_Health_Ins_Co_No_17cv10844DJC_2018_BL_2?1533762894">https://www.bloomberglaw.com/public/desktop/document/Vorpahl_v_Harvard_Pilgrim_Health_Ins_Co_No_17cv10844DJC_2018_BL_2?1533762894</a>, (last visited August 8, 2018).</p> </div> <div id="ftn5"> <p style="text-align: justify;"><sup>5</sup> Bushell v. Unitedhealth Group Inc., 2018 WL 1578167 (S.D.N.Y. 2018), <a href="https://law.justia.com/cases/federal/district-courts/new-york/nysdce/1:2017cv02021/471192/38/">https://law.justia.com/cases/federal/district-courts/new-york/nysdce/1:2017cv02021/471192/38/</a>, (last visited August 8, 2018).</p> </div> <div id="ftn6"> <p style="text-align: justify;"><sup>6</sup> 21<sup>st</sup> Century Cures Act, Pub. L. No. 114-255 (2016).</p> </div> <div id="ftn7"> <p style="text-align: justify;"><sup>7 </sup>FAQs About Affordable Care Act Implementation Part 38 and Mental Health And Substance Use Disorder Parity Implementation, <a href="https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-38.pdf">https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-38.pdf</a>, (last visited August 8, 2018).</p> <p>__________________________________________________________________________________________________________</p> <h1>Much Needed Correction in the Second Circuit … Is Relief (Equitable, That Is) Around the Corner?</h1> <h3><span style="color:#000000;"><em>By: Christopher Aguiar, Esq.</em></span></h3> <p> </p> <p>Third party subrogation and reimbursement rights and the State of New York have always had a bit of a contentious relationship.  At every turn it seems New York is tinkering with its state laws in a way that weakens the rights of insurance companies and (they think) benefit plans of all kinds.  Many arguments are available both for and against the viability of a benefit plan’s rights in New York.  As you can expect, Private Self-Funded ERISA Plans enjoy the benefit of preemption and <em>surely</em> do not have to be concerned with these changes in New York State Law … Or do they?</p> <p>Ask any attorney practicing personal injury law in the State of New York and most will argue(rather aggressively, in fact) that New York does not allow subrogation and reimbursement under any circumstances, and that they have the federal case law to prove it.  <em>Sereboff v. Mid Atlantic Medical Services, Inc.</em> and its progeny be damned, despite providing that a benefit plan with clear and explicit plan terms allowing for recovery without reduction is entitled to full recovery so long as it is proactive and can trace the actual settlement fund to traceable assets.  547 U.S. 356 (2006).  See also <em>US Airways, Inc. v. McCutchen</em>, 133 S.Ct. 1537 (2013). To them a quick read of <em>Wurtz v. Rawlings</em> is the law of the land. 761 F.3d 232 (2014).</p> <p>Recall <em><u>Wurtz</u></em> in 2014 when the Second Circuit Court of Appeals held that United Health, a fully insured benefit plan arrangement, was unable to satisfy the Davila test and obtain complete preemption from state law, and accordingly, the New York anti-subrogation law would apply to eliminate the rights of United Health and eradicate its right of recovery. <em>Aetna Health Inc. v. Davila</em>, 542 U.S. 200, 208 (2004).  That outcome, alone, is not all that surprising given the health plans fully insured status.  <em>Wurtz</em>, 761 F.3d. at n. 6. </p> <p>What did come as a bit of a surprise was the way in which the Second Circuit reached that decision.  Essentially, the court reasoned in a long, somewhat convoluted opinion that a law suit by a plan beneficiary against its employee benefit plan to enforce an anti-subrogation law does not “relate to” employee benefits and therefore cannot be preempted on a defensive pleading.  In pertinent part, the court stated:</p> <p style="margin-left:.5in;">This expansive interpretation of complete preemption ignores the fact that plaintiffs' claims are based on a state law that regulates insurance and are not based on the terms of their plans. As a result, state law does not impermissibly expand the exclusive remedies provided by ERISA § 502(a). Under ERISA § 514(a)-(b), state laws that "relate to" ERISA plans are expressly preempted, but not if they "regulate[] insurance." 29 U.S.C. § 1144(a)-(b). Based on this "insurance saving clause," the Supreme Court has held that state statutes regulating insurance that nonetheless affect ERISA benefits are not expressly preempted, with no hint that claims under these statutes might still be completely preempted and thus unable to be adjudicated under those state laws when they do not expand the remedies available for beneficiaries for claims based on the terms of their plans. <em>See </em>Rush Prudential HMO Inc. v. Moran, 536 U.S. 355, 377-79, 122 S.Ct. 2151, 153 L.Ed.2d 375 (2002); UNUM Life Ins. Co. of Am. v. Ward, 526 U.S. 358, 366-67, 119 S.Ct. 1380, 143 L.Ed.2d 462 (1999).</p> <p>This effectively created a race to the courthouse steps.  If the participant first sues the plan for enforcement of an anti-subrogation law, the plan would not be able to claim preemption and would be unable to litigate in federal court, potentially unable to enforce its right of recovery.<sup>1</sup>  Every plaintiff’s lawyer in New York (along with its sister states Connecticut and Vermont, all notoriously anti subrogation) was provided the leverage they needed to look at all benefit plans, even private self-funded plans whose rights have repeatedly been protected by The Supreme Court of the United States, and force them into settlements.  After all, do the plans really want to end up in state court and argue with a court consisting of New York judges with a bias against subrogation that just went to great lengths to interpret incorrectly ERISA’s preemption framework in order to reach its outcome?  Interestingly, the court itself acknowledged in footnote 6 of the decision that the outcome for a private self-funded plan would likely be different.  The footnote stated:</p> <p style="margin-left:.5in;">The issue in <em>FMC</em> was the effect of the so-called "deemer clause" of ERISA § 514(b)(2)(B), which exempts self-funded plans from the savings clause. The Supreme Court held that the deemer clause did not cause preemption of the entire statute in all cases, but only as applied to self-funded plans. <a href="https://scholar.google.com/scholar_case?case=5109237005708100614&hl=en&as_sdt=2006&as_vis=1">498 U.S. at 61, 111 S.Ct. 403</a>. Under <em>FMC,</em> the applicability of N.Y. Gen. Oblig. Law § 5-335 to self-funded plans would only mean that the law is preempted as applied to those plans (which is not the case here because the plans at issue are insured), not that the law is not "specifically directed" at insurance.  </p> <p style="margin-left:.5in;"><em>Wurtz</em>, 761 F.3d. at n. 6.</p> <p>You see, even there the court conceded that this outcome was based on the fact that this was an insured Plan, but of particular concern is how the Court determined that anti subrogation law did not relate to the benefit Plan.</p> <p>So really, what is the problem here?  It appears the court clearly misinterpreted ERISA’s preemption framework, while likely still reaching a correct outcome given that particular plans’ fully insured status, and even conceded that the outcome would likely be different for a Private Self-funded Plan?  Well, the problem is simple.  We lawyers find any leverage point we have and use it to our full advantage.  The fact of the matter is that that law is only as good as what can and reasonably in prudently be enforced, and lawsuits are expensive.  That, along with considering the risk of the Second Circuit Court again misinterpreting the “relation to” portion of ERISA, can be a risky proposition and not always a prudent use of Plan assets to win the race to the Court, so to speak.</p> <p>Enter <em>Cognetta v. Bonavita</em>, a case this author hopes is the beginning of a clarification of the decision in <em><u>Wurtz</u></em> that will finally give plan representatives the tool they need to once and for all quiet this race to the court nonsense.  E.D.N.Y. No. 1:17-cv-03065 (2018).  In <em><u>Cognetta</u></em>, the Plan paid approximately $110,000.00 to cover the medical expenses of plan participants injured in an automobile accident.  In an abundance of caution, the Plan got way ahead of the game and won the race to the court.  In fact, the Plan did not even wait for the case to settle.  Instead, while the participant’s injury claims were still pending with the third party, the Plan shrewdly filed for a Declaratory Judgement asking the court to determine that it did, in fact, have an equitable lien and a constructive trust over the possible settlement funds and sought a Court Order that upon settlement, those funds were to be held in Trust.</p> <p>Much to the delight of self-funded benefit plans everywhere, the court ruled in favor of the Plan.  Among the most interesting parts of the decision was how this court laid out the most important part of the entire dispute in <em><u>Wurtz</u></em>, and that is, how the Court handled this “relation to” notion.  In <em>Cognetta</em>, the Court provided in pertinent part:</p> <p style="margin-left:.5in;">…The purpose of ERISA is to provide a uniform regulatory regime over employee benefit plans." Aetna Health Inc. v. Davila, 542 U.S. 200, 208 (2004). To that end, ERISA Section 514(a) expressly preempts "any and all" state laws that "relate to any employee benefit plan." 29 U.S.C. § 1144(a). A state law "relate[s] to" an employee benefit plan if that law "has a connection with or reference to such a plan." Franklin H. Williams Ins. Tr. v. Travelers Ins. Co., 50 F.3d 144, 148 (2d Cir. 1995) (quoting Metro. Life Ins. Co. v. Massachusetts, 471 U.S. 724, 739 (1985)). The scope of ERISA's express preemption clause is "as broad as its language." FMC Corp. v. Holliday, 498 U.S. 52, 59 (1990) (quoting Shaw v. Delta Air Lines, 463 U.S. 85, 98 (1983))…</p> <p style="margin-left:.5in;">Even where a state law "relate[s] to" an employee benefit plan, however, ERISA does not expressly preempt that law if it "regulates insurance." 29 U.S.C. § 1144(b). A law "regulates insurance" if it is "specifically directed towards entities engaged in insurance" and "substantially affect[s] the risk pooling arrangement between the insurer and the insured." Wurtz v. Rawlings Co., 761 F.3d 232, 240 (2d Cir. 1994) (quoting Kentucky Ass'n of Health Plans, Inc. v. Miller, 538 U.S. 329, 342 (2003)). In such a situation, the state law is "saved" from express preemption. <em>Id.</em> Nevertheless, an employee benefit plan governed by ERISA cannot be "deemed . . . an insurance company or other insurer . . . for purposes of any law of any State purporting to regulate insurance." 29 U.S.C. § 1144(b)(2)(B). That is, a state law cannot escape ERISA preemption by erroneously classifying an employee benefit plan as "insurance." <em>See id.</em></p> <p style="margin-left:.5in;">Whether a state law that regulates insurance applies to a plan or is preempted by ERISA depends on whether the plan purchases insurance. <em>See </em>FMC Corp., 498 U.S. at 64; <em>see also </em>Arnone v. Aetna Life Ins. Co., 860 F.3d 97, 107 (2d Cir. 2017). Where a plan buys insurance, it "remains an insurer for purposes of state laws `purporting to regulate insurance.'" FMC Corp., 498 U.S. at 61. By contrast, where a plan is self-funded and does not purchase insurance from an insurance company, ERISA "exempt[s]" the plan "from state laws that `regulat[e] insurance.'" <em>Id.</em> (second alteration in original); <em>see also </em>Wurtz, 761 F.3d at 241 n.6. …</p> <p><em>Cognetta, </em>E.D.N.Y. No. 1:17-cv-03065</p> <p>And in that last paragraph lies the crux of the issue.  It is because the private self-funded plan does not purchase insurance, and under ERISA’s Deemer clause, cannot be considered “insurance” that application of the rule in <u>Wurtz</u> is incorrect as it relates to self-funded benefit plans.  Once one determines that a plan is not insurance pursuant to the Deemer clause, it is then that we determine whether the law a participant is seeking to enforce “relates to” an employee benefit Plan.  An anti-subrogation clause is by definition the attempt of a plan participant to seek benefits to which it is not entitled, i.e. the ability to keep benefits paid which are subject to a subrogation or reimbursement obligation.  </p> <p>While this is indeed an exciting development, some notes of caution. </p> <p>First, this decision was reached at the Federal Trial Court level.  There are three other Federal districts in New York and none of them have binding authority over the other; meaning that if this exact same issue were to be heard in the Southern District of New York, the outcome could be different. If and only if this decision is appealed, heard, and upheld, by the Second Circuit Court of Appeals will it then be the law of the land in all Federal Districts under the purview of the Second Circuit, including Connecticut and Vermont.  Until then, this decision simply gives plans the same leverage New York attorneys had against them, the risk of loss and cost of pursuit rendering such pursuit an imprudent use of funds, be that due to fiduciary concerns with respect to the plan, or practical concerns with the respect to the participant.</p> <p>Second, and perhaps most importantly, the ability of self-funded benefit plans to win on any issue in Federal Court in the Land still rests on one very basic concept … plan language.  If the Plan language is insufficient in any way, a plan is at serious risk of losing its rights.  In <em>Cognetta</em>, the Plan was well drafted, and assuming the Second Circuit makes good on its Footnote in the <em>Wurtz</em> decision, It would likely uphold the decision in the <em>Cognetta</em> case upon appeal.</p> <p>We will have to wait and see how this plays out. Either way, it is an exciting development in the Second Circuit and finally provides what looks to be a light at the end of the tunnel on the <em>Wurtz</em> problem in the Second Circuit.  Make no mistake, New York lawyers will find other ways to make our road to recovery more difficult.  Having the right tools and partners in place to identify recovery opportunities and act on them continues to be the best way to protect plan funds.  Then all we can do is roll with the punches, and every so often, we’ll get some relief!</p> <p> </p> <div> <div id="ftn1"> <p><sup>1 </sup>This can present insurmountable challenges in some states, such as Illinois, where state courts have repeatedly refused to apply clear plan terms that conflict with state laws. <em>Bishop v. Burgard</em>, 764 N.E. 2d 24 (Ill. 2002). As an intermediate court of appeals in the state noted “…<em>McCutchen</em> may foreshadow a different result than our supreme court has pronounced in the past.” <em>Schrempf, Kelly, Napp & Darr, Ltd. v. Carpenters’ Health and Welfare Trust Fund</em>, 35 N.E.3d 988 (2015).</p> </div> </div> <p>__________________________________________________________________________________________________________</p> <h1>When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements</h1> <h3><span style="color:#000000;"><em>By: Erin M. Hussey, Esq.</em></span></h3> <p>Plan Administrators of self-funded plans are able to customize their benefit offerings to meet the needs of the employer group, as long as that customization is compliant. Compliance for self-funded plans subject to the Employee Retirement Income Security Act (“ERISA”) includes federal health-related regulations such as the Patient Protection and Affordable Care Act (“PPACA” or “ACA”) and the Mental Health Parity and Addiction Equity Act (“MHPAEA”). The lurking problem exposing employers, who sponsor those self-funded plans, to unexpected liability are the federal employer-related regulations. The Equal Employment Opportunity Commission (“EEOC”) and the Department of Justice (“DOJ”) have taken action to enforce compliance with certain employer-related regulations such as the Americans with Disabilities Act (“ADA”) and Title VII of the Civil Rights Act of 1964 (“Title VII”).</p> <p>Provided below are examples of when an exclusion in a self-funded plan, such as an excluded medical condition or treatment for that medical condition, can be compliant with the applicable health-related regulations, such as the ACA and MHPAEA, but that same medical condition is still afforded protection under employer-related regulations such as the ADA and Title VII.  </p> <p><strong>ACA and Title VII Compliance</strong></p> <p><em>Discrimination on the Basis of Sex</em></p> <p>The ACA’s Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability with regards to certain covered entities’ health programs. A covered entity is one that receives federal funding as outlined in the ACA. The convoluted issue is whether treatment for gender identity is a protected class under the category of “discrimination based on sex.” While Section 1557 does not specifically state that plans subject to it must cover gender transition surgery, the rules do state that the Health and Human Services, Office for Civil Rights (“HHS, OCR”) will investigate any complaints. With that said, the December 31, 2016, U.S. District Court injunction (applicable nationwide) was placed on certain parts of Section 1557, including the prohibitions against discrimination on the basis of gender identity and termination of pregnancy, and that injunction is still in effect. The DOJ’s recent guidance, while it does not specifically address Section 1557, appears to hint that the current administration is not going to ask a federal judge to lift the current injunction.</p> <p>The self-funded plans that are not directly subject to Section 1557, because of the lack of federal funds, must still comply with the ACA. There are no actual benefit mandates for transgender services under the ACA for self-funded plans that are not subject to Section 1557. Therefore, there does not appear to be a direct benefit compliance issue for plans that exclude treatment for gender identity. Regardless, there is the potential for a discrimination issue under Title VII which may draw unwanted attention from the EEOC (as HHS does not have the authority in this case).  </p> <p>Whether a Plan is or is not subject to Section 1557, it would still be a plan’s best practices to cover gender identity services since employers are not shielded from liability under Title VII. Title VII prohibits employment discrimination based on race, color, religion, sex and national origin, and the EEOC’s interpretation of its prohibition on discrimination based on sex, includes discrimination based on gender identity and sexual orientation. The EEOC, as an independent commission, takes the stance that employees who undergo gender reassignment are protected under Title VII.  For example, the EEOC filed an amicus brief on August 22, 2016, arguing that an individual’s gender dysphoria made gender reassignment surgery “medically necessary” and that the failure to cover this surgery was a sex discrimination violation of Title VII. The case for which this amicus brief was filed, involved a self-funded health plan that had a sex transformation surgery exclusion. The above-noted case is a perfect example of when an exclusion that complies with health-related regulations can cause a discrimination lawsuit to be brought by the EEOC against the employer. Therefore, Plan Administrators must proceed with caution when excluding treatment for gender identity or dysphoria, even if they are not subject to Section 1557, because the EEOC may still have a discrimination claim under Title VII.</p> <p><strong>MHPAEA and ADA Compliance</strong></p> <p><em>Mental Health</em></p> <p>The MHPAEA requires mental health and substance use disorder benefits to be covered in parity with the plan’s medical and surgical benefits. The Department of Labor (“DOL”) recently issued proposed FAQs on mental health and substance use disorder parity, and they seem to imply that a plan can compliantly exclude a particular medical condition (i.e., autism), because the exclusion of all benefits for a particular condition would not be considered a “treatment limitation” in the MHPAEA regulations. Comments on these proposed FAQs should be submitted to the DOL by June 22, 2018. As for the medical condition of autism, there is currently no consensus in the medical community regarding whether autism should be classified as a mental health disorder (psychiatric disorder) or a neurological/developmental disorder. With that said if a private self-funded ERISA plan chose to explicitly exclude autism there would be no direct violation of the MHPAEA or the ACA.</p> <p>Excluding the medical condition of autism does not, however, shield the employer from responsibilities they have under the ADA. Pursuant to the ADA, a “qualified individual with a disability” must be provided with reasonable accommodations unless the employer can show that the accommodation would impose an undue hardship to them. An employee with autism, who would qualify as a disabled individual under the ADA, may request such reasonable accommodations.</p> <p>A violation of the ADA could result in a lawsuit being brought by the EEOC. For example, the EEOC filed a lawsuit against an employer in California who did not provide reasonable accommodations to their employee with autism. The employer was subject to a large fine, agreed to change their policies and procedures, and will also submit annual reports to the EEOC regarding compliance. Therefore, even if the medical condition of autism is compliantly excluded under the plan, the employer still has to comply with the ADA, such as providing reasonable accommodations. In addition, given the EEOC’s protection of individuals with autism, the EEOC may find an exclusion of autism to be discriminatory and employers of self-funded plans must be cautious.</p> <p><em>Substance Use Disorder</em></p> <p>As discussed above, private self-funded ERISA plans are not required to cover mental health and substance use disorder benefits, but if they do, they must cover them in parity with the medical and surgical benefits. In other words, if a plan chooses not to cover these benefits at all, the plan would still be in compliance with the ACA and the MHPAEA. With that said, this will pose the same situation as above, because even if these benefits are not covered, employees would still have federal rights under the ADA.</p> <p>For example, a qualified individual in Massachusetts had sought treatment for opioid use disorder and was denied treatment by a skilled nursing facility, creating action to be taken by the DOJ. The complaint was brought under the ADA because it was determined that these individuals were disabled on the basis of opioid use disorder. On May 10, 2018, the United States of America entered into a Settlement Agreement with Charlwell Operating, LLC, the skilled nursing facility, wherein the facility was found to be discriminating against individuals seeking treatment for opioid use disorder in violation of the ADA. The outcome of that settlement involved a penalty to be paid by the facility, and they were to adopt policies and conduct training, including training on the ADA itself.</p> <p>Although this settlement involved discrimination by a provider and not an employer, it brings to light that the ADA protects and encompasses medical conditions that, at the same time, are not covered under the plan. If a medical condition is not covered, the employer must still ensure that reasonable accommodations and potential discrimination issues are being monitored.  </p> <p><strong>Meeting at the Crossroads</strong></p> <p>Plan Administrators of self-funded plans should always keep in mind the protections of certain medical conditions that are enforced by the EEOC and DOJ. These protections are outside the realm of health-related requirements but inside the realm of employer-related requirements. When a plan’s benefit offerings or exclusions are compliant with the applicable health-related regulations, it does not mean the employer who sponsors that plan is safeguarded from (1) exclusions that may be deemed discriminatory under the ADA and Title VII, (2) the ADA requirements, such as reasonable accommodations, for those excluded medical conditions, or (3) general workplace discrimination regarding those excluded medical conditions.</p> <p> </p> </div> </div> 763Back to School: Renewal Timehttps://www.phiagroup.com/Media/Posts/PostId/761/back-to-school-renewal-timeWebinarsTue, 18 Sep 2018 14:03:38 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/lXjQDdY_qcU" width="560"></iframe></p> <p>In the self-funded industry, being diligent with respect to employer groups, vendors, and contracts is always important – but sometimes knowing what to put on a checklist in the first place is more difficult than checking off the items. Renewal time means it’s time to impress prospective clients, keep existing clients happy, and make sure the vendors and contracts being utilized are the best possible fit for your groups.<br />  <br /> Join The Phia Group’s legal team for an hour as they outline a laundry list of what employers, TPAs, brokers, and stop-loss carriers should look for this time of the year – and provide some guidance on how the industry’s players can stay ahead of the curve.</p> <p><a href="https://youtu.be/lXjQDdY_qcU">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 761Empowering Plans: P53 - The View from Nova Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/758/empowering-plans-p53-the-view-from-nova-healthcarePodcastsWed, 05 Sep 2018 15:37:04 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/HPMdov3hmOs" width="560"></iframe></p> <p>In this episode of Empowering Plans, Adam Russo and Jennifer McCormick interview Laura Hirsch, President of Nova Healthcare Administrators. They discuss the latest stop-loss trends, patient assistance programs for prescription drugs, and other issues facing the self-funded industry.</p> <p><a href="https://youtu.be/HPMdov3hmOs">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/HPMdov3hmOs">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 758Empowering Plans: P52 - The View from SIIA’s Political Perchhttps://www.phiagroup.com/Media/Posts/PostId/755/empowering-plans-p52-the-view-from-siias-political-perchPodcastsWed, 15 Aug 2018 18:03:50 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/7UGyV4aldnU" width="560"></iframe></p> <p>In this episode, Adam Russo and Brady Bizarro speak with Ryan C. Work &ndash; Vice President of Government Affairs at the Self-Insurance Institute of America (&ldquo;SIIA&rdquo;). They talk politics, D.C., and more importantly, about the efforts of the Government Relations Committee to advocate for the self-insured industry. From stop-loss protections and an updated &ldquo;ERISA Notebook&rdquo; to new wellness program rules, Ryan reveals the top issues on SIIA&rsquo;s political agenda and explains how member engagement can really make a difference.</p> <p><a href="https://youtu.be/7UGyV4aldnU">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/7UGyV4aldnU">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 755Breaking the Mold: Creative Solutions for Everyday Problemshttps://www.phiagroup.com/Media/Posts/PostId/753/breaking-the-mold-creative-solutions-for-everyday-problemsWebinarsTue, 14 Aug 2018 15:25:46 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/hHJABNMNsek" width="560"></iframe></p> <p>From drafting the plan document all the way to recovering subrogation claims, health plans (and the TPAs, brokers, stop-loss carriers, and other vendors that service them) need to be creative, diligent, and vigilant. Network contracts, stop-loss claims, and intricate medical claim determinations are just a few of the complications that self-funded health plans and their partners need to be able to successfully navigate.<br />  <br /> Join The Phia Group’s legal team for an hour as they discuss some common snafus that health plans and TPAs face, and propose some creative solutions for managing them.</p> <p><a href="https://youtu.be/hHJABNMNsek">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> <p> </p> <p>Check out these highlight snippets from our August 14 Webinar:</p> <h2> </h2> <p><strong>July 2018 PGC FAQs (11 minutes into Webinar)</strong></p> <p> </p> <p> </p> <h3><strong>Q</strong>: What is the difference between ADA Leave & Short-Term Disability/Long-Term Disability Leave?</h3> <p> </p> <p><strong>Jennifer McCormick:</strong> Continuation of coverage versus a leave of absence are completely different concepts. ADA leave, specifically, is granted to an individual as a reasonable accommodation. Employers began adding these provisions to their plans due to the UPS case in which there was an individual who was pregnant and unable to continue delivering packages for UPS and there was no other function that she could perform. Thus, the reasonable accommodation for her was a leave of absence under the ADA. This is separate from short-term disability or long-term disability in that the leave under the ADA is an accommodation, as opposed to a designated leave granted through a specific employer policy.</p> <p> </p> <h2> </h2> <p> </p> <p><strong>Network Contracts (28 minutes into Webinar)</strong></p> <p> </p> <p> </p> <h3><strong>Q</strong>: What can plans do about network contracts?</h3> <p> </p> <p><strong>Jon Jablon</strong>: First, plans can terminate network contracts. Obviously, you should not do this before notifying the parties involved. However, in terminating the contracts, there are many reference-based pricing (RBP) vendors out there that can help you achieve your payment goals. Every RBP vendor has their own style and techniques, so we recommend you vet each one prior to making a decision. RBP also includes carve-out options, and some popular ones associated with high-dollar claims are dialysis carve-outs and air ambulance carve-outs. If are seeing claims that you can carve out of your plan, chances are there is some way to address it. It is also possible to carve out all out-of-network claims – so not just dialysis or air ambulance. This would be anything not covered by the preferred provider organization (PPO) contract.</p> <p> </p> <p> </p> <p> </p> <h2><strong>Stop-Loss Issues (46 minutes into Webinar)</strong></h2> <p> </p> <p> </p> <h3><strong>Q</strong>: What are some important stop-loss issues that plans should be aware of?</h3> <p> </p> <p><strong>Brady Bizarro</strong>: We have seen a lot more new disputes lately. Many have to do with soft gaps, which may not catch your eye if you are reviewing a stop-loss policy on its own. For example, there may only be four exclusions and it may say that it otherwise mirrors the plan document, but you may not always be good to go. First, the treatment of Pharmacy Benefit Manager (PBM) rebates, which can be an issue if you have a high volume of drug claims. A plan, in theory, gets rebates from drug manufacturers, but in reality, it is the PBM who is getting those rebates. One plan’s stop-loss carrier somehow found out about these rebates through an audit and was then reducing the reimbursement amounts by the rebate figures, even if it was the PBM and not the plan getting money. The key was interpreting the wording, as some carriers may use “refund” instead of “rebate”. Another issue relates to billing protocols, as some stop-loss policies will reimburse claims in accordance with “standardized billing protocols”. Some carriers even cite Centers for Medicare & Medicaid Services (CMS) billing protocols even though CMS is not the payer and this is a private payer. Medicare reimbursement rates are not the issue here, it is the way Medicare itself pays claims.</p> 753Empowering Plans: P51 - A Healthcare Homerunhttps://www.phiagroup.com/Media/Posts/PostId/751/empowering-plans-p51-a-healthcare-homerunPodcastsWed, 08 Aug 2018 14:17:40 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/PbCtpNfMs2Q" frameborder="0" allow="autoplay; encrypted-media" allowfullscreen></iframe> <p style="text-align: justify;"><span style="font-size:11.0pt;font-family:&quot;Calibri&quot;,sans-serif; mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;color:black; mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">In this episode, Adam Russo, Brady Bizarro, and Ron Peck (yes - he&rsquo;s back!), chat with Mark S. Gaunya &ndash; Chief Innovation Officer and Principal of Borislow Insurance.&nbsp; As an author, innovator, and passionate industry advocate touting more than 25 years of experience, Mark doesn&rsquo;t pull punches as he addresses the biggest opportunities and threats facing employers, employees, and their plans.&nbsp; If you want to know what&rsquo;s wrong with the nation&rsquo;s healthcare system, what we need to do to fix it, and enjoy it when someone teases Adam &ndash; this episode is a must listen.</span></p> <p><a href="https://youtu.be/PbCtpNfMs2Q">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/PbCtpNfMs2Q">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 751Empowering Plans: P50 - Where is Ron? A Very Personal Podcast from the SVPhttps://www.phiagroup.com/Media/Posts/PostId/748/empowering-plans-p50-where-is-ron-a-very-personal-podcast-from-the-svpPodcastsThu, 26 Jul 2018 15:29:04 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/wBnp-f6QiQ4" frameborder="0" allow="autoplay; encrypted-media" allowfullscreen></iframe> <p style="text-align: justify;">In this episode, our Senior Vice President &amp; General Counsel dials in to describe where he&#39;s been, what major health issue is impacting his family, and what he hopes we can all learn from their experiences thus far - as members of the industry, potential patients, and human beings.</p> <p><a href="https://youtu.be/wBnp-f6QiQ4">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/wBnp-f6QiQ4">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 748Empowering Plans: P49 - Issues with Inaction: Balance Billing and Wellness Programshttps://www.phiagroup.com/Media/Posts/PostId/746/empowering-plans-p49-issues-with-inaction-balance-billing-and-wellness-programsPodcastsMon, 23 Jul 2018 17:32:15 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/QKsOkr4C7sA" width="560"></iframe></p> <p>In this episode, hosts Jennifer McCormick, Brady Bizarro and Erin Hussey discuss issues with inaction. The first issue is with balance billing, and a recent case involving a patient who was balance billed and refused to pay the bill. The hospital now seeks declaratory judgement stating that the patient-hospital contract is valid. This case is a good example of the interaction of third party agreements and the SPD, and the ongoing issue of the reasonableness of Chargemaster rates. The second issue is with wellness incentive rules and the lack of guidance from the EEOC, following the <em>AARP v. EEOC </em>case. This EEOC was ordered to re-write wellness program rules regarding incentives and issue proposed rules on August 31, 2018, with an effective date of January 1, 2019. If the EEOC does not re-write the rules, the old rules (the 30% incentive maximum) will be vacated and there will be no new rules for employers to follow.</p> <p><a href="https://youtu.be/QKsOkr4C7sA">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/QKsOkr4C7sA">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 746 Empowering Plans: P48 - Make Cost Containment Great Again https://www.phiagroup.com/Media/Posts/PostId/744/empowering-plans-p48-make-cost-containment-great-againPodcastsTue, 17 Jul 2018 15:59:20 GMT<p style="text-align: justify;">In this episode, hosts Brady Bizarro and Adam Russo discuss the recent webinar&rsquo;s success, hot topics impacting the industry today, and new methods to contain rising costs by taking advantage of changes in law and policy. If you like spending too much on healthcare, stay away. If you want to trump rising costs and achieve cost containment greatness, come on in.</p> <p><a href="https://www.youtube.com/watch?v=8o0pWHCL-mY">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=8o0pWHCL-mY">YouTube</a><a href="https://youtu.be/MhVGaw6hybQ"> </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 744Hottest Industry Trends and Topics – This is What You Asked Forhttps://www.phiagroup.com/Media/Posts/PostId/742/hottest-industry-trends-and-topics-this-is-what-you-asked-forWebinarsThu, 12 Jul 2018 13:46:02 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/UQqXOoRMBi0" width="560"></iframe></p> <p><span class="registration-description" data-bind="expander:{'expandText': moreButtonText(), 'userCollapseText': lessButtonText(), 'text':getWebinarInfo().description}">The industry is ablaze! From specialty drugs, to association health plans, to the “right to try” law, we’re all feeling the heat. </span> <span class="registration-description" data-bind="expander:{'expandText': moreButtonText(), 'userCollapseText': lessButtonText(), 'text':getWebinarInfo().description}">The Phia Group’s leadership team attempts to address these scorching issues and perhaps cool some nerves in the process.</span></p> <p><a href="https://youtu.be/UQqXOoRMBi0">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 742Empowering Plans: P47 - Coaching the Self-Funded Industryhttps://www.phiagroup.com/Media/Posts/PostId/740/empowering-plans-p47-coaching-the-self-funded-industryPodcastsWed, 11 Jul 2018 13:09:54 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/eyKPUl4exYc" width="560"></iframe></p> <p>In this episode of Empowering Plans, Adam and Brady interview Rick Koven, President of Koven Consulting &amp; Coaching. They discuss his work with health plan startups, small regional TPAs, and micro-insurance in developing countries. Rick also explains his role as a coach for executives and corporate leaders in our industry. As a special treat, they are also joined by Lisa from the claims department.</p> <p><a href="https://youtu.be/eyKPUl4exYc">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/eyKPUl4exYc">YouTube</a><a href="https://youtu.be/MhVGaw6hybQ"> </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 740The Phia Group's 3rd Quarter 2018 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/739/the-phia-groups-3rd-quarter-2018-newsletterNewslettersTue, 10 Jul 2018 17:37:57 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; } 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/Newsletter%202018%20Q2/header2018.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/icons4.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p1"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/b13qtr.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pcert"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/b23qtr.png" 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="53%"><br /> <br /> <br /> <br /> <img height="315" src="/Portals/phiagroup/Newsletter%202018%20Q2/adam.jpg" width="300" /></td> <td valign="top" width="47%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;">The heat wave is here in Boston and so is the increased interest in self-funding. It seems that every day there are new employers, brokers, and others interested in getting in on the fun. What they all don&rsquo;t realize is that there is no easy button. Building the perfect empowered self-funded employee benefit plan takes time and hard work. It requires attention to detail and a realization that you truly can control the overall cost of claims in your own unique way. Whether it&rsquo;s changing your payment methodology, your access to pharmacy drugs, your contracting with facilities, or just how you cover out of network claims, the options are endless. Here lies the rub. Having all of these options makes all of us vulnerable to potential pitfalls like gaps in coverage with stop loss or language that is ambiguous at best; worst of all is the potential fiduciary breaches around the corner. This is why The Phia Group exists &ndash; to assist all of you in making the perfect self-funded plan. The opportunities are everywhere but so are the traps and the landmines. So while you enjoy a nice cold iced tea reading this quarter&rsquo;s newsletter, feel happy knowing that we got your back&hellip; no matter what.<br /> &nbsp;</p> <p class="bodytext">&nbsp;</p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </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%202018%20Q2/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: Phia Unwrapped</a><br /> <a href="#p1">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2018 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a name="p1"></a> <p>&nbsp;</p> <p class="heading1">Service Focus of the Quarter: Phia Unwrapped</p> <p class="bodytext" style="text-align: justify;">The Phia Group is proud to announce that its &ldquo;Phia Unwrapped&rdquo; program has been generating extraordinary savings.<br /> <br /> Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited 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.<br /> <br /> 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&rsquo;s payment as payment in full. 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 percent of actual savings, leading to fair rates and no excessive costs for unprecedented savings &ndash; and if there&rsquo;s pushback or balance-billing, our Provider Relations team is ready to handle it.<br /> <br /> Out-of-network claims run through The Phia Group&#39;s Unwrapped program have yielded a whopping average savings of 74% off billed charges (three times the average wrap discount). On average, The Phia Group sees less than 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.<br /> <br /> Based on our data, Phia Unwrapped has proven to yield significantly better savings than wrap networks. Can you and your clients afford to maintain the status quo in the face of results like this?<br /> <br /> Contact our Vice President of Sales and Marketing, Attorney Tim Callender, to learn more about Phia Unwrapped. Tim can be reached by phone at 781-535-5631 or by email at TCallender@phiagroup.com.</p> <a id="p2" name="p2"></a> <p class="bodytext"><span style="font-size:130%;"><strong>Phia Case Study: Phia to the Rescue!</strong></span></p> <p class="bodytext" style="text-align: justify;">A particular plan participant, covered by a health plan whose subrogation services were provided by The Phia Group, slipped and fell while walking in a parking lot. She subsequently retained a personal injury attorney to represent her and pursue a claim against the owner of the parking lot. The Phia Group promptly placed the attorney on notice of the Plan&rsquo;s lien.<br /> <br /> After some time had elapsed, the plan participant notified The Phia Group that she had only received around $20,000.00 in settlement funds, which was almost equal to the amount of the Plan&rsquo;s lien; accordingly, the participant requested a reduction, which The Phia Group considered in due course.<br /> <br /> After doing some due diligence to confirm the settlement, and examining the considerable resources available to us, The Phia Group&rsquo;s subrogation team was able to discover that this particular case had actually settled for many times the amount that the participant claimed to have received.<br /> <br /> Armed with this information gleaned from diligent investigation, The Phia Group was able to recover the full amount of the Plan&rsquo;s lien, without the need for any reduction.</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> _ <p>&nbsp;</p> <p class="bodytext"><span style="font-size:130%;"><strong>Fiduciary Burden of the Quarter: Making Sure the SPD is Sufficient! </strong></span></p> <a id="p2a" name="p2a"></a> <p class="bodytext" style="text-align: justify;">The issue of what must be present in an SPD is fairly straightforward at this point; ERISA, the ACA, and other laws have been issued and interpreted, and those that haven&rsquo;t are subject to the &ldquo;good faith, reasonable interpretation&rdquo; guidelines that we all know and love.<br /> <br /> In the modern self-funded industry, though, the entities drafting Plan Documents and SPDs are very often not the entities that are legally responsible for creating and ratifying them; the Plan Sponsor must ultimately approve the SPD and is ultimately responsible for the content, but it is very uncommon for the Plan Sponsor itself to do the drafting. There&rsquo;s nothing wrong with this, of course; everyone uses vendors!<br /> <br /> When the employer itself doesn&rsquo;t draft the Plan Document, though, how diligent is the employer in ensuring compliance and that the document meets the needs of the health plan &ndash; and who takes the blame if the document isn&rsquo;t perfect?<br /> <br /> We at The Phia Group have seen numerous instances &ndash; both in court and out &ndash; of employers &ldquo;rubber-stamping&rdquo; a plan document without truly reviewing and approving it. That doesn&rsquo;t change who is responsible, of course, so the Plan Sponsor could be severely handicapping itself and violating its considerable fiduciary duties to ensure that its plan documents are up to snuff.<br /> <br /> A best practice is for TPAs and brokers to ensure that the Plan Sponsor is given an opportunity to truly review and consent to the terms of its plan document. Employers love having the hard parts of self-funding done for them &ndash; but TPAs and brokers need to protect themselves!<br /> <br /> We also recommend making sure that a TPA&rsquo;s Administrative Services Agreement holds the TPA harmless in the event the plan document is somehow noncompliant or incorrect, regardless of who has drafted it, since it is the Plan Sponsor&rsquo;s ultimate responsibility to approve it.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="font-size:130%;"><strong>Success Story of the Quarter: Egregious Billing</strong></span></p> <p class="bodytext" style="text-align: justify;">A TPA with which The Phia Group works closely has a benefit plan client that incurred an $860,000 NICU claim. Luckily, this particular client happened to be utilizing The Phia Group&rsquo;s Phia Unwrapped service. Accordingly, when the claim was incurred, it was repriced based on a percentage of Medicare chosen by the Plan, and paid accordingly, at the Plan&rsquo;s Maximum Allowable Charge.<br /> <br /> A few months later, the provider sent a balance-bill to the member, attempting to force the member to pay the entire balance of the claim. The Phia Group became involved, and after a lengthy negotiation process, The Phia Group was able to get the balance settled for 17% of the amount the hospital originally demanded from the patient. The utilization of the Phia Unwrapped service saved this health plan over half a million dollars &ndash; and what&rsquo;s more, the wrap network (which the Plan abandoned in favor of utilizing Phia Unwrapped) would have afforded the Plan a contractual 22% discount.<br /> <br /> The result? Phia Unwrapped netted the Plan savings of over $400,000 above and beyond its previous wrap network &ndash; and the patient is fully protected from balance-billing via the settlement agreement.</p> <p class="bodytext"><br /> &nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</p> <p class="bodytext" style="text-align: justify;">&bull; Money Inc. &ndash; <a href="https://moneyinc.com/state-reactions-and-their-power-over-association-health-plans/" target="_blank">State Reactions and their Power over Association Health Plans</a> &ndash; June 30, 2018<br /> <br /> &bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Conflicting Policies and Courts When Plan Language Creates More Litigation than Coverage by Catherine Downie.pdf" target="_blank">Conflicting Policies and Courts: When Plan Language Creates More Litigation than Coverage</a> &ndash; June 1, 2018<br /> <br /> &bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/The Practical Impact of Ariana M_ v_ Humana Health Plan of Tex_%2C Inc_ on ERISA Denials of Benefits by Patrick Ouellette%2C Esq.pdf" target="_blank">The Practical Impact of Ariana M. v. Humana Health Plan of Tex., Inc. on ERISA Denials of Benefits</a> &ndash; May 8, 2018<br /> <br /> &bull; Money Inc. &ndash; <a href="https://moneyinc.com/the-rising-cost-of-cost-containment/" target="_blank">The Rising Cost of Cost Containment</a> &ndash; May 5, 2018<br /> <br /> &bull; Money Inc. &ndash; <a href="https://moneyinc.com/freedom-blue-why-the-trump-administration-picked-obamacare-over-idaho/" target="_blank">Freedom Blue: Why the Trump Administration Picked Obamacare over Idaho</a> &ndash; April 2, 2018<br /> <br /> &bull; Self-Insurers Publishing Corp. &ndash; <a href="https://www.sipconline.net/files/Drowning in A Sea of Paper by Tim Callendar%2C Esq.pdf" target="_blank">Drowning in A Sea of Paper</a> &ndash; April 1, 2018</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a>From the Blogosphere:</p> <p class="bodytext" style="text-align: justify;">&bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/703/the-tangled-web-of-eligibility" target="_blank">The Tangled Web of Eligibility</a>. Eligibility issues are typically very fact specific. Do you know the facts?<br /> <br /> &bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/711/the-complications-surrounding-intermittent-fmla-leave" target="_blank">The Complications Surrounding Intermittent FMLA Leave!</a> Allow us to uncomplicated intermittent FMLA Leave for you.<br /> <br /> &bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/723/bridging-the-gaps-betweeneverything" target="_blank">Bridging the Gaps Between...Everything!</a> It&rsquo;s very important that you avoid all gaps, and here&rsquo;s why.<br /> <br /> &bull; <a href="https://www.phiagroup.com/Media/Posts/PostId/729/an-addiction-to-health-insurance" target="_blank">An Addiction to Health Insurance.</a> For too long insurance has been treated as a shield, blinding people from the cost of their care.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;"><a href="https://register.gotowebinar.com/register/8354714256140621827">Click HERE to Register!</a></p> <p class="bodytext" style="text-align: justify;">&bull; On June 21, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/732/final-rule-on-association-health-plans-and-you-phias-take" target="_blank">Final Rule on Association Health Plans and YOU: Phia&#39;s Take</a>,&rdquo; where we discussed the final rule and explain the significant impact it is expected to have on the self-funded industry.</p> <p class="bodytext" style="text-align: justify;">&bull; On June 12, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/727/the-buck-stopswhere-pointing-fingers-in-the-self-funded-industry" target="_blank">The Buck Stops&hellip;Where? Pointing Fingers in the Self-Funded Industry</a>,&rdquo; where we discussed why it&rsquo;s in everyone&rsquo;s best interests to work together to overcome issues rather than point fingers.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 15, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/715/the-case-for-collusion-how-the-power-players-may-have-defrauded-us-all" target="_blank">The Case for Collusion: How the Power Players May Have Defrauded Us All</a>,&rdquo; where we discussed the ways in which our industry can fight back and tackle the underlying problem of specialty drug prices.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 19, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/706/4-horsemen-of-the-plan-pocalypse" target="_blank">4 Horsemen of the Plan-pocalypse</a>,&rdquo; where we discussed four issues that may not presently be keeping you up at night, but will certainly be disturbing your slumber very soon.</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> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:Now Introducing Video Podcasts!</span></p> <p class="bodytext" style="text-align: justify;">&bull; On June 29, 2018, The Phia Group presented its first video podcast, &ldquo;You&rsquo;ve Gotta Fight, For Your Right, to Try,&rdquo; where the team addresses the recently passed Right To Try Laws, and dissect the impact it may have &ndash; if any &ndash; on your health benefit plans.</p> <p class="bodytext" style="text-align: justify;">&bull; On June 22, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/733/empowering-plans-p45-super-empowerment" target="_blank">Super-Empowerment</a>,&rdquo; where our hosts chat with none other than Brooks Goodison, President &amp; Principal Partner at Diversified Group.</p> <p class="bodytext" style="text-align: justify;">&bull; On June 12, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/726/empowering-plans-p44-the-phia-group-mvp-post-mortem" target="_blank">The Phia Group &ldquo;MVP&rdquo; Post-Mortem</a>,&rdquo; where our hosts discuss the recently concluded Phia Group Most-Valuable-Partners or &ldquo;MVP&rdquo; forum; an event that took place June 4th to the 6th at Gillette Stadium, home of the New England Patriots..</p> <p class="bodytext" style="text-align: justify;">&bull; On June 1, 2018, The Phia Group presented, &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/721/empowering-plans-p43-a-debrief-of-siias-fly-in-on-the-hill" target="_blank">Empowering Plans: P43 - A Debrief of SIIA&rsquo;s Fly-In on the Hill</a>,&rdquo; where Adam, Ron, and Brady discuss their trip to Washington, D.C. in which they took part in SIIA&rsquo;s &ldquo;Fly-In&rdquo; event, where SIIA members met with their elected representatives to discuss self-insurance/captive insurance issues.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 29, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/720/empowering-plans-p42-eliminating-the-noise" target="_blank">Eliminating the Noise</a>,&rdquo; where Adam, Ron, and Brady interview David Contorno, President of Lake Normal Benefits.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 24, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/719/empowering-plans-p41-the-case-for-collusion-continued" target="_blank">The Case for Collusion (Continued)</a>,&rdquo; where The Phia Group&rsquo;s Sr. VP, Ron E. Peck, and healthcare attorney Brady C. Bizarro as they answer the questions that you asked during our webinar on PBMs, specialty drug prices, and lawsuits alleging fraud.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 17, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/717/empowering-plans-p40-rbp-yeah-you-know-me" target="_blank">RBP - Yeah, You Know Me</a>,&rdquo; where The Phia Group chats once again with one of their Partners in Empowerment, Gregory S. Everett, President and CEO of Payer Compass.</p> <p class="bodytext" style="text-align: justify;">&bull; On May 7, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/712/empowering-plans-p39-everythings-bigger-in-texas" target="_blank">Everything&#39;s Bigger In Texas</a>,&rdquo; where our hosts interview Third Party Administrator, visionary, and industry expert &ndash; Caprock Healthplans&rsquo; own Executive Vice President, John Farnsley</p> <p class="bodytext" style="text-align: justify;">&bull; On April 24, 2018, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/PostId/707/empowering-plans-p38-a-labor-of-love" target="_blank">&ldquo;A Labor of Love</a>,&rdquo; where Adam, Ron, and Brady interview in-house specialist, VP of Consulting Attorney Jennifer McCormick, and discuss the many complicated issues surrounding surrogacy, and the costs for which benefit plans may be responsible.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 18 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/705/empowering-plans-p37-arresting-the-financial-serial-killers" target="_blank">Arresting the Financial Serial Killers</a>,&rdquo; where Adam and Ron interview the industry, and nationally, renowned Dr. Keith Smith of the Surgery Center of Oklahoma.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 9, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/702/empowering-plans-p36-new-kids-on-the-block" target="_blank">New Kids on the Block</a>,&rdquo; where Adam, Ron and Brady interview one member of our industry&rsquo;s too-small youth movement, Brian Olsen.</p> <p class="bodytext" style="text-align: justify;">&bull; On April 4, 2018, The Phia Group presented &ldquo;<a href="https://www.phiagroup.com/Media/Posts/PostId/696/empowering-plans-p35-direct-primary-care-the-pot-of-gold-youre-looking-for" target="_blank">Direct Primary Care &ndash; The Pot of Gold You&rsquo;re Looking For</a>,&rdquo; where the Phia team interviews Doctor Jeff Gold of Gold Direct Care.</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"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/itunes.png" style="width: 251px; height: 78px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2018 Charity</span></p> <p class="bodytext" style="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.<br /> <br /> The Phia Group&#39;s 2018 charity is the Boys &amp; Girls Club of Brockton.</p> <p><img src="/Portals/phiagroup/Newsletter%202018%20Q2/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;">The mission of The Boys &amp; 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="text-align: justify;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.</p> <p>&nbsp;</p> <p><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/donation.jpg" style="width: 600px; height: 400px;" title="" /></p> <p class="bodytext" style="text-align: justify;">On Wednesday, April 24, 2018, The Phia Group announced The Boys &amp; Girls Club of Brockton&#39;s Youth of the Year! The Youth of the Year was given a check for $2,500, as well as a new Dell laptop! So many congratulations to Adande Bien-Aime, you have embodied what a true role model should be for the youth of America.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/auction.jpg" style="width: 600px; height: 400px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;">At the 2018 MVP Phia Forum we held a silent auction of which all proceeds were donated to The Boys and Girls Club! The auction was a hit and we cannot thank all those who donated enough for their generosity in supporting such a wonderful organization. In addition to bids on great items like a signed Tom Brady jersey, a signed Lionel Messi jersey, and more, we received many kind donations after the event. We love The Boys and Girls Club and everything they stand for, we could not have wished for a better event to support an amazing organization!</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold">Conflicting Policies and Courts: When Plan Language Creates More Litigation than Coverage</p> <p class="bodytext" style="font-weight: normal">By: Catherine Dowie, Esq. &ndash; June 2018- <a href="https://www.sipconline.net/files/Conflicting Policies and Courts When Plan Language Creates More Litigation than Coverage by Catherine Downie.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Mostly, working on any given subrogation file for a private, self-funded benefit plan is all about the hurry up and wait. Hurrying to communicate with the injured party, their attorney, the adjusters, investigators, and making sure everyone knows about the plan&rsquo;s involvement and rights. Then waiting for the completion of treatment, the compilation of damages and some initial negotiations before racing to remind everyone of those rights, and potentially racing to the courthouse to make sure those rights are preserved. As the Supreme Court reminded us in Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan, timing is everything. 136 S. Ct. 651 (2016).</p> <p><span class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/738/the-stacks-3rd-quarter-2018">Click here to read the rest of this article </a></span></p> <p><br /> <span class="bodytext"><strong>The Practical Impact of Ariana M. v. Humana Health Plan of Tex., Inc. on ERISA Denials of Benefits </strong></span></p> <p class="bodytext" style="font-weight: normal">By: Patrick Ouellette, Esq. &ndash; May 2018 &ndash; <a href="https://www.sipconline.net/files/The Practical Impact of Ariana M_ v_ Humana Health Plan of Tex_%2C Inc_ on ERISA Denials of Benefits by Patrick Ouellette%2C Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The abuse of discretion standard has long been a proverbial ace in the hole for self-funded employee benefit plan administrators in making factual determinations that, while perhaps not popular with the participant, they believed were consistent with the terms of the plan document. While the recent Ariana M. v. Humana Health Plan of Tex., Inc. is noteworthy for many reasons, the most immediate effect will be on the Fifth Circuit&rsquo;s allowance of plan administrator discretion in making factual determinations.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/738/the-stacks-3rd-quarter-2018">Click here to read the rest of this article. </a></p> <p>&nbsp;</p> <p class="bodytext"><strong>Drowning in A Sea of Paper</strong></p> <p class="bodytext">By: Tim Callender, Esq. &ndash; April 2018 - <a href="https://www.sipconline.net/files/Drowning in A Sea of Paper by Tim Callendar%2C Esq.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="text-align: justify;">The challenges of setting up and administering an employer-sponsored, self-funded health plan are many. One of the largest challenges a self-funded plan sponsor faces is reconciling the vast number of documents that make a self-funded health plan &ldquo;go.&rdquo;</p> <p class="bodytext" style="text-align: justify;">When navigated correctly, these challenges yield immense results in terms of rich benefit delivery within a fiscally responsible health plan mechanism. Still, challenges remain and should be discussed openly so that we can continue to grow and strengthen our industry.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/738/the-stacks-3rd-quarter-2018" target="_blank">Click here to read the rest of this article.</a></p> <p>&nbsp;</p> <p class="bodytext">To stay up to date on other industry news, <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a>Phia&rsquo;s 2018 Speaking Events:</p> <p class="bodytext"><strong>Phia&rsquo;s Speaking Engagements:</strong></p> <p class="bodytext">Adam Russo&rsquo;s 2018 Speaking Engagements:</p> <ul class="bodytext"> <li>1/23/18 &ndash; Q4 Intelligence Conference &ndash; Tampa, FL</li> <li>2/2/2018 &ndash; Benefit Intelligence School District Conference &ndash; Phoenix, AZ</li> <li>3/7/2018 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charleston, NC</li> <li>3/9/2018 &ndash; CGI Business Solutions Seminar &ndash; Manchester, NH</li> <li>3/14/2018 &ndash; Pareto StructuRE Meeting &ndash; Park City, UT</li> <li>4/12/2018 &ndash; Caprock Health Care Forum &ndash; Dallas, TX</li> <li>4/25/2018 &ndash; Berkley Captive Symposium &ndash; Grand Cayman Islands</li> <li>4/26/2018 &ndash; Innovative Risk &ndash; Grand Cayman Islands</li> <li>4/30/2018 &ndash; World Health Care Congress &ndash; Washington, DC</li> <li>5/17/2018 &ndash; Prairie States Broker Event &ndash; Chicago, IL</li> <li>6/21/2018 &ndash; GBSI Conference &ndash; Springfield, MO</li> <li>6/26/2018 &ndash; Leavitt Annual Event &ndash; Big Sky, MT</li> <li>8/24/2018 &ndash; WellHealth Workshop &ndash; Berkley Captive Program &ndash; Itasca, IL</li> <li>8/29/2018 &ndash; Gus Bates Insurance &ndash; Fort Worth, TX</li> <li>9/24/2018 &ndash; SIIA&rsquo;s Annual National Educational Conference &amp; Expo &ndash; Austin, TX</li> </ul> <p class="bodytext">Ron Peck&rsquo;s 2018 Speaking Engagements:</p> <ul class="bodytext"> <li>1/25/2018 &ndash; HealthFirst TPA Client Conference &ndash; Tyler, TX</li> <li>3/6/2018 &ndash; SIIA National Conference &ndash; Charleston, SC</li> <li>3/7/2018 &ndash; CGI Business Solutions Seminar &ndash; Manchester, NH<strong> </strong></li> <li>3/23/18 &ndash; Health Rosetta - Module 5: Next-Gen Plan Design &ndash; Boston, MA<strong> </strong></li> </ul> <p class="bodytext">Tim Callender&rsquo;s 2018 Speaking Engagements:</p> <ul class="bodytext"> <li>2/14/2018 &ndash; BevCap Captive Group, 10th Anniversary Meeting &ndash; Kona, HI</li> <li>4/25/2018 &ndash; Cypress University &ndash; Las Vegas, NV</li> <li>5/7/2018 &ndash; UBA Spring Conference &ndash; Chicago, IL</li> <li>5/16/2018 &ndash; Sun Life MVP Forum &ndash; Kansas City, KS</li> <li>5/24/2018 &ndash; Pareto Captive Services, Contrarian Re Captive Meeting &ndash; Nashville, TN</li> <li>6/25/2018 &ndash; Leavitt Conference &ndash; Big Sky, MT</li> <li>7/17/2018 &ndash; HCAA TPA Summit &ndash; Minneapolis, MN</li> </ul> <p class="bodytext">Jen McCormick&rsquo;s 2018 Speaking Engagements:</p> <ul class="bodytext"> <li>4/17/2018 &ndash; Texas Association of Benefit Advisors &ndash; Dallas, TX</li> <li>5/16/2018 &ndash; IOA RE &ndash; Indianapolis, IN</li> </ul> <p class="bodytext">&nbsp;</p> <p>&nbsp;</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a>Get to Know Our Employee of the Quarter:<br /> Ulyana Bevilacqua</span></p> <p class="bodytext" style="text-align: justify;">Congratulations to Ulyana Bevilacqua, The Phia Group&rsquo;s Q2 2018 Employee of the Quarter!</p> <p class="bodytext" style="text-align: justify;"><br /> Ulyana maintains great client relationships because clients can trust her to send their requests on time and that the deliverable will always contain quality work. She remains professional in her correspondence and makes sure everything is done accurately. She also puts in extra hours to ensure organization with all client requests. This reflects positively on The Phia Group because it sends a message to our clients of our professionalism and how much we care.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/ulyana.jpg" style="width: 310px; height: 420px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">Congratulations Ulyana and thank you for your many current and future contributions.</p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a>Phia News</span></p> <p class="bodytext"><span style="font-size:130%;"><strong>World Congress 2018 Health Value Awards </strong></span></p> <p class="bodytext">On April 29, 2018, more than 350 nominees competed in the World Congress 2018 Health Value Awards to be the best and brightest applications to improve health outcomes, reduce costs and implement innovative health industry practices. The Phia Group is excited to announce we have placed Diamond in the Small Group Employer category and our co-founder and CEO, Adam Russo, has placed Silver in the Outstanding Benefits Provider category!</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" height="425" src="/Portals/phiagroup/Newsletter%202018%20Q2/award2018.jpg" title="" width="299" /></p> <a id="pcert" name="pcert"></a> <p class="bodytext"><span style="font-size:130%;"><strong>Phia Certification has Arrived!</strong></span></p> <p class="bodytext" style="text-align: justify;">We are pleased to announce our new internal Phia Certification Program. The Phia Group maintains lofty standards for the industry, and expects the same of our staff. Phia has always developed and implemented best-in-class training programs, keeping our employees up to date and comprehensively educated. As a result, our team is second to none in that regard&hellip; and today we are excited to announce a new way to show it. Phia has established its new Phia Certification Program for its employees; this internal program consists of 3 levels, each level testing an even higher caliber of industry expertise than the last.<br /> <br /> By the end of 2018 all Phia employees, from our interns to our attorneys, will be Level 1 certified. For leaders and those seeking to take it to the next level, Level 2 of the Phia Certification Program is made available. Finally, for those who dare to dream &ndash; Level 3 is indicative of being &ldquo;the best of the best&rdquo; &ndash; capable of addressing any and all issues impacting our industry, as well as being able to predict the issues headed our way. Our Phia Certification Program will ensure that a consistent knowledge base and industry expertise is embedded in the entirety of our staff, providing you with the best service our industry has to offer.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/cert.jpg" style="width: 400px; height: 343px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="font-size:130%;"><strong>The Phia Group Recognizes Diversified Group with 2018 Empowered Plan Award</strong></span></p> <p class="bodytext" style="text-align: justify;">At our annual MVP (Most Valuable Partners) event, we were pleased to recognize this year&rsquo;s winner of The Phia Group &ldquo;Trophy of Empowerment.&rdquo; It is with appreciation that we publically announce the name of our 2018 Empowered Plan Award winner, Diversified Group.</p> <p class="bodytext" style="text-align: justify;"><br /> After analyzing all of our MVPs based on a number of parameters including, but not limited to, collaboration with The Phia Group, a willingness to innovate, as well as application of a forward thinking methodology &ndash; reflected through efforts taken to secure the future of our industry &ndash; Diversified Group of Marlborough, CT &ndash; was a clear winner.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/diverse.jpg" style="width: 600px; height: 401px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="font-size:130%;"><strong>New Client Account Manager &ndash; Matthew Painten</strong></span></p> <p class="bodytext" style="text-align: justify;">As you may know, Matthew Painten has recently been promoted to Client Account Manager at The Phia Group, in addition to his Marketing Management role. Although you may already have a direct point of contact at Phia, please feel free to start communicating with Matthew directly for any and all of your requests. You may email him personally at MPainten@phiagroup.com or send an email to CAM@phiagroup.com.</p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/matthew.jpg" style="width: 481px; height: 600px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p><span style="font-size:130%;"><span class="boldtext">Job Opportunities:</span></span></p> <ul> <li>ETL Specialist</li> <li>IT Systems Administrator</li> <li>Health Benefit Plan Drafting Consultant</li> <li>Claims Specialist, Provider Relations</li> </ul> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="font-size:130%;"><strong>Promotions </strong></span></p> <ul> <li>Matthew Painten was promoted from Marketing Coordinator to Marketing &amp; Accounts Manager</li> <li>Hannah Sedman was promoted from Marketing Intern to Marketing &amp; Accounts Coordinator</li> <li>Garrick Hunt was promoted from Sales Executive to Sales Manager</li> <li>Jacob Falkof was promoted from Customer Service Representative to Case Investigator</li> <li>Nick O&rsquo;Neill was promoted from Case Analyst to Legal Assistant</li> </ul> <p class="bodytext"><span style="font-size:130%;"><strong>New Hires</strong></span></p> <ul> <li>Dakota Bagley was hired as an IT Intern&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li> <li>Holly Blackstead was hired as a Marketing Intern</li> <li>Andrew Modelane was hired as a Training Intern</li> <li>Colleen Ahern was hired as a Case Investigator</li> <li>Bethany LaChance was hired as a Recovery Intern</li> <li>Alanah Lopes was hired as a Sales Intern</li> <li>Philip Qualo was hired as an HR Compliance Specialist</li> <li>Gambit Hunt was hired as a Sales &amp; Accounts Coordinator</li> </ul> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="font-size:130%;"><strong>Fun at Phia:</strong></span></p> <p class="bodytext" style="text-align: justify;">The Phia Family is one good-looking group of wiffle-ballers! Our wiffle ball team entered the 7th annual John Waldron Memorial Wiffle Ball Tournament, where we were one game away from entering the semi-finals. We were up against some fierce competition, including some courageous Brockton Fire Fighters, that most certainly brought the heat. This tournament raised over $20,000! We are proud of the work our team did and can&rsquo;t wait to play again next year.</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/baseball3.jpg" style="width: 600px; height: 426px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/footerlogo.png" 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> 739The Stacks - 3rd Quarter 2018https://www.phiagroup.com/Media/Posts/PostId/738/the-stacks-3rd-quarter-2018NewslettersMon, 09 Jul 2018 18:34:44 GMT<h3 style="text-align: justify;"><span style="color:#000000;"><strong>Conflicting Policies and Courts: When Plan Language Creates More Litigation than Coverage</strong></span></h3> <h2 style="font-style:italic;"><span style="color:#000000;"><span style="font-size:12.0pt;line-height:115%; font-family:&quot;Century Schoolbook&quot;,serif;mso-fareast-font-family:Calibri; mso-fareast-theme-font:minor-latin;mso-bidi-font-family:&quot;Times New Roman&quot;; mso-bidi-theme-font:minor-bidi;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA">By: Catherine Dowie</span> </span></h2> <p style="text-align: justify;"><span style="color:#000000;">Mostly, working on any given subrogation file for a private, self-funded benefit plan is all about the hurry up and wait.&nbsp; Hurry to communicate with the injured party, their attorney, the adjusters, investigators, and make sure everyone knows to about the plan&rsquo;s involvement and rights.&nbsp; Then wait for the completion of treatment, the compilation of damages and some initial negotiations before racing to remind everyone of those rights, and potentially racing to the courthouse to make sure those rights are preserved.&nbsp; As the Supreme Court reminded us in <em>Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan</em>, timing is everything.&nbsp;&nbsp; 136 S. Ct. 651 (2016).&nbsp;</span></p> <p style="text-align: justify;"><span style="color:#000000;">For the most part, the bulk of the plan&rsquo;s cost-containment opportunity has always come at the resolution of some liability claim, which is usually years after the bulk of the treatment and payments. &nbsp;Although many states require Medical Payments Coverage, Personal Injury Protection or some other form of no-fault coverage, they are typically in very small amounts.&nbsp; There are exceptions, of course, Michigan&rsquo;s unlimited PIP scheme, potential advancement of funds in Montana under <em>Ridley v. Guaranty National Insurance Co.</em>, and high-minimum states like New York and New Jersey, but usually very little coverage is available to alleviate the burden on a plan to pay up front or leave a member to address bills with providers directly.&nbsp; 951 P 2d 987 (Mont. 1997).</span></p> <p style="text-align: justify;"><span style="color:#000000;">In some circumstances, however, acting quickly when the case begins does turn up a policy that will meaningfully impact the plan&rsquo;s liability from the start, where there is a policy for a specific loss or a high no-fault policy.&nbsp; The problem arises when these policies are designed to be excess, which they usually are.&nbsp; An excess policy is a policy designed to provide coverage only when no other coverage exists.&nbsp; They are often inexpensive because they are designed to often only bear liability for a patient&rsquo;s copayment or deductible obligations, rather than the bulk of the responsibility for medical claims.&nbsp; Some are also only designed to cover bills associated with a specific event or activity, such as high school sports.</span></p> <p style="text-align: justify;"><span style="color:#000000;">This issue frequently arises not only in the context of automobile no-fault coverage, but with school and recreational policies.&nbsp; Schools will often secure excess policies for athletes or even students hurt in gym class, and they are common in adult recreational leagues (usually soccer, but I&rsquo;ve handled a case where an adjuster was shocked to find that his company had issued a policy for a lawnmower racing league&hellip;).</span></p> <p style="text-align: justify;"><span style="color:#000000;">So what happens when a health plan has a valid excess provision, but the accident or automobile policy that covers a specific incident does as well?&nbsp; Although ERISA might allow a plan to preempt state laws, policy or plan provisions may call for a slightly different analysis.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Various Federal Circuit Courts of Appeal have heard this question and have reached a somewhat surprising conclusion, especially following the <em>Montanile</em> decision from the Supreme Court in 2016.&nbsp; There is a long-standing split between the circuits on this question.&nbsp; <em>See</em> <em>Auto Owners Ins. Co. v. Thorn Apple Valley, Inc.</em>, 31 F.3d 371 (6th Cir. 1994) (terms of an ERSIA plan are enforceable over conflicting policy language of an insurer) <em>c.f.</em> <em>Winstead v. Ind. Ins. Co., </em>855 F.2d 430 (7th Cir. 1988) (apportioning liability for claims <em>pro rata</em>).&nbsp; Both of these cases addressed Michigan PIP policies, which provide unlimited coverage for, among other things, medical bills related to automobile accidents.&nbsp; Both the PIP policy and the health plans involved in the dispute had excess provisions, and in both cases the auto insurer filed suit, asking the court to declare that the that the health plan should pay the bills as primary.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The 6<sup>th</sup> Circuit concluded that the ERISA plan terms were not entitled to any deference over the terms of the auto policy and ordered the two litigants to pay the claims on a prorated basis.&nbsp; Straightforward enough.&nbsp; Neither policy had a cap on coverage, and the outstanding bills could be split on a 50/50 basis.&nbsp; One significant problem with this decision as applied to slightly different facts, is how does one pro-rate a theoretically infinite policy with a more standard PIP policy which might have limits of $10,000 or less. <em>McGurl v. Trucking Emps. of N.J. Welfare Fund, Inc.</em> , 124 F.3d 471, 485 (3d Cir. 1997) (noting that it is &ldquo;unclear how the rule [prorating] would operate in practice&rdquo;).</span></p> <p style="text-align: justify;"><span style="color:#000000;">The 7<sup>th</sup> Circuit, when faced with the same issue, gave more weight to the primary purpose of ERISA.&nbsp; These conclusions were perfectly in line with what the Supreme Court would later point out, the whole reason that the plan, &ldquo;in short, is at the center of ERISA&rdquo; and &ldquo;[t]his focus on the written terms of the plan is the linchpin of &lsquo;a system that is [not] so complex that administrative costs, or litigation expenses, unduly discourage employers from offering [ERISA] plans in the first place.&rsquo;&rdquo; <em>Helimeshoff v. Hartford</em>, 134 S.Ct. 604, 612 (2013) (quoting <em>Varity Corp. v. Howe</em>, 516 U.S. 489, 497 (1996)).&nbsp; Without giving force to valid and clear terms, uniform nationwide enforcement would be undercut.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In the last 5 years, this issue has been somewhat frequently litigated in the context of non-automobile excess policies.</span><a href="#_ftn1" name="_ftnref1" title=""><span style="color:#000000;">[1]</span></a><span style="color:#000000;">&nbsp; In addition to the existing split on what weight to give the terms of an ERISA plan, courts have now drawn a distinction based on if the plan paid claims before initiating suit.&nbsp; Courts have allowed plans to pursue declaratory relief, obligating the insurer to issue payment in the future, but not recover from insurance policies with excess provisions once the plan has already paid claims.</span></p> <p style="text-align: justify;"><span style="color:#000000;">This pre/post payment distinction is based on the idea that plans can only seek a monetary award with a court if they can identify a specific pool of money that they have a right to, like a settlement fund, which does not exist when benefits are being coordinated between two payors.&nbsp; Additionally, some insurers have argued that ERISA is irrelevant even to the determination of primary liability for payment, asking courts to leave these &ldquo;run-of-the-mill contract disputes&rdquo; to state courts.</span></p> <p style="text-align: justify;"><span style="color:#000000;">As one court noted:</span></p> <p style="margin-left: 0.5in; text-align: justify;"><span style="color:#000000;">The paradoxical result [of this argument] is that as an ERISA plan, has fewer remedies than it would if it were a non-ERISA plan, and its beneficiary, through no fault of his own, is considerably worse off for having two policies that coincidentally had conflicting language than he would be if he had only one. One might think that the underlying purposes of ERISA and of equitable relief generally would permit a court to fashion an appropriate remedy.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><em>Cent. States, Se. &amp; Sw. Areas Health &amp; Welfare Fund v. Gerber Life Ins. Co</em>., 771 F.3d 150, 159 (2d Cir. 2014).</span></p> <p style="text-align: justify;"><span style="color:#000000;">As long as these issues remain unresolved, health plan liability will remain uncertain, and insurers and plans alike will be encouraged to leave claims denied and turn to courts before issuing payments.&nbsp; This leaves plan participants to deal with bills everyone agrees will not ultimately be their responsibility, and forces plans into a position where they may risk loss of discounted rates or access to other benefits that are only available if payment is made within a specific timeframe.&nbsp; Health plans can seek to preserve enforcement of their terms through diligent investigation and coordination with &ndash; and education of &ndash; all parties and payors as soon as claims are incurred.</span></p> <div> <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p><a href="#_ftnref1" name="_ftn1" title="">[1]</a> <a name="_Hlk513668898"><em>Dakotas &amp; W. Minn. Elec. Indus. Health &amp; Welfare Fund v. First Agency, Inc.</em></a>, 865 F.3d 1098 (8th Cir. 2017);<em> Cent. States, Se. &amp; Sw. Areas Health &amp; Welfare Fund v. Am. Int&#39;l Grp., Inc.</em>, 840 F.3d 448 (7th Cir. 2016); <em>Cent. States v. <em>Student Servs., 797 F.3d 512, 60 EBC 1857 (8th Cir. 2015)</em></em>; <em>Cent. States, Se. &amp; Sw. Areas Health &amp; Welfare Fund v. Gerber Life Ins. Co.</em>, 771 F.3d 150 (2d Cir. 2014); <em>Cent. States, Se. &amp; Sw. Areas Health &amp; Welfare Fund v. First Agency, Inc.</em>, 756 F.3d 954 (6th Cir. 2014); <em>Cent. States, Se. &amp; Sw. Areas Health &amp; Welfare Fund v. Health Special Risk, Inc.</em>, 756 F.3d 356 (5th Cir. 2014); <em>Cent. States, Se. &amp; Sw. Areas Health &amp; Welfare Fund v. Bollinger, Inc.</em>, 573 F. App&#39;x 197 (3d Cir. 2014).</p> <p>____________________________________________________________________________________________________</p> <h3><span style="color:#000000;"><strong><b style="mso-bidi-font-weight:normal"><span style="font-size:12.0pt;line-height:115%;font-family:&quot;Times New Roman&quot;,serif; mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language: EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">The Practical Impact of Ariana M. v. Humana Health Plan of Tex., Inc. on ERISA Denials of Benefits</span></b> </strong></span></h3> <h6 style="font-style: italic;"><span style="font-size:130%;"><span style="color:#000000;">Patrick Ouellette, Esq.</span></span></h6> <p style="text-align: justify;"><span style="color:#000000;">The abuse of discretion standard has long been a proverbial ace in the hole for self-funded employee benefit plan administrators in making factual determinations that, while perhaps not popular with the participant, they believed were consistent with the terms of the plan document. While the recent <em>Ariana M. v. Humana Health Plan of Tex., Inc.</em> is noteworthy for many reasons, the most immediate effect will be on the Fifth Circuit&rsquo;s allowance of plan administrator discretion in making factual determinations.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The Fifth Circuit finally joined the fraternity of all other circuit courts that has held decisions made by plan administrators under ERISA Section 1132(a)(1)(B), whether legal or factual, are to be reviewed using a default de novo standard. In addition to introducing consistency across the circuit courts regarding standard of review, the en banc holding in <em>Ariana M. v. Humana Health Plan of Tex., Inc.</em> greatly reduced the amount of inherent deference granted to plan administrators for factual determinations. Self-funded employee benefit plans should be aware of the repercussions of no longer having the abuse of discretion standard available in the Fifth Circuit if there is an appeal regarding its factual determinations relating to, for instance, a denial of benefits.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Prior to this decision, every other circuit court except the Fifth Circuit had applied a de novo review when an ERISA plan document does not expressly grant discretion to plan administrators. These courts based their rationale on the fact that the famed <em>Firestone Tire &amp; Rubber Co. v. Bruch</em> case does not make a distinction between a trustee&rsquo;s legal interpretations versus their factual decisions regarding the requirement for de novo review. <em>Ariana M. v. Humana Health Plan of Tex., Inc.</em> is legally significant because Fifth Circuit had long held that, under ERISA, a plan administrator was entitled to an abuse of discretion standard of review with respect to its factual determinations. In short, the court to this point had given plans the benefit of the doubt for factual determinations unless the plan had made an unreasonable decision. Now these administrators will be held to the de novo standard, without deference to its factual findings. This shift the court considering an issue for the first time without this deference will likely affect how and under what circumstances plan decisions are made. Thus, it is critical to also consider the practical impact that the holding will have on plan administrators that have relied for years upon Fifth Circuit providing them with this high degree of discretion in making factual determinations even when a plan has not expressly granted them that discretion.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Fifth Circuit Standard of Review Background</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Employers, and the plan administrators, traditionally have broad discretion to determine how plan terms will be used, as well as to decide which entities will have the authority to make benefits determinations, factual determinations, appeals determinations, and language interpretations. The Supreme Court in <em>Firestone</em> held that only if a plan explicitly delegated authority to a plan administrator, the decision would be reviewed under a heightened &ldquo;abuse of discretion&rdquo; standard. The Court famously stated a &ldquo;denial of benefits challenged under &sect; 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.&rdquo; If there was no express delegation, however, the Court held that courts would need to review a denial of benefits challenged under ERISA using a de novo standard. The holding did not directly clarify whether it was referring to both legal interpretations and factual determinations for the de novo standard.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In <em>Ariana M. v. Humana Health Plan of Tex., Inc.</em>, the Humana Health Plan of Texas argued that it had a discretionary clause granting to Humana &ldquo;full and exclusive discretionary authority to: [i]nterpret plan provisions; [m]ake decisions regarding eligibility for coverage and benefits; and [r]esolve factual questions relating to coverage and benefits.&rdquo; Due to a Texas antidelegation statute making discretionary clauses unenforceable, Humana agreed not to use the argument that the plan document gave it direct authority. Notably, the court remained silent on whether ERISA preemption came into play because Humana did not raise the argument. Instead, Humana relied upon the Fifth Circuit&rsquo;s holding in <em>Pierre v. Conn. Gen. Life Ins. Co. to argue that for factual determinations under ERISA plans, the abuse of discretion standard of review is the appropriate standard and therefore it had not abused its discretion in making its determination. </em>The Fifth Circuit granted en banc review to reconsider <em>Pierre</em> and determine the default standard of review that would apply in these situations.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The Fifth Circuit&rsquo;s decision in <em>Ariana v. Humana Health Plan of Texas</em> essentially reversed its own interpretation of <em>Firestone</em> in <em>Pierre.</em> According to <em>Pierre</em>, without delegation of authority to a plan administrator, challenges to a <em>legal</em> interpretation of a plan should be considered under a de novo standard of review while factual determinations were to be under an abuse of discretion standard of review. The <em>Pierre</em> court based its reasoning on the concept that an administrator&#39;s factual determinations are inherently discretionary and the Restatement (Second) of Trusts supports giving deference to an ERISA plan administrator&#39;s resolution of factual disputes even when the plan does <em>not</em> grant discretion.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The <em>Ariana</em> court essentially held that <em>Pierre&rsquo;s interpretation is no longer good law, despite some strong dissenting opinions, including from Judge E. Grady Jolly, who authored Pierre. The dissent focused its dissatisfaction with the majority&rsquo;s opinion on the discrepancy between </em>legal analysis and credibility determinations and a lack of express authority in <em>Firestone</em>.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Factual Determinations That May Now Be Subject to De Novo Review</strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Now that<em> Ariana</em> held that <em>Firestone</em>&#39;s default de novo standard applies when the denial is based on a factual determination, it is worthwhile to see how this change would play out in the types of factual determinations that plan administrators make on a regular basis. This is not intended to be an exhaustive list of decisions that will be affected, but instead meant to illustrate the types of complications that <em>Ariana </em>could create for plan administrators if they are a party to case that reaches the Fifth Circuit.</span></p> <p style="text-align: justify;"><span style="color:#000000;">First and foremost, Humana Health Plan of Texas in <em>Ariana</em> used its discretion to decline to allow partial hospitalization for Ariana beyond June 5<sup>th</sup>, claiming it was no longer medically necessary. Using <em>Pierre</em>&rsquo;s precedent, the district court concluded only that &quot;Humana did not abuse its discretion in finding that Ariana M.&#39;s continued treatment at Avalon Hills was not medically necessary after June 4, 2013.&quot; Plan administrators are often making factual decisions as to whether treatment is &ldquo;medically necessary&rdquo; and therefore whether it should provide coverage according to the terms of the plan document. In the Fifth Circuit, these plans were granted broad deference regarding these determinations because of its decision in <em>Pierre</em>. Similar to the rest of the circuit courts, medical necessity determinations are now subject to de novo review. However, <em>Ariana</em> is merely the tip of the iceberg in that these types of factual determinations are not limited only to questions of medical necessity.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Another determination in which plan administrator discretion is paramount is the application of plan document exclusions, such as excluding coverage if the treatment or care was the result of illegal or hazardous activity. Each plan document has its own set of exclusions that it can choose whether or not to apply to a given set of facts, but the Fifth Circuit had traditionally separated itself from the rest of the circuit courts up until this point as to the standard by which these exclusion determinations would be judged. Anyone who works in the self-funded industry knows how controversial and fact-dependent the practice of excluding participant claims can be for a plan administrator. Without an abuse of discretion standard and de novo standard now in place, however, these administrators may potentially be more wary to automatically exclude a plan participant&rsquo;s claims due to an illegal or hazardous activity exclusion if, for example, the facts are unclear.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Next, plan administrators often make plan eligibility decisions that will be affected by the <em>Ariana</em> decision in the Fifth Circuit. These determinations will include, for instance, whether spouses are eligible for coverage after they dropped their own plan based on the plan&rsquo;s eligibility language. Previously free from the potential second-guessing involved in with the de novo standard of review, administrators now more than ever will need to be sure to document their coverage decisions based on the plan document language and be able to defend them in court if necessary.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Administrators also make factual determinations regarding administration of high-deductible health plans (HDHPs), health savings accounts (HSAs), flexible spending accounts (FSAs). Some prime examples of these administrative issues would be deciding which items covered under an HSA would be deemed &ldquo;preventive&rdquo; or whether the plan had avoided first-dollar coverage under an HDHP. Similar to the above, the Fifth Circuit will now view the process of how these factual decisions were made in a much different light.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Finally, now that these plan administrators are subject to the de novo standard of review instead of abuse of discretion review, they should remember the ERISA requirement that factual determinations must be made consistently in similar scenarios in the future. Though this is not necessarily a novel consideration for plan administrators, it is a worthwhile reminder that decisions made under this &ldquo;new&rdquo; standard of review will be used as precedent for its decisions made in the future as well, adding to the weight of these determinations.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Patrick Ouellette, Esq., is an attorney with The Phia Group, LLC.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong><u>Biography</u></strong></span></p> <p style="text-align: justify;"><span style="color:#000000;">Patrick joined the Phia Group in 2017. He earned his B.A. in journalism and writing from the University of Rhode Island and spent time as a sports writer and also as a healthcare technology journalist. He later graduated from the Suffolk University Law School evening program with a health and biomedical concentration with distinction. Patrick has legal experience with healthcare providers and in state government. He was also a published staff member of the Suffolk University Law School Journal of Health and Biomedical Law and later served as Chief Content Editor on the journal&rsquo;s executive board.</span></p> <p style="text-align: justify;"><span style="color:#000000;">_______________________________________________________________________________________________________</span></p> <h3><span style="font-size:130%;"><strong>Drowning in A Sea of Paper</strong></span></h3> <h6 style="font-style: italic;"><span style="color:#000000;">By: Tim Callender, Esq.</span></h6> <p style="text-align: justify;"><span style="color:#000000;">The challenges of setting up and administering an employer-sponsored, self-funded health plan are many. One of the largest challenges a self-funded plan sponsor faces is reconciling the vast number of documents that make a self-funded health plan &ldquo;go.&rdquo;</span></p> <p style="text-align: justify;"><span style="color:#000000;">When navigated correctly, these challenges yield immense results in terms of rich benefit delivery within a fiscally responsible health plan mechanism. Still, challenges remain and should be discussed openly so that we can continue to grow and strengthen our industry.</span></p> <p style="text-align: justify;">&nbsp;</p> <p style="text-align: justify;"><span style="color:#000000;">The task of reconciling governing documents is challenging for anyone, but it can be an especially daunting job for any plan sponsor, broker/consultant, or interested party mostly familiar with the fully insured platform. In that relatively simple world, everything &ldquo;goes&rdquo; with minimal paperwork &ndash; at least in the front of the house &ndash; but, this simplicity comes at a significant cost and with a significant lack of control and customization.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Clearly, for most employers that really look into the options, self-funding is the way to go. But, if you want to play in the self-insured world and reap the significant financial benefits of the self-funded model &ndash; get ready to read, re-read, audit, reconcile, and review more paperwork than a forensic accountant scouring financial records written in invisible ink.</span></p> <p style="text-align: justify;"><span style="color:#000000;">In the interest of staging the optics for this brief piece, let me be incredibly clear that I am 10,000% a believer that self-funding is the best model to deliver rich and affordable health benefits, and the success of the self-funded industry is a personal goal and passion of mine. I am a firm believer that all stakeholders in the self-funded space are vital for the success of this model.</span></p> <p style="text-align: justify;"><span style="color:#000000;">The comments made herein are not meant to demonize any one player, nor am I out to state that any particular stakeholder causes more complication than anyone else. Rather, I hope that through an honest, and a little self-critical conversation (laced with humor), we can identify some brutal truths regarding our great industry so that we can continue to work together for the betterment of self-funding, as a whole!</span></p> <p style="text-align: justify;"><span style="color:#000000;">To approach this in an organized fashion, let&rsquo;s make a list of some of the array of paperwork needed for a self-funded health plan to fully function (at least the top documents most commonly involved). From there, we can explore one or two examples that reflect &ldquo;problem areas,&rdquo; and/or bullet points that we should all think about when reflecting on these documents. Not all problems will be (or should be) explored in this article, but, hopefully, this conversation gets the wheels turning and points us toward improvements and solutions.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Governing Plan Document / Summary Plan Description </strong>&ndash; This is the cornerstone of every self-funded health plan. Without a governing plan document, you have.... Well... a nebulous concept of a health plan devoid of any defining rules or benefit structure, with all the details living in someone&rsquo;s head and likely spread across a series of emails and meeting notes! Good luck with a government audit on that one!</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be &ldquo;problem areas&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">Does the plan document contain benefit carve outs that fly in the face of a network contract?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Is the plan document written before the current plan year is even over?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Was the plan document compared to the relevant stop-loss policy to look for coverage / reimbursement gaps?</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>Summary of Benefits and Coverage (SBC)</strong> &ndash; Thank you Affordable Care Act! As we all know, health insurance is confusing and saturated with paperwork. Well, thankfully the ACA saw fit to &ldquo;simplify&rdquo; health coverage by requiring, yes, you guessed it, more paperwork! Better hope your SBC lines up with your SPD or you might be SOL with the DOL while listening to OPP in the LBC.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be &ldquo;problem areas&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">Do the benefit examples in the SBC actually match up with the intended benefits of the plan document (what if a plan member relies on the SBC for benefits and the plan document has not been fully written/issued yet...?)</span></li> <li style="text-align: justify;"><span style="color:#000000;">Was the benefit structure of the Plan fully finalized before issuing pre-enrollment SBCs (in other words, how many people have pushed SBCs out, just to &ldquo;get them done,&rdquo; while recognizing that the benefit structure of the plan document is likely to change by the time it is finalized?).</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>PBM Agreement </strong>&ndash; And then, let&rsquo;s add drugs. No, I don&rsquo;t mean &ldquo;let&rsquo;s add drugs&rdquo; in the context of a 1970s Grateful Dead, San Francisco acid test &ndash; rather, and as if it&rsquo;s not confusing enough, let&rsquo;s take a completely separate entity, bring them to the party to assist with a plan&rsquo;s Rx benefits, and then, in the frantic insanity that is a 60 hour work week, hope that we all read over the PBM agreement to see if it lines up with the intent of our health plan and that the language in the plan document echoes that same alignment &ndash; oh, and maybe stop-loss to?</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be a &ldquo;problem area&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">Is there a clear alignment in the contracting (and the plan document!) regarding which entity might handle / administer claims and appeals for particular Rx benefits? &ndash; Has the language in the plan document, as required by the PBM, been reconciled with the Plan&rsquo;s stop-loss policy, network agreement, and/or SBC?</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>Network Agreement </strong>&ndash; Where to start...?</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be &ldquo;problem areas&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">How many parties are expected to be bound by a particular network agreement?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Are there inconsistencies in how particular benefits should be paid as laid out between the network agreement and a plan&rsquo;s governing plan document?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Is the Plan administering a reference-based pricing program, and, if so, have network obligations been taken into account?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Have all vendor contracts, and their roles, as related to the administration of a plan, been reconciled against the roles and responsibilities of the plan, as laid out in the network contract?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Are there inconsistent medical management criteria as laid out between the plan document, the network contract, the PBM contract, and other documents?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Are the benefit payment timelines (and appeal timelines), as between the plan document and the Network Agreement, cogent so as to assure the Plan is not losing a network discount or risking a prompt-payment Network Agreement breach term?</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>Stop-Loss Policy / Agreement </strong>&ndash; Too often we see material variances in the wording of definitions and exclusions, as between plan documents and stop-loss policies. To state the obvious, this can create significant coverage gaps, manifesting in reimbursement denials that are not necessarily invalid. Common discrepancies include a disconnect in a &ldquo;medical necessity&rdquo; definition or an &ldquo;experimental and investigational&rdquo; definition.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Additionally, what about notice provisions? While not directly related to a misalignment between plan document and stop-loss terms, this concept can create havoc when a plan-sponsor does not pay especially close attention to the notice requirements present in a stop-loss contract. More specifically, does the contract require the sponsor to provide notice to the carrier any time the Plan modifies benefits? If so, and if the Plan fails to do so, a significant (and likely valid) coverage gap may exist.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be &ldquo;problem areas&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">Pretty much everything I&rsquo;ve written above, plus this one, often forgotten gem: gaps that might exist between a plan document and an employer-sponsor&rsquo;s employee handbook, related to leave of absence provisions, which may lead to eligibility issues and subsequent reimbursement denials at the stop-loss level.</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>Administrative Services Agreement (typically with a TPA or a carrier on its ASO platform) </strong>&ndash; This document can tend to be the &ldquo;unifier&rdquo; or the &ldquo;great divider.&rdquo; So many solutions and pieces that make up a self-funded plan all fall together in the ASA. This document is key. I&rsquo;ll say it again, KEY.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be &ldquo;problem areas&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">Who is the named fiduciary outside of the Plan Sponsor (are there others &ndash; are there shared duties &ndash; are there fiduciary inconsistencies between the ASA, the plan document and the various vendor contracts involved?)</span></li> <li style="text-align: justify;"><span style="color:#000000;">Are all vendors mentioned and/or properly referenced within the ASA?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Does the ASA properly outline a scope of duties and responsibilities in a way that mirrors the intent of the Plan and as reflected in all other governing plan documents?</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>Employee / Employer Handbooks </strong>&ndash; This one just splashed onto the scene in a pretty incredible way over the past year or so.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Items that could be &ldquo;problem areas&rdquo; include:</span></p> <ul> <li style="text-align: justify;"><span style="color:#000000;">As discussed above, have the handbook, plan document, and stop-loss policy been &ldquo;bounced together&rdquo; to assure there are no issues that might result in valid reimbursement denials?</span></li> <li style="text-align: justify;"><span style="color:#000000;">Leave of absence provisions and plan document eligibility provisions...</span></li> </ul> <p style="text-align: justify;"><span style="color:#000000;"><strong>Plan Amendments </strong>&ndash; I had a dream once, about a Plan that had not had its plan document restated in 8 years, and, during that time, the Plan Sponsor had amended the plan 16 times. All amendments existed as separate documents, referencing one another from time to time, and, oftentimes, referencing various vendors that no longer worked for the Plan. Then, the Plan Sponsor came to me and hired me in November to restate the plan for a January 1 kick off. I woke up screaming. That kept me up at night.</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Notifications (of material modification; open enrollment; HIPAA privacy notifications; etc.)</strong> &ndash; While many of these may not need to line up with a plan&rsquo;s specific benefit grid, network alignment, or the definition of &ldquo;maximum allowable,&rdquo; you can easily see how a bit more paperwork, directly impacting the member&rsquo;s understanding of a plan, can be cumbersome and can easily cause confusion if not handled carefully, especially when bundled into an envelope (or email) containing a plan document and an SBC!</span></p> <p style="text-align: justify;"><span style="color:#000000;"><strong>Miscellaneous Vendor Contracts </strong>&ndash; Take everything discussed above and add in a few more. Time to turn up the volume! All the above is enough to strike fear into the heart of the most diligent and thorough paper pushing accountants, advisors, and attorneys. But, it is the price of admission and a piece of our business that we should be aware of and work through carefully. As a best practice, every Plan Sponsor should engage in expert gap reviews of all documents and should do so on a routine basis.</span></p> <p style="text-align: justify;"><span style="color:#000000;">To conclude, and hopefully provide some closure and definition to my thoughts, I will leave you with this: our industry is complicated. There is no denying it. Let&rsquo;s acknowledge it, be willing to criticize it, and even be willing to poke fun at it.</span></p> <p style="text-align: justify;"><span style="color:#000000;">But, at the end of the day, let&rsquo;s recognize that our industry &ndash; our platform &ndash; is the best. So, we owe it to each other, as stakeholders in this space, to work hard to accomplish the goal of aligning the documents that govern the administration of a self-funded health plan.</span></p> <p style="text-align: justify;"><span style="color:#000000;">Should the first and foremost guardian of this alignment be the Plan Sponsor? Absolutely &ndash;and with expert guidance! We are all in this together and should strive to achieve harmony in a Plan&rsquo;s governing documents, wherever possible, together. All boats rise.</span></p> </div> </div> 738 Empowering Plans: P46 - You’ve Gotta Fight, For Your Right, to Try!https://www.phiagroup.com/Media/Posts/PostId/735/empowering-plans-p46-youve-gotta-fight-for-your-right-to-tryPodcastsFri, 29 Jun 2018 14:57:21 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/M_7buCGAkaE" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:11.0pt;font-family:&quot;Calibri&quot;,sans-serif; mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;color:black; mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">In this very special episode, our hosts embark on a maiden voyage &ndash; their first ever video podcast!&nbsp; Listen in, and even better &ndash; watch &ndash; as the team addresses the recently passed Right To Try Laws, and dissect the impact it may have &ndash; if any &ndash; on your health benefit plans.&nbsp; Whether you choose to cover these treatments or not, there is action you must take&hellip; tune in to find out what you need to do.</span></p> <p><a href="https://youtu.be/M_7buCGAkaE">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/M_7buCGAkaE">YouTube</a><a href="https://youtu.be/MhVGaw6hybQ"> </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 735 Empowering Plans: P45 - Super-Empowerment https://www.phiagroup.com/Media/Posts/PostId/733/empowering-plans-p45-super-empowermentPodcastsFri, 22 Jun 2018 14:26:49 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/MhVGaw6hybQ" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size: 11pt; font-family: &quot;Calibri&quot;, sans-serif;">Sitting with Our Most Empowered Plan Award Winner.&nbsp; In this episode, our hosts chat with none other than Brooks Goodison, President &amp; Principal Partner at Diversified Group.&nbsp; Brooks and his team won The Phia Group&rsquo;s Most Empowered Plan award at the recent MVP Forum, and we are all excited to learn more from this cutting edge thinker.&nbsp; From internal vision to lobbyist efforts taken on behalf of the entire industry, you&rsquo;ll be glad you tuned in.</span></p> <p style="text-align: justify;">You can visit Diversified Group&#39;s website, here: <a href="https://www.dgb-online.com/">www.dgb-online.com</a></p> <p><a href="https://youtu.be/MhVGaw6hybQ">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/MhVGaw6hybQ">YouTube</a><a href="https://youtu.be/MhVGaw6hybQ"> </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 733Final Rule on Association Health Plans and YOU: Phia's Takehttps://www.phiagroup.com/Media/Posts/PostId/732/final-rule-on-association-health-plans-and-you-phias-takeWebinarsThu, 21 Jun 2018 18:29:24 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/xPGGLyzM5G0" width="560"></iframe></p> <p><span class="registration-description" data-bind="expander:{'expandText': moreButtonText(), 'userCollapseText': lessButtonText(), 'text':getWebinarInfo().description}">On Tuesday, June 19th, the Department of Labor issued a final rule on Association Health Plans. Supporters claim the rule will allow millions of Americans to access more affordable coverage options. Critics contend that it will reduce patient access and weaken the insurance markets, leading to increased costs for all. Join The Phia Group's legal team in this special edition webinar in which they <span class="details" style="display: inline;"> will break down the final rule and explain the significant impact it is expected to have on the self-funded industry.</span></span> </p> <p><a href="https://youtu.be/xPGGLyzM5G0">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 732The Buck Stops…Where? Pointing Fingers in the Self-Funded Industryhttps://www.phiagroup.com/Media/Posts/PostId/727/the-buck-stopswhere-pointing-fingers-in-the-self-funded-industryWebinarsTue, 12 Jun 2018 16:17:35 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/M_nPIMloGvo" width="560"></iframe></p> <p><span class="registration-description" data-bind="expander:{'expandText': moreButtonText(), 'userCollapseText': lessButtonText(), 'text':getWebinarInfo().description}">In a financial climate where saving money has to be made a top priority, so many entities within the insurance industry have fallen victim to someone trying to shift blame onto them. Regardless of fault, it’s in everyone’s best interests to work together to overcome issues rather than point fingers – but it’s not always that simple. </span></p> <p><span class="registration-description" data-bind="expander:{'expandText': moreButtonText(), 'userCollapseText': lessButtonText(), 'text':getWebinarInfo().description}">Join The Phia Group’s legal team <span class="details" style="display: inline;">as they discuss some situations where fingers have been pointed, how those situations were resolved, and how you can help insulate yourself from similar circumstances.</span></span></p> <p><a href="https://youtu.be/M_nPIMloGvo">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 727 Empowering Plans: P44 - The Phia Group “MVP” Post-Mortemhttps://www.phiagroup.com/Media/Posts/PostId/726/empowering-plans-p44-the-phia-group-mvp-post-mortemPodcastsTue, 12 Jun 2018 14:23:17 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/2AMVtLnXQZ8" width="560"></iframe></p> <p>&nbsp;</p> <p style="text-align: justify;">In this episode, our hosts discuss the recently concluded Phia Group Most-Valuable-Partners or &ldquo;MVP&rdquo; forum; an event that took place June 4<sup>th</sup> to the 6<sup>th</sup> at Gillette Stadium, home of the New England Patriots.&nbsp; &nbsp;From the subject matter, to the client feedback&hellip; experiences, to comical coincidences&hellip; For those who attended, and those who wish they could have been there&hellip; This episode of Empowering Plans is not to be missed.</p> <p><a href="https://youtu.be/2AMVtLnXQZ8">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/2AMVtLnXQZ8">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 726Empowering Plans: P43 - A Debrief of SIIA’s Fly-In on the Hillhttps://www.phiagroup.com/Media/Posts/PostId/721/empowering-plans-p43-a-debrief-of-siias-fly-in-on-the-hillPodcastsFri, 01 Jun 2018 16:50:14 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/-g4TOR-3m2E" width="560"></iframe></p> <p>In this episode of Empowering Plans, Adam, Ron, and Brady discuss their recent trip to Washington, D.C. in which they took part in SIIA&rsquo;s &ldquo;Fly-In&rdquo; event, where SIIA members met with their elected representatives to discuss self-insurance/captive insurance issues. It was a great success, as they were able to promote the interests of self-funded health plans and their TPAs as well as advocate for <span style="font-size:11.0pt;font-family:&quot;Calibri&quot;,sans-serif; mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;color:#1F497D; mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">a Senate version of the Self-Insurance Protection Act.</span></p> <p><a href="https://youtu.be/-g4TOR-3m2E">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/-g4TOR-3m2E">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 721Empowering Plans: P42 - Eliminating the Noisehttps://www.phiagroup.com/Media/Posts/PostId/720/empowering-plans-p42-eliminating-the-noisePodcastsTue, 29 May 2018 21:24:03 GMT<iframe width="560" height="315" src="https://www.youtube.com/embed/goYdHALDGjA" frameborder="0" allow="autoplay; encrypted-media" allowfullscreen></iframe> <p>In this episode, Adam, Ron, and Brady interview David Contorno, President of Lake Normal Benefits. They discuss emerging trends in the industry; from reference-based pricing to direct primary care. They also address the incentive problem and how HSAs are harming the health insurance industry.</p> <p><a href="https://youtu.be/goYdHALDGjA">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/goYdHALDGjA">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 720Empowering Plans: P41 - The Case for Collusion (Continued)https://www.phiagroup.com/Media/Posts/PostId/719/empowering-plans-p41-the-case-for-collusion-continuedPodcastsThu, 24 May 2018 15:25:09 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/BclJgXPsot8" width="560"></iframe></p> <p>Join The Phia Group&rsquo;s Sr. VP, Ron E. Peck, and healthcare attorney Brady C. Bizarro as they answer the questions that you asked during our webinar on PBMs, specialty drug prices, and lawsuits alleging fraud.</p> <p><a href="https://youtu.be/BclJgXPsot8">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/BclJgXPsot8">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 719Empowering Plans: P40 - Reference Based Pricing - Yeah, You Know Mehttps://www.phiagroup.com/Media/Posts/PostId/717/empowering-plans-p40-rbp-yeah-you-know-mePodcastsThu, 17 May 2018 18:47:41 GMT<p>&nbsp;</p> <p>In this episode, The Phia Group chats once again with one of their Partners in Empowerment, Gregory S. Everett, President and CEO of Payer Compass.&nbsp; Greg addresses all of our hosts&rsquo; questions regarding reference based pricing, balance billing, the value of physician networks, and the future of RBP.</p> <p><a href="https://youtu.be/5njJT-deoFE">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=3EbdW_MYFXI&amp;feature=youtu.be">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 717The Case for Collusion: How the Power Players May Have Defrauded Us Allhttps://www.phiagroup.com/Media/Posts/PostId/715/the-case-for-collusion-how-the-power-players-may-have-defrauded-us-allWebinarsTue, 15 May 2018 14:23:13 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/tia5md4s0WE" width="560"></iframe></p> <p> </p> <p>At long last, after a lengthy investigation, we are ready to present the allegations of collusion. It is alleged that powerful forces have been working together in a complex scheme to mislead us. To be clear, we are talking about Big Pharma and certain PBMs. A new class action lawsuit has been filed against CVS Health alleging that it knowingly colluded with PBMs to raise generic drug prices. The claim is that health plans and consumers alike have been overpaying for drugs. We have seen this playbook before. This time, however, there is potential for TPAs and their groups to join the lawsuit to recoup funds allegedly overpaid to CVS. Join The Phia Group’s Special Counsels for an hour as they share reports on this alleged fraudulent scheme and discuss the ways in which our industry can fight back and tackle the underlying problem of specialty drug prices.<br />  </p> <p><a href="https://youtu.be/tia5md4s0WE">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 715Empowering Plans: P39 - Everything's Bigger In Texas!https://www.phiagroup.com/Media/Posts/PostId/712/empowering-plans-p39-everythings-bigger-in-texasPodcastsMon, 07 May 2018 19:42:17 GMT<p><span class="pre_wrap">In this episode, our hosts interview Third Party Administrator, visionary, and industry expert &ndash; Caprock Healthplans&rsquo; own Executive Vice President, John Farnsley &ndash; as we review some of his recent talking points, cover where he thinks the industry is headed, and dissect the biggest issues he thinks will impact everyone involved.</span><br /> <br /> <a href="https://www.youtube.com/watch?v=3EbdW_MYFXI&amp;feature=youtu.be">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=3EbdW_MYFXI&amp;feature=youtu.be">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 712Empowering Plans: P38 - A Labor of Love?https://www.phiagroup.com/Media/Posts/PostId/707/empowering-plans-p38-a-labor-of-lovePodcastsTue, 24 Apr 2018 15:03:36 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/nbr7-WIodGA" width="560"></iframe></p> <p>In this episode, Adam, Ron, and Brady interview in-house specialist, VP of Consulting Attorney Jennifer McCormick, and discuss the many complicated issues surrounding surrogacy, and the costs for which benefit plans may be responsible.&nbsp; What can be denied?&nbsp; What must be paid?&nbsp; Why is this a threat?&nbsp; What can we do to avoid it, or at least minimize the risks?&nbsp; Listen and find out!<br /> <br /> <a href="https://youtu.be/nbr7-WIodGA">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/nbr7-WIodGA">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 7074 Horsemen of the Plan-pocalypsehttps://www.phiagroup.com/Media/Posts/PostId/706/4-horsemen-of-the-plan-pocalypseWebinarsThu, 19 Apr 2018 15:17:25 GMT<p>Nostradamus?  Miss Cleo?  The Phia Group?  In a psychic feat of foresight, The Phia Group’s team has gazed into their crystal ball and identified four issues that may not presently be keeping you up at night, but will certainly be disturbing your slumber very soon.  From being forced to pay for surrogate pregnancy and births, to the IRS actively issuing letters notifying employers of 2015 tax year penalties; from a new wave of fraud, errors, and abuse leading to heretofore unseen overpayments, to case law addressing the rights of plans to utilize reference based pricing – you’ve been warned!  We predict this complimentary webinar will open your eyes.  Miss this webinar at your own peril… You’ve been warned!<br />  </p> <p><a href="https://youtu.be/J6d4jKYw-Fg">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 706Empowering Plans: P37 - Arresting the Financial Serial Killershttps://www.phiagroup.com/Media/Posts/PostId/705/empowering-plans-p37-arresting-the-financial-serial-killersPodcastsWed, 18 Apr 2018 14:34:00 GMT<p>Today Adam and Ron interview the industry, and nationally, renown Dr. Keith Smith of the Surgery Center of Oklahoma.&nbsp; This pioneer of transparent pricing and forefather of the Free Market Medical Association waxes poetic regarding everything from issues with provider pricing, the status of medicine today, and his predictions for the future of health care.&nbsp; If you don&rsquo;t think surgeons can offer a clear and transparent price for care before they provide the treatment is provided, listen to this episode and prepare to be shocked!</p> <p><a href="https://youtu.be/z8CDN6-rCLk">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/z8CDN6-rCLk">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 705Empowering Plans: P36 - New Kids on the Blockhttps://www.phiagroup.com/Media/Posts/PostId/702/empowering-plans-p36-new-kids-on-the-blockPodcastsMon, 09 Apr 2018 16:32:30 GMT<p>In this episode, Ron, Adam and Brady interview one member of our industry&rsquo;s albeit too small youth movement.&nbsp; Our hosts discuss with Brian Olsen what we all can do to attract new interest, and talent, to the business of risk management and hopefully help our industry not only survive, but thrive.<br /> <br /> <a href="https://youtu.be/GoHh1c1aXzY">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/GoHh1c1aXzY">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 702The Phia Group's 2nd Quarter 2018 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/699/the-phia-group-2nd-quarter-2018-newsletterNewslettersThu, 05 Apr 2018 20:34:40 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; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 12px; color:#000000; } .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: #000000">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%20Q1%202018/header2018.jpg" style="width: 667px; height: 303px;" /></td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/icons3.png" style="width: 650px; height: 152px;" /></td> </tr> <tr> <td valign="top" width="312"><a href="#p1"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/b12qtr.png" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#p2a"><img src="/Portals/phiagroup/Newsletter%202018%20Q2/b22qtr.png" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" height="447" width="648"> <tbody> <tr> <td valign="top" width="53%"><br /> <img height="316" src="/Portals/phiagroup/Newsletter%202018%20Q2/adam.jpg" width="302" /></td> <td valign="top" width="47%"> <p class="bodytext heading1" style="font-size: 14px; font-weight: bold;">&nbsp;</p> <p class="bodytext heading1" style="font-size: 14px; font-weight: bold;">The Book of Russo:<br /> From the Desk of the CEO</p> <p class="bodytext"><span style="color:#000000;">It is busy&hellip; I mean really busy. From conferences to claim issues, never has The Phia Group seen the volume and variety that it is seeing now. That is why this month&rsquo;s webinar on April 19th is a must-see event. We are witnessing new and unique claim issues, ranging from surrogacy to scary IRS notices being sent to employers across the country. This webinar will discuss what we have learned and what you can do to protect yourselves and your clients. It is only spring here in Boston but the heatwave of self-funding is being felt across Phia. By the way, I wanted to congratulate the following 8 employees of The Phia Group for officially being approved to attend the Future Leaders Track at the 2018 National SIIA Conference in late September.</span></p> </td> </tr> </tbody> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p><span class="bodytext">&bull; Toussaint Anderson<br /> &bull; Ulyana Bevilacqua<br /> &bull; Brady Bizarro<br /> &bull; Amanda Grogan<br /> &bull; Garrick Hunt<br /> &bull; Amanda Lima<br /> &bull; Maribel McLaughlin<br /> &bull; Victoria Pace<br /> <br /> These fine people will represent our company at SIIA&rsquo;s first foray into ensuring the future of self-funding. I would encourage all of you to identify the future leaders of your organization and send them to SIIA as well. Happy reading!</span></p> <p>&nbsp;</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%202018%20Q2/inthisissue.png" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><br /> <a href="#p1">Service Focus of the Quarter: Plan Appointed Claim Evaluator (PACE)</a><br /> <a href="#p2">Phia Case Study: Overpayment Schmoverpayment</a><br /> <a href="#p3">Success Story of the Quarter: The Phia Group Saves an Employer Thousands of Dollars</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2018 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p><a id="p1" name="p1"></a></p> <p><span class="heading1">Register for The Phia Group&#39;s Next Webinar</span></p> <p class="bodytext" style="text-align: center;"><span style="font-size:larger;"><span style="color: rgb(0, 0, 0);"><strong>4 Horsemen of the Plan-pocalypse</strong></span></span></p> <p style="text-align: justify;"><span class="bodytext">Nostradamus? Miss Cleo? The Phia Group? In a psychic feat of foresight, The Phia Group&rsquo;s team has gazed into their crystal ball and identified four issues that may not presently be keeping you up at night, but will certainly be disturbing your slumber very soon. From being forced to pay for surrogate pregnancy and births, to the IRS actively issuing letters notifying employers of 2015 tax year penalties; from a new wave of fraud, errors, and abuse leading to heretofore unseen overpayments, to case law addressing the rights of plans to utilize reference based pricing &ndash; you&rsquo;ve been warned! We predict this complimentary webinar, taking place at 1pm (EST) on April 19, 2018, will open your eyes. Miss this webinar at your own peril&hellip; You&rsquo;ve been warned! </span></p> <p class="bodytext" style="text-align: center;"><span style="font-size:2.3em;"><a href="https://register.gotowebinar.com/register/6269371710856854273" target="_blank">Click HERE to Register!</a></span></p> <p class="heading1">&nbsp;</p> <p class="heading1"><span style="color:#000000;">Service Focus of the Quarter: Plan Appointed Claim Evaluator&reg; (PACE)</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Making determinations on medical claim appeals is a frightening prospect. The process can involve complex factual, legal, and medical issues, and can distract an employer plan sponsor from its ordinary business functions, posing a significant resource drain. The PACE service allows the plan sponsor to shift fiduciary duty away, onto the PACE, for final, internal claim appeals. With PACE, plan sponsors and TPAs assign the riskiest fiduciary duty (that is, the power to make payment decisions in response to final, internal appeals), to The Phia Group. This authority carries with it the most risk, because it is this final payment directive that may be scrutinized upon external review or in the courtroom.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Self-funding veterans and novices alike will benefit from PACE. Groups that are moving from fully-insured or ASO arrangements can use PACE as a valuable tool to aid in the transition; these groups have never before been faced with such fiduciary liability - with the PACE, that daunting responsibility can be delegated to a neutral and capable third party. In addition to having a third party expert analyze all final, internal appeals, before they reach an external review, the PACE also ensures that legally mandated independent review organizations (IROs) are in place, and the PACE handles facilitation of external appeals with these IROs. Regardless of whether the PACE upholds or reverses a denial, the PACE&#39;s service continues to apply. This includes coordinating efforts with stop-loss, plan sponsors, brokers, and TPAs whenever these partners do not align. PACE is a way for the employer to be able to focus less on the complexities of its health plan, fiduciary duties, and stop-loss concerns, and more on what matters - its business. PACE is also a way for the payor to rest easy knowing that it is not unwittingly assuming fiduciary duties on final, internal appeals.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">For years, self-funded plan sponsors and TPAs have asked how they can avoid the risks inherent in self-funding, while still enjoying the benefits of that plan structure. According to The Phia Group&#39;s CEO, Adam Russo, &quot;With a PACE in place, we&#39;re taking a giant step in the right direction. It&#39;s a game changer.&quot; Contact Tim Callender at</span> <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a> <span style="color:#000000;">or 781-535-5631 to learn more about how PACE can help you.</span></p> <a id="p2" name="p2"></a> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="font-size:larger;"><span style="color: rgb(0, 0, 0);"><strong>Phia Case Study: Overpayment, Schmoverpayment!</strong></span></span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The Phia Group was presented with a situation in which a TPA had processed a claim in error. The issue was one of eligibility; the TPA processed the claim as usual, without realizing that the member had in fact termed the prior week. The TPA had the information, but through a fairly common record update delay, the claim was paid at the appropriate out-of-network rate - but for a termed member.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The group&#39;s broker contacted the TPA and was somewhat upset at the erroneous claim processing. The TPA explained the circumstances - and the TPA&#39;s Administrative Services Agreement did not hold the TPA responsible - but the broker expressed interest in pursuing the matter, given the sizeable amount of money involved. The broker was also looking into having the group switch TPAs.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">When this matter was brought to the attention of The Phia Group&#39;s consulting team, our first two actions were to try to diffuse the situation between the broker and TPA, and to try to recoup the overpayment to keep both sides happy.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">As it happened, The Phia Group&#39;s dedicated overpayment team had a prior relationship with this particular provider, and our overpayment recovery specialists were able to recover $40,000.00 of the $42,000.00 erroneous payment. That recovery satisfied the broker and the group, and the TPA agreed to credit the group the remaining $2,000.00 as a gesture of good faith (and a smart business decision to boot).</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The recovery obtained by The Phia Group&#39;s overpayment team not only salvaged $40,000.00 for the group, but it avoided a feud between a TPA and broker, and also helped the TPA keep a valuable block of business that it would otherwise have lost.</span></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="bodytext"><span style="font-size:larger;"><span style="color: rgb(0, 0, 0);"><strong>Fiduciary Burden of the Quarter: Following the Plan Documents&hellip;Unless&hellip; </strong></span></span></p> <span style="color:#000000;"> <a id="p2a" name="p2a"></a></span> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Generally, it is fairly simple to comply with the duty to follow the terms of the plan documents. That important duty, however, applies only &quot;insofar as such documents and instruments are consistent with the provisions of [ERISA].&quot; In other words, you must follow the plan documents, unless the plan documents violate ERISA, in which case you must follow ERISA instead. The powers that be have interpreted this as applying not just to ERISA, but to all federal laws. The result is that federal law &quot;overrides&quot; any conflicting terms of the plan documents - so Plan Administrators are sometimes forced to ignore the terms of the plan documents in favor of following federal law.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">So what does this mean? Well, if the plan documents have provisions that violate federal law, the fiduciary duty morphs from one requiring the fiduciary to comply with the terms of the plan documents to one requiring the fiduciary to comply with the law instead of the plan document.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">An example we have seen are the new regulations promulgated under ACA Section 1557 regarding transgender surgery. There is a certain amount of legal discord at the moment surrounding the interpretation of these regulations, but the status quo is that self-funded health plans are not permitted to exclude transgender surgery, or they risk violation of the Affordable Care Act. Many employers, however, have taken a stance against this mandate, by excluding transgender surgery within their plan documents. This is a textbook instance where the fiduciary duty would change: if following the terms of the plan document would be noncompliant with other federal laws, then the fiduciary is required to follow those federal laws instead.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">This can be a very tricky situation, and it emphasizes the notion that the plan documents should always be as compliant and current as possible to avoid having to analyze situations like this. As always, if you have questions about your plan documents, fiduciary duties, or how to reconcile the two, please contact</span> <a href="mailto:PGCReferral@phiagroup.com">PGCReferral@phiagroup.com</a>.</p> <p>&nbsp;</p> <hr class="horiz" /> <p class="heading1"><a id="p3" name="p3"></a><span style="color:#000000;">Success Story of the Quarter: The Phia Group Saves an Employer Thousands of Dollars</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The IRS has recently been enforcing the Employer Shared Responsibility Mandate (&ldquo;employer mandate&rdquo;) by sending letters to employers implicating that they may have violated the employer mandate rules and may owe a substantial penalty called an Employer Shared Responsibility Payment (&ldquo;ESRP&rdquo;). This employer mandate was put in place by the Affordable Care Act (&ldquo;ACA&rdquo;). The ACA requires Applicable Large Employers (&ldquo;ALEs&rdquo;) who have 50 or more employees to (1) provide minimum essential health coverage to all full-time employees and their dependents (or the employer will face a subsection (a) penalty); or (2) offer eligible employer-sponsored coverage that is &ldquo;affordable&rdquo; and meets &ldquo;minimum value&rdquo; (or the employer will face a subsection (b) penalty). Employers who receive these letters may have to pay the ESRP, but have a chance to respond to the letter before the penalty is mandated.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">A client was presented with one of these letters from an employer. The employer was facing over $50,000.00 dollars in penalties if they did not respond to the letter properly and explain why they were/were not at fault. The IRS has specific guidelines of how to respond to these letters. This can become very daunting and confusing for employers facing these high penalties. The client reached out to The Phia Group for consultation. Attorneys Krista Maschinot and Erin Hussey analyzed the situation and explained what the employer may or may not have done wrong to receive this large employer mandate penalty, and with their consultation, the employer was able to identify their mistake and properly respond to the IRS letter. After the employer explained their mistake and properly responded to the IRS letter, the IRS sent a second letter to the employer which lowered their penalty to less than $2,500.00, saving the employer thousands in penalties.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Disclaimer: As these forms are heavily based in IRS regulations and taxation, we strongly recommended to the broker that the employer should discuss this with their tax advisor and/or the entity that assisted in preparing their tax forms.</span><br /> &nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><span style="color:#000000;"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a>Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Self-Insurers Publishing Corp. -</span> <a href="https://www.sipconline.net/files/Buyer%20Beware%20-%20No%20Good%20Deed%20Goes%20Unpunished%20by%20Ron%20E_%20Peck%2C%20Esq.pdf" target="_blank">Buyer Beware - No Good Deed Goes Unpunished</a> <span style="color:#000000;">- January 3, 2018</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Money Inc. -</span> <a href="http://o http://moneyinc.com/good-pass-overcome-loss-individual-mandate/">Too Good to Pass Up: How we Over Come the Loss of the Individual Mandate</a> <span style="color:#000000;">- January 24, 2018</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Money Inc. -</span> <a href="http://o http://moneyinc.com/the-best-of-times-and-the-worst-of-times-how-imperfect-regulatory-action-may-still-create-opportunities-for-self-funding/">The Best of Times and the Worst of Times&hellip; How Imperfect Regulatory Action May Still Create Opportunities for Self-Funding</a> <span style="color:#000000;">- February 22, 2018</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Self-Insurers Publishing Corp. -</span> <a href="https://www.sipconline.net/files/Trump%20Tax%20Bill%20Signals%20the%20Swan%20Song%20for%20Obamacare's%20Individual%20Mandate%20by%20Sean%20Donnelly.pdf" target="_blank">Trump Tax Bill Signals the Swan Song for Obamacare&#39;s Individual Mandate</a> <span style="color:#000000;">- March 4, 2018</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Money Inc. -</span> <a href="http://moneyinc.com/freedom-blue-why-the-trump-administration-picked-obamacare-over-idaho/" target="_blank">Freedom Blue: Why the Trump Administration Picked Obamacare over Idaho</a><span style="color:#000000;"> - March 29, 2018</span></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><span style="color:#000000;">From the Blogosphere:</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; </span><a href="https://www.phiagroup.com/Media/Posts/PostId/683/contraceptive-update-appeals-and-intervenors" target="_blank">Contraceptive Update - Appeals and Intervenors</a> <span style="color:#000000;">There is a process that must be followed before a party can intervene.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; </span><a href="https://www.phiagroup.com/Media/Posts/PostId/680/what-do-all-these-new-paid-sick-laws-mean-for-employers">What do All These New Paid Sick Laws Mean for Employers?</a> <span style="color:#000000;">The regulations vary by state (and city).</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull;</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/672/even-the-best-plans-can-backfire">Even the Best Plans can Backfire!</a> <span style="color:#000000;">It&#39;s very important in subrogation cases to consider all options.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull;</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/670/youre-plan-isnt-a-cadillac-yet">Your Plan isn&#39;t a Cadillac &hellip;Yet.</a> <span style="color:#000000;">The ACA Health Insurance Provider Tax is applicable for fully-insured plans</span></p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">To stay up to date on other industry news, please </span><a href="https://www.phiagroup.com/Media/Blog.aspx">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a>Webinars</span></p> <p class="bodytext"><span style="color:#000000;"><strong>4 Horsemen of the Plan-pocalypse</strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Nostradamus? Miss Cleo? The Phia Group? In a psychic feat of foresight, The Phia Group&#39;s team has gazed into their crystal ball and identified four issues that may not presently be keeping you up at night, but will certainly be disturbing your slumber very soon. From being forced to pay for surrogate pregnancy and births, to the IRS actively issuing letters notifying employers of 2015 tax year penalties; from a new wave of fraud, errors, and abuse leading to heretofore unseen overpayments, to case law addressing the rights of plans to utilize reference based pricing - you&#39;ve been warned! We predict this complimentary webinar, taking place at 1pm (EDT) on April 19, 2018, will open your eyes. Miss this webinar at your own peril&hellip; You&#39;ve been warned!</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;"><a href="https://register.gotowebinar.com/register/6269371710856854273">Click HERE to Register!</a></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">On March 20, 2018, The Phia Group presented, &quot;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/689/transparency-use-it-to-your-advantage" target="_blank">Transparency: Using it to Your Advantage,</a><span style="color:#000000;">&quot; where we discussed the need for, and effects of, contractual and price transparency on the self-funded industry - and how health plans, TPAs, and brokers can use transparency to their advantage.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">On February 27, 2018, The Phia Group presented, &quot;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/679/evolve-or-dissolve-responding-to-todays-tax-law-to-save-the-health-benefit-plan-industry-tomorrow" target="_blank">Evolve or Dissolve - Responding to Today&#39;s Tax Law to Save the Health Benefit Plan Industry Tomorrow,</a><span style="color:#000000;">&quot; where we discussed what you need to know about the new law, and how to navigate the treacherous path that lies ahead.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">On February 22, 2018, The Phia Group presented, &quot;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/677/keeping-it-under-wraps-what-the-networks-dont-advertise" target="_blank">Keeping it Under Wraps: What the Networks Don&#39;t Advertise,</a><span style="color:#000000;">&quot; where we discussed how the importance of cost-containment is at an all-time high.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">On January 30, 2018, The Phia Group presented, &quot;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/669/plan-on-saving-by-saving-your-plan-applying-lessons-learned-to-create-the-perfect-plan-document" target="_blank">Plan on Saving by Saving Your Plan - Applying Lessons Learned to Create the Perfect Plan Document,</a><span style="color:#000000;">&quot; where we discussed The Phia Group&#39;s Flagship Template.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">On January 18, 2018, The Phia Group presented, &quot;</span><a href="https://www.phiagroup.com/Media/Webinars" target="_blank">A Taxing Time: The Tax Bill&#39;s Impact on Self-Insurance</a><span style="color:#000000;">,&quot; where we discussed the latest tax law.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Be sure to check out all of our</span> <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a>Podcasts:</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull;On March 23, 2018, The Phia Group presented, &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/691/empowering-plans-p34-loopholes-untouchables-and-an-unlikely-ally">Loopholes, Untouchables, and An Unlikely Ally</a><span style="color:#000000;">,&rdquo; where Adam, Ron, and Brady went around the horn discussing a few hot button topics.<br /> <br /> &bull;On March 16, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/685/empowering-plans-p33-partners-in-empowerment-a-prescription-for-savings">Partners in Empowerment &ndash; A Prescription for Savings</a><span style="color:#000000;">,&rdquo; where Ron and Brady were thrilled to interview LG Hanzel of Rx Results.<br /> <br /> &bull;On March 1, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/681/empowering-plans-p32-red-cross-blood-drive-special-episode">Red Cross Blood Drive Special Episode</a><span style="color:#000000;">,&rdquo; where The Phia Group in partnership with the Red Cross hosted an on-site blood drive. Ron Peck interviewed members of The Phia Group staff and Red Cross regarding personal experiences, the Phia event, and the ever present need for donors.<br /> <br /> &bull;On February 26, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/678/empowering-plans-p31-3-scoops-of-knowledge">3 Scoops of Knowledge</a><span style="color:#000000;">,&rdquo; where Adam, Ron and Brady celebrated the forthcoming change in seasons and warming weather, by each selecting a unique topic that was bugging them, and offered their opinions regarding how we should react.<br /> <br /> &bull;On February 16, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/675/empowering-plans-p30-fireside-chat-with-the-president">Fireside Chat with The President</a><span style="color:#000000;">,&rdquo; where our first Empowering Plans guest, the Self-Insurance Institute of America&rsquo;s CEO and President, Michael Ferguson, sat down with Adam, Ron and Brady to discuss everything &ndash; from past wins and losses, to plans for 2018.<br /> <br /> &bull;On February 7, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/671/empowering-plans-segment-29-disruption-or-not">Disruption or Not?</a><span style="color:#000000;">,&rdquo; where our hosts discussed the recent announcement that Amazon, Berkshire Hathaway and JPMorgan are looking to collaborate on &ldquo;health care.&rdquo;<br /> <br /> &bull;On January 29 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/668/empowering-plans-segment-28-game-changers">Game-changers</a><span style="color:#000000;">&rdquo; where our hosts discussed Adam&rsquo;s recent travels and review events.<br /> <br /> &bull;On January 22, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/664/empowering-plans-segment-27-mandate-we-dont-need-no-stinking-mandate">Mandate? We don&rsquo;t need no stinking mandate</a><span style="color:#000000;">,&rdquo; where Adam, Ron, and regular co-host &ndash; Brady Bizarro &ndash; addressed the new tax law, elimination of the individual mandate, and how it may impact benefit plans of all types.<br /> <br /> &bull;On January 10, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/660/empowering-plans-segment-26-lightning-strikes-twice-top-2017-issues-impacting-2018">Lightning Strikes Twice &ndash; Top 2017 Issues Impacting 2018</a><span style="color:#000000;">,&rdquo; where the &ldquo;Phia Group Boys&rdquo; freestyled as they shared the issues they felt defined 2017 and are likely to influence 2018.</span></p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Be sure to check out all of</span> <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext" style="margin-left: 200px;"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/itunes.png" style="width: 251px; height: 78px;" title="" /></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a>The Phia Group&rsquo;s 2018 Charity</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">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.<br /> <br /> The Phia Group&#39;s 2018 charity is the Boys &amp; Girls Club of Brockton.</span></p> <p><img src="/Portals/phiagroup/Newsletter%202018%20Q2/bandgclub.png" style="width: 202px; height: 56px;" /></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The mission of The Boys &amp; Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.</span></p> <p>&nbsp;</p> <p><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/bandg.jpg" style="width: 478px; height: 357px;" title="" /></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">On Thursday, February 8th, CEO of The Phia Group, Adam Russo, invited 50+ children from The Boys &amp; Girls Club of Brockton to a Seussical play at the Inly School in Adam&#39;s hometown of Scituate, MA. It was truly a pleasure to see the look on their faces while watching the play.</span></p> <p class="bodytext">&nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/donations.jpg" style="width: 478px; height: 357px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The Phia Group invites its staff to donate various items for the benefit of The Boys and Girls Club of Brockton. For more information or to get involved, visit</span> <a href="http://www.bgcbrockton.org/">www.bgcbrockton.org</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a>The Stacks</span></p> <p class="bodytext" style="font-weight: bold"><span style="color:#000000;">Trump Tax Bill Signals the Swan Song for Obamacare&#39;s Individual Mandate</span></p> <p class="bodytext" style="font-weight: normal"><span style="color:#000000;">By: Sean Donnelly, Esq. - March 2018 -</span> <a href="https://www.sipconline.net/files/Trump%20Tax%20Bill%20Signals%20the%20Swan%20Song%20for%20Obamacare's%20Individual%20Mandate%20by%20Sean%20Donnelly.pdf" target="_blank">Self-Insurers Publishing Corp.</a></p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><span style="color:#000000;">The &quot;tax&quot; bill that Congress passed in late December was somewhat of a wolf in sheep&#39;s clothing from a health care perspective. It certainly overhauled the tax code and instituted tax cuts for corporations and many American taxpayers, but it also doubled as a thinly veiled health care bill through its repealing of Obamacare&#39;s individual mandate. Authors of the tax bill postulated that such a repeal could save the federal government more than $330 billion over the next decade, as fewer Americans will end up receiving subsidies or Medicaid, savings that could then be used to finance the bill&#39;s tax cuts and lower tax rates. The tax bill was not the complete eradication of Obamacare that the Trump administration had set its sights on during the first year of Trump&#39;s presidency, but the dismantling of the individual mandate marks the first removal of a key pillar in the Obamacare foundation. </span></p> <span style="color:#000000;"> </span> <p><span style="color:#000000;"><span class="bodytext"><a href="https://www.sipconline.net/files/Trump%20Tax%20Bill%20Signals%20the%20Swan%20Song%20for%20Obamacare's%20Individual%20Mandate%20by%20Sean%20Donnelly.pdf">Click here to read the rest of this article </a></span></span></p> <span style="color:#000000;"> </span> <p><br /> <span style="color:#000000;"><span class="bodytext"><strong>The Best of Times and the Worst of Times&hellip; How Imperfect Regulatory Action May Still Create Opportunities for Self-Funding </strong></span></span></p> <span style="color:#000000;"> </span> <p class="bodytext" style="font-weight: normal"><span style="color:#000000;">By: Jen McCormick, Esq. - February 2018</span></p> <span style="color:#000000;"> </span> <p class="bodytext" style="font-weight: normal; text-align: justify;"><span style="color:#000000;">Regulators have been busy over the course of the past few months. Between the issuance of executive orders, a tax bill, and state regulatory action, employers are scrambling to understand the implications. And while regulatory action has been quick, it has not necessarily been thorough, creating possibilities and opportunities for self-funded health plans. Upon review of the various regulations, it seems new incentives for the creation of self-funded employer plans now exist. Employers may investigate taking advantage of this environment to form, create, or modify their self-funded benefit plans. Let&#39;s examine certain recent regulatory developments. </span></p> <p class="bodytext" style="text-align: justify;"><a href="https://www.phiagroup.com/Media/Posts/PostId/695/the-phia-groups-2nd-quarter-2018-newsletter">Click here to read the rest of this article. </a></p> <p style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;"><strong>Buyer Beware - No Good Deed Goes Unpunished</strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">By: Ron E. Peck, Esq. - January 2018 - Self-Insurers Publishing Corp.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Employers and their advisors may soon find themselves accused of breaching their fiduciary duty if they continue to allow their benefit plans to pay inflated rates for medical services, without any justification for the excessive prices. Blindly paying fees that are not revealed until after the service is provided, to practitioners who cannot explain why their rates are many times more than comparable providers of equal or greater skill, is not a prudent use of plan assets and does violate one of the core tenets of the Employee Retirement Income Security Act of 1974 (&quot;ERISA&quot;) and fiduciary law.</span> <strong> </strong></p> <p class="bodytext" style="text-align: justify;"><a href="https://www.sipconline.net/files/Buyer%20Beware%20-%20No%20Good%20Deed%20Goes%20Unpunished%20by%20Ron%20E_%20Peck%2C%20Esq.pdf" target="_blank">Click here to read the rest of this article.</a></p> <p style="text-align: justify;">&nbsp;</p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">To stay up to date on other industry news,</span> <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <em><a href="#top">Back to top ^</a> </em></p> <em><em><em> </em></em></em> <hr class="horiz" /><em><em><em> </em></em></em> <p class="heading1"><em><em><em><a id="p10" name="p10"></a></em></em></em><span style="color:#000000;">Phia&rsquo;s 2018 Speaking Events:</span></p> <span style="color:#000000;"> </span> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;"><strong>Adam Russo&rsquo;s 2018 Speaking Engagements:</strong> </span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;">&bull; 1/23/18 - Q4 Intelligence Conference - Tampa, FL<br /> &bull; 2/2/2018 - Benefit Intelligence School District Conference - Phoenix, AZ<br /> &bull; 3/7/2018 - SIIA Self-Insured Health Plan Executive Forum - Charleston, NC<br /> &bull; 3/9/2018 - CGI Business Solutions Seminar - Manchester, NH<br /> &bull; 3/14/2018 - Pareto StructuRE Meeting - Park City, UT<br /> &bull; 4/12/2018 - Caprock Health Care Forum - Dallas, TX<br /> &bull; 4/25/2018 - Berkley Captive Symposium - Grand Cayman Islands<br /> &bull; 4/26/2018 - Innovative Risk - Grand Cayman Islands<br /> &bull; 4/30/2018 - World Health Care Congress - Washington, DC<br /> &bull; 5/17/2018 - Prairie States Broker Event - Chicago, IL<br /> &bull; 6/21/2018 - GBSI Conference - Springfield, MO<br /> &bull; 6/26/2018 - Leavitt Annual Event - Big Sky, MT</span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;"><strong>Ron Peck&rsquo;s 2018 Speaking Engagements:</strong></span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;">&bull; 1/25/2018 - HealthFirst TPA Client Conference - Tyler, TX<br /> &bull; 3/6/2018 - SIIA National Conference - Charleston, SC<br /> &bull; 3/7/2018 - CGI Business Solutions Seminar - Manchester, NH<br /> &bull; 3/23/18 - Health Rosetta - Module 5: Next-Gen Plan Design - Boston, MA </span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;"><strong>Tim Callender&rsquo;s 2018 Speaking Engagements:</strong></span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;">&bull; 2/14/2018 - BevCap Captive Group, 10th Anniversary Meeting - Kona, HI<br /> &bull; 4/25/2018 - Cypress University - Las Vegas, NV<br /> &bull; 5/7/2018 - UBA Spring Conference - Chicago, IL<br /> &bull; 5/16/2018 - Sun Life MVP Forum - Kansas City, KS<br /> &bull; 5/24/2018 - Pareto Captive Services, Contrarian Re Captive Meeting - Nashville, TN<br /> &bull; 6/25/2018 - Leavitt Conference - Big Sky, MT<br /> &bull; 7/17/2018 - HCAA TPA Summit - Minneapolis, MN</span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;"><strong>Jen McCormick&rsquo;s 2018 Speaking Engagements:</strong></span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;">&bull; 4/17/2018 &ndash; Texas Association of Benefit Advisors &ndash; Dallas, TX<br /> &bull; 5/16/2018 &ndash; IOA RE &ndash; Indianapolis, IN </span></p> <em><em><em> </em></em></em> <p>&nbsp;</p> <em><em><em> </em></em></em> <p class="bodytext"><em><em><em><a href="#top">Back to top ^</a> </em></em></em></p> <em><em><em> </em></em></em> <hr class="horiz" /><em><em><em> </em></em></em> <p class="bodytext"><em><em><em><span class="heading1"><a id="p11" name="p11"></a></span></em></em></em><span class="heading1">Get to Know Our Employee of the Quarter: Catherine Dowie</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">Congratulations to Catherine Dowie, The Phia Group&#39;s Q1 2018 Employee of the Quarter!</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">When we think of passion, we think of Catherine. Not only is she working full time, but she is also going to law school full time at night. Even with all the work she has from attending law school, she still manages to find time at night, after school and on weekends, to work. Anyone can always go to her with a question on case law, and if she does not have an answer right away, she is always able to find an argument on the Plan&#39;s side.</span></p> <p class="bodytext">&nbsp;</p> <em><em><em> </em></em></em> <p class="bodytext"><em><em><em><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/dowie.jpg" style="width: 310px; height: 300px;" title="" /></em></em></em></p> <em><em><em> </em></em></em> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="color:#000000;">Congratulations Catherine and thank you for your many current and future contributions.</span></p> <span style="color:#000000;"> <em><em><em> </em></em></em></span> <p class="bodytext">&nbsp;</p> <span style="color:#000000;"> <em><em><em> </em></em></em></span> <hr class="horiz" /><span style="color:#000000;"><em><em><em> </em></em></em></span> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="color:#000000;"><em><em><em><span class="heading1"><a id="p12" name="p12"></a></span></em></em></em><span class="heading1">Phia News</span></span></p> <span style="color:#000000;"> </span> <p class="bodytext"><span style="color:#000000;"><strong>2017 Community Partner of the Year Award! </strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The Phia Group and Adam Russo were recently awarded the &quot;2017 Community Partner of the Year Award&quot; in Easton, Massachusetts, on March 1, 2018. The Community Partner of the Year Award is presented annually to a company, foundation, or community organization that has made significant contributions to advance the work of the Boys &amp; Girls Club of Brockton. In 2017, The Phia Group gave more than just financial support to propel the programs forward, and their employees and leadership gave generously of our time and talents to create special, lasting memories for the boys and girls throughout the year. </span></p> <p class="bodytext" style="text-align: justify;">&nbsp;</p> <p class="bodytext"><em><em><em><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/award1.jpg" style="width: 500px; height: 400px;" title="" /></em></em></em></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="color:#000000;"><strong>The American Red Cross Visits Phia!</strong> </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The American Red Cross came to visit The Phia Group and 18 of our employees successfully donated a pint of blood. With those 18 donations, we were able to save 54 lives. We take great pride in knowing the impact this can have. To learn more about the American Red Cross and how you can help save a life, make sure you check out</span> <a href="http://www.redcross.org/?scode=RSG00000E017&amp;cid=generic&amp;med=cpc&amp;source=google&amp;ds_lpt_start&amp;ds_lpt_end&amp;gclid=CjwKCAjwhcjVBRBHEiwAoDe5x1juxCAUJ2v-p39shpHFJM1eWZINWzoVe3UA9es5ggwEjFzW7QJ_uhoC5B4QAvD_BwE&amp;gclsrc=aw.ds&amp;dclid=COOh-Nv3_dkCFYO3yAodewAJFQ" target="_blank">The American Red Cross website.</a></p> <p class="bodytext"><em><em><em><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/redcross.jpg" style="width: 500px; height: 500px;" title="" /></em></em></em></p> <p>&nbsp;</p> <p><span style="color:#000000;"><strong><span class="boldtext">Job Opportunities:</span></strong></span></p> <p class="bodytext"><span style="color:#000000;">&bull; Health Benefit Plan Administration - Attorney<br /> &bull; Consultant I </span></p> <p class="bodytext"><span style="color:#000000;">See the latest job opportunities, here:</span> <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><span style="color:#000000;"><strong>Promotions </strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Brady Bizarro was promoted from Staff Attorney to Director, Healthcare Attorney </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Amanda Lima was promoted from Medical Bill Negotiator to Team Lead, Provider Relations</span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Ulyana Bevilacqua was promoted from Consultant I to Supervisor, PGC </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Jillian Painten was promoted from Claim Recovery Specialist IV to Team Leader </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Toussaint Anderson was promoted from Project Manager, PGC to Manager, PDM </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Kelly Dempsey was promoted from Staff Attorney to Director, Independent Consultation &amp; Evaluation (ICE) </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Sabrina Centeio was promoted from Case Investigator to Claim Recovery Specialist III </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Amanda Grogan was promoted from Sr. Claim Recovery Specialist to Team Lead </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Kerri Sherman was promoted from Team Lead, CI / BI to Sr. Team Lead, CI / BI </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Cara Carll was promoted from Team Lead, Recovery MPC/WC to Sr. Team Lead, CA/CSR </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Lisa Tangney was promoted from Manager, Accounting to Controller </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Rose Jardim was promoted from Accounting Administrator to Team Lead, Accounting </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Hemant Dua was promoted from Dir. Applications &amp; Business Intelligence to Sr. Director of Technology </span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">&bull; Garrick Hunt was promoted from Sales Executive to Sales Manager </span><br /> &nbsp;</p> <p class="bodytext"><span style="color:#000000;"><strong>New Hires</strong></span></p> <p class="bodytext"><span style="color:#000000;">&bull; Grace Barron was hired as a Customer Care Representative </span></p> <p class="bodytext"><span style="color:#000000;">&bull; Jacob Falkof was hired as a Customer Care Representative </span></p> <p class="bodytext"><span style="color:#000000;">&bull; David Clasby was hired as an IT Technologist </span></p> <p class="bodytext"><span style="color:#000000;">&bull; Cindy Royle was hired as a Legal Assistant</span><br /> &nbsp;</p> <p class="bodytext"><span style="color:#000000;"><strong>Fun at Phia:</strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color:#000000;">The Phia Family is one good-looking group of footballers! Our Superbowl Party was a hit and we thank all those who participated. Although we did have fans from both teams in the office that day, there were no casualties; and that in itself was a huge success! </span></p> <p class="bodytext"><em><em><em><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/pats.jpg" style="width: 478px; height: 330px;" title="" /></em></em></em></p> <p class="bodytext"><br /> <br /> <em><em><em><a href="#top">Back to top ^</a> </em></em></em></p> <p class="bodytext" style="text-align: center"><em><em><em><img src="/Portals/phiagroup/Newsletter%202018%20Q2/footerlogo.png" style="width: 372px; height: 346px;" /></em></em></em></p> <ul> </ul> </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> 699Empowering Plans: P35 - Direct Primary Care – The Pot of Gold You’re Looking Forhttps://www.phiagroup.com/Media/Posts/PostId/696/empowering-plans-p35-direct-primary-care-the-pot-of-gold-youre-looking-forPodcastsWed, 04 Apr 2018 15:19:06 GMT<p>In this episode, part of our Partners in Empowerment series, we interview Doctor Jeff Gold of Gold Direct Care (golddirectcare.com). Join us as we ask the questions you want answered regarding this innovative and interesting approach to &ldquo;real&rdquo; medical care.<br /> <br /> <a href="https://www.youtube.com/watch?v=IKqc4MXyPOE&amp;t=100s">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/watch?v=IKqc4MXyPOE&amp;t=100s">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 696The Stacks - 2nd Quarter 2018https://www.phiagroup.com/Media/Posts/PostId/695/the-phia-groups-2nd-quarter-2018-newsletterNewslettersMon, 02 Apr 2018 18:38:18 GMT<p><span style="font-size:larger;"><strong>Trump Tax Bill Signals the Swan Song for Obamacare&rsquo;s Individual Mandate</strong></span><br /> By: Sean Donnelly, Esq.<br /> <br /> <u>Background</u></p> <p style="text-align: justify;">The &ldquo;tax&rdquo; bill that Congress passed in late December was somewhat of a wolf in sheep&rsquo;s clothing from a health care perspective.&nbsp; It certainly overhauled the tax code and instituted tax cuts for corporations and many American taxpayers, but it also doubled as a thinly-veiled health care bill through its repealing of Obamacare&rsquo;s individual mandate.&nbsp; Authors of the tax bill postulated that such a repeal could save the federal government more than $330 billion over the next decade as fewer Americans will end up receiving subsidies or Medicaid, savings that could then be used to finance the bill&rsquo;s tax cuts and lower tax rates.<sup>1</sup>&nbsp; The tax bill was not the complete eradication of Obamacare that the Trump administration had set its sights on during the first year of Trump&rsquo;s presidency, but the dismantling of the individual mandate marks the first removal of a key pillar in the Obamacare foundation.</p> <p style="text-align: justify;">The individual mandate, one of the linchpins of the Affordable Care Act, required Americans who did not otherwise qualify for an exception to obtain minimum essential health coverage.&nbsp; Those Americans who did not have minimum essential health coverage for any month during the year were required to pay a penalty during tax season.&nbsp; This mandate was essential to pressure younger and healthier Americans to purchase insurance coverage, thereby bringing balance to the risk pools and stabilizing the health insurance marketplace.&nbsp; &nbsp;</p> <p style="text-align: justify;">The concept of the individual mandate was actually spawned by conservative policymakers who posited that health coverage should be mandatory in order to produce a sustainable insurance pool with the right balance of healthy and sick individuals to properly spread the risk.&nbsp; The underlying theory was that by compelling healthier Americans to enter the marketplace and obtain coverage, premiums would begin to decrease across-the-board as the influx of healthier participants would help to absorb the costs of those less healthy and more expensive participants.&nbsp; In 2006, Mitt Romney, Massachusetts&rsquo; Republican governor, was able to convince the largely Democratic state to adopt an individual mandate as part of its health care overhaul. &nbsp;The relative success of the mandate&rsquo;s Massachusetts audition eventually paved the way for then-President Obama to include an individual mandate as a vital component of the 2010 Affordable Care Act. &nbsp;Even as the Trump tax bill begins to take effect this year, the individual mandate will still remain in effect in 2018.&nbsp; The repeal of the individual mandate won&rsquo;t actually take effect until 2019.&nbsp; Accordingly, the mandate&rsquo;s penalties will continue to be levied in 2018 unless the Trump administration otherwise attempts to have them waived.</p> <p style="text-align: justify;"><u>A Short and Bumpy Ride</u></p> <p style="text-align: justify;">The individual mandate faced intense partisan scrutiny both before and after the passage of the Affordable Care Act.&nbsp; Republicans viewed the mandate as an unconstitutional scheme to coerce Americans to participate in a commercial activity, an act that they argued amounted to an impermissible overreach of Congress&rsquo; powers to regulate commerce.&nbsp; Following the enactment of the Affordable Care Act, a total of twenty-seven states challenged the law&rsquo;s constitutionality in federal court.<sup>2</sup>&nbsp; In the seminal case of <em>National Federation of Independent Business v. Sebelius,<sup>3</sup></em> the Supreme Court agreed with the Republican position and held that the individual mandate was outside of the scope of Congress&rsquo; authority to regulate commerce because the Constitution&rsquo;s Commerce Clause does not afford Congress the power to <em>force</em> people to engage in commerce.&nbsp; However, the individual mandate ultimately managed to withstand judicial scrutiny as the Supreme Court held in its 5-4 decision that the mandate penalty amounted to a permissible <em>tax</em> that Congress could lawfully levy under its taxing and spending power.</p> <p style="text-align: justify;">Even though the mandate survived its main Constitutional challenge, it nonetheless sustained a shellacking in the court of public opinion.&nbsp; A tracking poll conducted by Kaiser Health<sup>4</sup> just a week after the presidential election in November 2016 found that sixty-three percent of Americans viewed the individual mandate as &ldquo;very unfavorable&rdquo; or &ldquo;somewhat unfavorable.&rdquo;&nbsp; Comparably, only thirty-five percent of Americans viewed the mandate as &ldquo;very favorable&rdquo; or &ldquo;somewhat favorable.&rdquo;&nbsp; A whopping sixty-one percent of Republicans polled perceived the individual mandate as &ldquo;very unfavorable.&rdquo;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p> <p style="text-align: justify;">The Heritage Foundation, the conservative think tank that many credit as the originator of the concept of the individual mandate, renounced any affiliation with Obamacare&rsquo;s iteration of the mandate and opposed it as an unconstitutional anachronism no longer considered necessary to achieve universal coverage.<sup>5</sup>&nbsp; Notable among those who continued to champion the repeal of Obamacare and its individual mandate in the wake of the <em>Sebelius</em> decision was Mitt Romney, the very same architect behind the individual mandate&rsquo;s debut in Massachusetts.&nbsp; The mandate was branded by its challengers as an un-American and officious overreach of government authority, a pariah in the land of free people, free markets, and free choice.&nbsp; &nbsp;&nbsp;&nbsp;</p> <p style="text-align: justify;"><u>Broad Implications of the Repeal</u></p> <p style="text-align: justify;">Despite President Trump&rsquo;s pronouncement that the tax bill &ldquo;essentially repealed Obamacare,&rdquo; the Affordable Care Act will continue to be the law of the land.&nbsp; Left untouched in the wake of the tax bill are the federal income-based subsidies intended to assist American consumers with purchasing individual policies, the expansion of Medicaid for low-income adults, the prohibition against denying coverage to consumers with pre-existing health conditions, and the edict that insurers must cover those health benefits deemed &ldquo;essential&rdquo; by the Department of Health and Human Services.&nbsp; Also surviving is the employer mandate, which requires certain employers to provide affordable health care coverage to their employees or else face a penalty.&nbsp; However, the repeal of the individual mandate will undoubtedly trigger some significant shifts in the health care landscape.&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p> <p style="text-align: justify;">The majority of Americans won&rsquo;t be personally impacted, since most people already obtain health insurance either through their employer or through a public program such as Medicare, and thus were never really at risk of being subjected to the individual mandate penalty.&nbsp; Nevertheless, for those Americans who do not receive health insurance from an employer or public program and who instead purchase coverage from an Obamacare health exchange, such individuals are now free to forego their coverage entirely without fear of having to pay a penalty.&nbsp; Those who are completely healthy and those who are financially well-off may now decide to ditch their health coverage as being needless or expendable.&nbsp; Comparably, even those who are sick or less financially stable may ultimately decide not to carry health insurance without the looming threat of the penalty to force them into action.</p> <p style="text-align: justify;">Consequently, the Congressional Budget Office (CBO) is estimating that the individual mandate repeal will result in thirteen million fewer Americans being insured within the next decade.&nbsp; The CBO is also forecasting that the premiums for coverage obtained on the health exchanges will rise approximately ten percent per year over the next decade due to healthy participants scattering from the markets without fear of the penalty and leaving the sicker participants behind to overburden the risk pools.&nbsp; Some health policy experts are expecting that the removal of the individual mandate will simultaneously give rise to increased premiums and decreased coverage rates, ultimately leading to a market collapse.<sup>7</sup>&nbsp; In order to head off this potential outcome, lawmakers in states such as California are already looking to push legislation that would adopt versions of the individual mandate as state law, <em>à la</em> Massachusetts.&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p> <p style="text-align: justify;"><u>Overtones for Employer-Sponsored Plans</u></p> <p style="text-align: justify;">As a result of the repeal of the individual mandate, the CBO is projecting that fewer employees will be joining their employer&rsquo;s self-funded plans with the mandate&rsquo;s penalty no longer in play.&nbsp; Specifically, the CBO anticipates that the removal of the individual mandate will result in three million fewer Americans having coverage through their employer over the next decade.<sup>8</sup>&nbsp; Accordingly, employers may begin to experience a decline in health plan enrollees.&nbsp;</p> <p style="text-align: justify;">As noted earlier, however, the Affordable Care Act&rsquo;s <em>employer</em> mandate will remain after the enactment of the Trump tax bill.&nbsp; Employers subject to the mandate, those with fifty or more &ldquo;full-time equivalent employees,&rdquo; face penalties if they fail to offer minimum essential coverage that provides minimum value and at least one full-time employee receives a premium tax credit for purchasing individual coverage on the health insurance marketplace.&nbsp; Timothy Jost, a law professor at the Washington and Lee University School of Law, deduced that if fewer Americans end up seeking coverage through the health care exchange, then it follows that some employers may be able to avoid paying the employer mandate penalties that are only levied if at least one full-time employee receives a premium tax credit through the exchange.&nbsp; In this way, the individual mandate repeal is somewhat of a double-edged sword; fewer employees may end up enrolling in employer-sponsored plans, but fewer may also look to purchase coverage on the exchange, thereby reducing the risk to their employers who would otherwise be exposed to the strict penalties imposed by the employer mandate.&nbsp; Still, Jost surmises that as over 150 million Americans already have health coverage through their employers, the &ldquo;effects of the individual mandate repeal on the employer-sponsored market will be marginal.&rdquo;<sup>9</sup></p> <p style="text-align: justify;">The repercussions of the repeal will certainly be felt hardest in the individual market, but employer-sponsored plans will likely experience some fallout as healthier, lower-risk employees begin to question if it might make more financial sense to withdraw from their plans entirely.&nbsp; As these healthier, less expensive employees begin to disenroll, the all-important balance each plan seeks to achieve will be disrupted as the scales start to tilt back towards the sicker, higher-risk and more expensive employees.&nbsp; A resulting risk pool made up of a disproportionate number of the costliest employees is the kiss of death for an employer-sponsored plan.&nbsp; As employees are no longer &ldquo;mandated&rdquo; to enroll in the plans offered by their employers, self-funded plans will need to devise more alluring and increasingly innovative methods to retain their healthiest participants.&nbsp; With the individual mandate repealed, the driving force of the mandate&rsquo;s penalty can no longer be relied upon to funnel low-risk lives towards enrollment.&nbsp; Employer-sponsored plans will need to fill this void by offering more comprehensive benefits, designing more creative incentive programs, and prioritizing enrollee engagement in order to secure these vital, low-cost lives.&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p> <div> <div id="ftn1"> <p style="text-align: justify;"><sup>1</sup>See Congressional Budget Office, <em>Repealing the Individual Health Insurance Mandate: An Updated Estimate </em>(November 2017), <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf">https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf</a>.</p> </div> <div id="ftn2"> <p style="text-align: justify;"><sup>2</sup>Park, Katie &amp; Rolfe, Rebecca (2013, September 23). How states approached health-care reform. <em>The Washington Post</em>. Retrieved from <a href="http://www.washingtonpost.com/wp-srv/special/politics/state-healthcare-progress/">http://www.washingtonpost.com/wp-srv/special/politics/state-healthcare-progress/</a>.&nbsp;</p> </div> <div id="ftn3"> <p style="text-align: justify;"><sup>3</sup>See 567 U.S. 519 (2012).</p> </div> <div id="ftn4"> <p style="text-align: justify;"><sup>4</sup>Kirzinger, Ashley, Sugarman, Elise &amp; Brodie, Mollyann (2016, December 01). Kaiser Health Tracking Poll: November 2016. <em>The Henry J. Kaiser Family Foundation</em>. Retrieved from <a href="https://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-november-2016/">https://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-november-2016/</a>.</p> </div> <div id="ftn5"> <p style="text-align: justify;"><sup>5</sup>Butler, Stuart M., Ph.D. (2012, February 06). Don&rsquo;t Blame Heritage for ObamaCare Mandate. <em>The Heritage Foundation</em>. Retrieved from <a href="https://www.heritage.org/health-care-reform/commentary/dont-blame-heritage-obamacare-mandate">https://www.heritage.org/health-care-reform/commentary/dont-blame-heritage-obamacare-mandate</a>.</p> </div> <div id="ftn6"> <p style="text-align: justify;"><sup>6</sup>See Congressional Budget Office, <em>Repealing the Individual Health Insurance Mandate: An Updated Estimate </em>(November 2017), <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf">https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf</a>.</p> </div> <div id="ftn7"> <p style="text-align: justify;"><sup>7</sup>Sanger-Katz, Margot (2017, December 21). Requiem for the Individual Mandate. <em>The New York Times</em>. Retrieved from <a href="https://www.nytimes.com/2017/12/21/upshot/individual-health-insurance-mandate-end-impact.html">https://www.nytimes.com/2017/12/21/upshot/individual-health-insurance-mandate-end-impact.html</a>.</p> </div> <div id="ftn8"> <p style="text-align: justify;"><sup>8</sup>See Congressional Budget Office, <em>Repealing the Individual Health Insurance Mandate: An Updated Estimate </em>(November 2017), <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf">https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf</a>.</p> </div> <div id="ftn9"> <p style="text-align: justify;"><sup>9</sup>Jost, Timothy (2017, December 20). The Tax Bill And The Individual Mandate: What Happened, And What Does It Mean? <em>Health Affairs</em>. Retrieved from <a href="https://www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/">https://www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/</a>.</p> </div> </div> <div> <div id="edn1"> <p style="text-align: justify;"><sup>i</sup>Bennett, Brian (2017, December 20). &lsquo;We have essentially repealed Obamacare,&rsquo; Trump says after tax bill passes. <em>Los Angeles Times</em>. Retrieved from <a href="http://www.latimes.com/politics/washington/la-na-pol-essential-washington-updates-trump-sees-an-end-to-obamacare-in-the-1513794883-htmlstory.html">http://www.latimes.com/politics/washington/la-na-pol-essential-washington-updates-trump-sees-an-end-to-obamacare-in-the-1513794883-htmlstory.html</a>.</p> <p style="text-align: justify;">____________________________________________________________________________________________________</p> <p style="text-align: justify;"><span style="font-size:larger;"><b style="mso-bidi-font-weight:normal"><span style="line-height: 115%; font-family: &quot;Calibri&quot;, sans-serif;">The Best of Times and the Worst of Times &hellip; How Imperfect Regulatory Action May Still Create Opportunities for Self-Funding</span></b></span><br /> By: Jen McCormick, Esq.<br /> &nbsp;</p> <p style="text-align: justify;">Regulators have been busy over the course of the past few months. Between the issuance of executive orders, a tax bill, and state regulatory action, employers are scrambling to understand the implications. And while regulatory action has been quick, it has not necessarily been thorough, creating possibilities and opportunities for self-funded health plans.</p> <p style="text-align: justify;">Upon review of the various regulations, it seems new incentives for the creation of self-funded employer plans now exist.&nbsp; Employers may investigate taking advantage of this environment to form, create, or modify their self-funded benefit plans.&nbsp; Let&rsquo;s examine certain recent regulatory developments.</p> <p style="text-align: justify;"><strong>Executive Order 13813</strong></p> <p style="text-align: justify;">On October 12, 2017 President Trump issued Executive Order 13813 to save &ldquo;the American people from the nightmare of Obamacare.&rdquo; While this executive order did not modify any laws or regulations, it did direct the Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Department of the Treasury to issue proposed regulations concerning expanded coverage under health reimbursement arrangements (HRAs) and association health plans (AHPs).</p> <p style="text-align: justify;">HRAs are tax advantaged arrangements subject to the Affordable Care Act (ACA) regulations. As a result, an HRA may not impose annual dollar limits on benefits unless it is integrated with a group health plan. An exception exists, however, for small employers. Pursuant to a provision within the 21<sup>st</sup> Century Cures Act, certain small employers may offer a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA).&nbsp; This provision allows small businesses (i.e. employers with under 50 employees) to reimburse employees for out of pocket costs and premiums on the individual market. The regulations, however, impose tight restrictions on the employers&rsquo; ability to offer a QSEHRA.</p> <p style="text-align: justify;">Based on the current regulations and guidance for QSEHRAs issued by the Internal Revenue Service (IRS) in Notice 2017-67, an employer offering <em>any</em> group health plan is ineligible.&nbsp; As a result, even employers who only offered group dental coverage, for example, would be disqualified.&nbsp; The IRS did request comments on this guidance (due January 19, 2018).</p> <p style="text-align: justify;">The anticipated comments on Notice 2017-67, combined with the executive order directing the agencies to propose regulations expanding opportunities for employers to offer an HRA, may loosen current restrictions and expand the employer eligibility requirements. &nbsp;Guidance is still pending, but the proposed regulations could present options for self-funding which do not currently exist.</p> <p style="text-align: justify;"><strong>Proposed DOL Regulations </strong></p> <p style="text-align: justify;">In addition to the expansion of HRAs, the executive order directed regulators to increase access to health care by allowing a broader pool of employers to create AHPs. In early January 2018, responding to the executive order, the DOL issued proposed regulations to extend the circumstances under which an association may function as an employer under the Employee Retirement Income Security Act (ERISA).</p> <p style="text-align: justify;">Currently, coverage provided via an AHP is regulated pursuant to the same standards applicable to the individual and small employer health insurance market. &nbsp;Under ERISA, an AHP&rsquo;s reach is currently limited to circumstances where it is an employer sponsored plan. Specifically, association members must share a common interest, connect for reasons other than providing health insurance, exercise sufficient control over the health plan, and have at least one non-business owner employee.</p> <p style="text-align: justify;">The proposed rules may be game-changing for working owners (i.e. sole proprietors and self-employed individuals), allowing them to function as both the employer &ndash; for purposes of joining the association &ndash; and as the employee &ndash; for purposes of being covered by the plan.&nbsp; This unique dual status could allow working owners to participate in association health plans, and the adjustment could allow a new class of individuals (and potentially attract a large and previously ineligible pool of individuals) to self-funding.</p> <p style="text-align: justify;">Additionally, the proposed regulations contemplate the formation of an association for the purpose of offering health insurance. The rule does not impose prohibitions on forming new associations (or specify size limitations), but it does provide formal organizational requirements for associations. These newly formed associations would need affordable health insurance options, and may want to explore the benefits of self-funding. This could also create a new pool of entities for self-funding.</p> <p style="text-align: justify;"><strong>Tax Cuts and Jobs Act</strong></p> <p style="text-align: justify;">In December 2017, the Tax Cuts and Jobs Act (Act) was signed into law, reforming both individual and corporate income tax issues in the most sweeping and drastic changes to the Tax Code since 1986.</p> <p style="text-align: justify;">While the Act maintains 7 tax brackets for individuals, it reduces the rates and increases the thresholds on the brackets for individuals.&nbsp; Potentially even more significantly, the Act reduces the individual mandate penalty to $0 (as of January 1, 2019). While the elimination of the individual tax penalty will likely have a significant negative impact on employers, and their employer sponsored health plans, the greater fear is that if individuals are no longer required to have coverage, the healthy, low risk individuals will terminate coverage altogether (whether individual or employer based). Without healthy lives the risk pools will suffer.</p> <p style="text-align: justify;">While the Act affects the individual mandate, it does not alter current employer mandate requirements; employers are still required to offer affordable coverage meeting minimum value requirements, or face an excise tax. This is troubling for employers.&nbsp; If, with the reduction of the individual mandate penalty to $0 employees are effectively no longer required to maintain coverage, employers anticipate covering a less balanced risk pool, making (still) mandated employer coverage more expensive.</p> <p style="text-align: justify;">While the individual and employer mandate were intended to work together to increase access to care and balance risk, the elimination of the individual mandate does not fully undermines the continued value of offering employer sponsored coverage as an employee benefit.&nbsp; Employers still recognize the culture and corporate benefits that attract and retain a talented work force, like employee health plans. Many employees (even healthy ones) value the benefit of comprehensive healthcare and the elimination of the individual mandate will not deter them from continuing coverage under an employer plan, or seeking an employer that provides one.</p> <p style="text-align: justify;">This does mean, however, that employers will need to be creative and flexible to counterbalance the potential new costs. One way to offset costs would be to create a tailored plan, designed specifically for the individuals that value healthcare as an employee benefit, and the best way to offer flexibility is via a self-funded plan.&nbsp; This might be an opportunity to attract more employers who are concerned about rising costs and investigating new solutions.&nbsp; Only with self-funding can an employer implement a targeted health plan that is loaded with unique benefits and creative cost-containment methodologies.</p> <p style="text-align: justify;">The Act also creates tax savings for businesses by slashing the corporate income tax rate from 35% to 21%, and creating a 20% deduction for qualified business income (QBI). While the specifics of the business tax changes are beyond the scope of this discussion, and the determination of QBI is not a straightforward analysis, the takeaway is that these tax benefits should (in theory) generate opportunities for employers to save on their tax bill.&nbsp; With the savings, employers invest in more creative employee benefits, like self-funded healthcare plans.</p> <p style="text-align: justify;">Despite the complexity of the Act and the continued uncertainty of some of its implications, the potential opportunities for self-funding should not be overlooked.&nbsp; Employers should discuss the impact of the Act on their individual situation with their tax advisors to better understand planning opportunities.</p> <p style="text-align: justify;"><strong>State Action</strong></p> <p style="text-align: justify;">In response to the Act&rsquo;s repeal of the individual mandate, certain states are taking action. For example, a Maryland proposal would require individuals to have insurance or pay a penalty of 2.5% of their income or $696 (whichever is greater).&nbsp;&nbsp; The imposition of insurance mandates at the state level would encourage participation in employer plans, making employer sponsored coverage an attractive option and broadening the risk pool.&nbsp;&nbsp; If states like Maryland join Massachusetts in mandating coverage it could positively impact self-funding.&nbsp; More individuals would be looking for cost effective health plan options, something that an employer with a self-funded plan would be able to provide.</p> <p style="text-align: justify;"><strong>Summary</strong></p> <p style="text-align: justify;">While recent regulatory developments have been swift, leaving anxiety over their interplay and interaction, employers should look for opportunities to embrace change as it relates to benefits they must offer (i.e. employers are still subject to the employer mandate), and those that could be advantageous or strategic to offer.</p> <p style="text-align: justify;">With new challenges come new opportunities for HRAs, AHPs, and employers under the executive orders, proposed DOL regulations, tax reform, and state level developments.&nbsp; Self-funding, with unmatched flexibility for employers of all sizes, could be a cornerstone of the solution to reduce costs in the provision of healthcare.</p> <p style="text-align: justify;">_________________________________________________________________________________________________________</p> <p style="text-align: justify;"><span style="font-size:2.3em;"><strong><span style="font-family: &quot;Calibri&quot;, sans-serif;">Buyer Beware &ndash; No Good Deed Goes Unpunished</span></strong></span><br /> By: <span style="font-size:11.0pt;font-family:&quot;Calibri&quot;,sans-serif; mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language: EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">Ron E. Peck, Esq.</span></p> <p style="text-align: justify;">Employers and their advisors may soon find themselves accused of breaching their fiduciary duty if they continue to allow their benefit plans to pay inflated rates for medical services, without any justification for the excessive prices.&nbsp; Blindly paying fees that are not revealed until after the service is provided, to practitioners who cannot explain why their rates are many times more than comparable providers of equal or greater skill, is not a prudent use of plan assets and does violate one of the core tenets of the Employee Retirement Income Security Act of 1974 (&ldquo;ERISA&rdquo;) and fiduciary law.</p> <p style="text-align: justify;">Employers who choose to provide quality health insurance for their employees are generally performing an act of generosity.&nbsp; Certainly studies show that employers who offer health benefits recruit and retain the best employees, but not all benefit plans are equal -&nbsp;and those employers who choose to offer more than the mandated minimum coverage are indeed combining generosity with good business sense.</p> <p style="text-align: justify;">As mentioned, however, not all benefit plans are the same.&nbsp; For many, purchasing what we label as &ldquo;fully funded&rdquo; or &ldquo;fully insured&rdquo; traditional insurance, is enough.&nbsp; For these consumers, risk aversion is king, and they will pay a premium (more likely than not more costly than their employees&rsquo; health expenditures) to an insurance carrier.&nbsp; In exchange for that premium, said carrier will take on the risk associated with paying the employees&rsquo; medical bills.&nbsp; Is there a chance some catastrophic claim, injury, or illness will cause the total medical expense to exceed the collective value of the premium?&nbsp; Sure.&nbsp; Is it likely?&nbsp; No.&nbsp; Insurance carriers are in the business of assessing risk, and calculating premium that will earn profit.</p> <p style="text-align: justify;">For other employers less concerned with risk, the decision to keep the profit that would otherwise be paid to the carrier, and fund only the actual medical expenses, leads them to engage in the act of self-funding or self-insuring.&nbsp; It is to those employers that I now direct my commentary.</p> <p style="text-align: justify;">Studies have shown time and again that employers who self-fund their benefit plan are more likely to save money over five years of doing so, when compared to a comparable fully insured policy. &nbsp;This is due in part to customizing the plan to address only that population&rsquo;s needs, adjusting benefits as the data requires, quickly implementing cost containment programs, shopping around for the best vendors, stop loss, and other elements of the plan, and otherwise ensuring that a customized approach trims the fat and applies each plan dollar where it will do the most good.&nbsp; So, you ask, if self-funding is such a panacea, why doesn&rsquo;t everyone do it?</p> <p style="text-align: justify;">The answer is multifaceted.&nbsp; First of all, if you plan to provide benefits to a population with high medical expenses, you may benefit from fully insuring and working with the carrier to spread the risk over their entire risk pool.&nbsp; A self-funded employer takes on the entire plan&rsquo;s expense, with few exceptions.&nbsp; Next, some employers prefer to pay &ldquo;more&rdquo; when that amount is something they can afford, to avoid the risk of paying &ldquo;MORE&rdquo; when that amount is something they cannot afford (even if the likelihood of such a massive claim is slim).</p> <p style="text-align: justify;">Another consideration employers seeking to self-fund must consider (but few sadly do) is the matter of fiduciary authority.&nbsp; Indeed, ERISA dictates, among other things, that an employer who self-funds a benefit plan either acts as or appoints a plan administrator.&nbsp; That administrator is a fiduciary of the plan and its members, with a very serious legal obligation to perform numerous tasks &ndash; all with the plan&rsquo;s best interest in mind.&nbsp; Make one wrong move, and you&rsquo;ll not only have to fix the damage you cause, but potentially be liable for up to treble-damages.</p> <p style="text-align: justify;">It is true that a self-funded plan administrator can transfer some or all of their fiduciary duties &ndash; meaning they share the burden &ndash; but most agree that at best the plan administrator is still responsible to monitor that assignee&rsquo;s actions, and at worst, they maintain the burden as well.</p> <p style="text-align: justify;">As a result, employers who self-fund are not only at risk for the medical bills they will pay on their employees&rsquo; behalves, but are also at risk of being deemed to have &ldquo;breached&rdquo; their fiduciary duty if and when they make a mistake resulting in expenditures not in the best interest of the plan, and take action not in accordance with the terms of the plan document.</p> <p style="text-align: justify;">This may not sound like a big deal to you.&nbsp; You may be saying, &ldquo;Ron!&nbsp; I ain&rsquo;t afraid of no breach!&rdquo;&nbsp; Indeed; it would be great if all we had to do was follow the terms of the plan document like the instructions that come with your kid&rsquo;s new toy.&nbsp; Yet, like those instructions, saying is easier than doing; (where did I put that screw driver)?&nbsp; This is particularly true in today&rsquo;s self-funded industry.&nbsp; Why?&nbsp; Because things are so good!&nbsp; Because today is a great time to be self-funded.&nbsp; What???&nbsp; At this point you should be thoroughly confused.&nbsp; I did just say that today is the riskiest time to be a plan fiduciary because it is the best time to be a plan fiduciary.&nbsp; Let me explain.</p> <p style="text-align: justify;">More so now than ever before, innovators are developing new services, products, and methodologies to maximize benefits while minimizing costs.&nbsp; They are taking advantage of the self-funded plan structure, using our ability to customize, and targeting the high cost claims while increasing coverage elsewhere.&nbsp; Everything is being examined and new approaches are being applied to old issues and new.&nbsp; From medical tourism, to carve outs.&nbsp; From technologically advanced subrogation tactics to reference based pricing network alternatives.&nbsp; These are just a few examples of new and amazing ideas helping self-funded plans to evolve.&nbsp; Unfortunately, just like Kevin McCallister (Macaulay Culkin) who, in that 1990 classic film, is left &ldquo;Home Alone&rdquo; when the rest of his family rushes out the door to embark on an exciting adventure&hellip; so too are plan administrators and their supporting cast rushing into fun and exciting adventures without making sure their plan document is along for the ride.</p> <p style="text-align: justify;">Too often, these self-funded benefit plans &ndash; which are controlled by the terms of their plan document &ndash; implement a new, shiny service, product, or process and forget to update their plan document to match.&nbsp; The plan document is how the plan administrator communicates to the plan members (current and prospective), providers, department of labor, etc., what the plan does and doesn&rsquo;t do &ndash; and sets forth the terms by which people decide whether to enroll and contribute their hard earned money in exchange for membership.&nbsp; If the plan in practice doesn&rsquo;t match the plan in writing, that is bad news.</p> <p style="text-align: justify;">Many self-funded employers believe that by hiring brokers, third party administrators, and advisors, they can somehow protect themselves from this fiduciary threat.&nbsp; Yet, case after case has shown that &ndash; even though the broker, TPA, and the rest may ALSO be a fiduciary &ndash; the employer / plan administrator is still going to come along for the ride.</p> <p style="text-align: justify;">The case that has &ldquo;set me off&rdquo; and gotten me to head down this mental-path is the case of <em>Acosta v. Macy&#39;s, Inc</em>., S.D. Ohio, No. 1:17-cv-00541; (August 29, 2017).&nbsp; In that case, among other things, we see a benefit plan sponsor and their TPA attempting to contain costs by applying a reference based pricing methodology to their claims.&nbsp; This is great, and I applaud their efforts.&nbsp; Unfortunately, however, it appears that they may not have adjusted the applicable plan document to adequately reflect this new approach.&nbsp; While I&rsquo;m sure this employer is thinking, &ldquo;I thought the TPA does this for me?&rdquo; Regardless of the truth of the matter, the employer &ndash; as a fiduciary &ndash; will be dragged into the complaint.&nbsp; This will &ndash; at best &ndash; harm the relationship between the plan and TPA, but &ndash; at worst &ndash; it will cause the plan to leave the TPA and possibly self-funding altogether.</p> <p style="text-align: justify;">This is why I feel that TPAs, and all of us in the business of servicing self-funded employers, need to protect employers even when we&rsquo;re not obligated to do so.&nbsp; I fear, as in this case, that even if a self-funded employer &ldquo;gets burnt&rdquo; by something that is in no way, shape, or form our &ldquo;fault&rdquo; or &ldquo;responsibility,&rdquo; it&rsquo;s still a black eye for the industry as a whole.</p> <p style="text-align: justify;">This takes me, then, to my next concern.&nbsp; For some time now, (since the last major economic downturn), we&rsquo;ve been hearing via mass media all about situations where employees are suing employers, and their brokers, over mismanagement of 401(K) and pension plans.&nbsp; Indeed, these advisors are in many instances fiduciaries of these employee investors, and &ndash; in most of these cases &ndash; the employees are accusing their &ldquo;fiduciaries&rdquo; of wasting the plan&rsquo;s (aka their) money on less-than-advisable investments.&nbsp; Consider, for instance, the case of <em>Lorenz v. Safeway, Inc</em>., 241 F. Supp. 3d 1005, 1011 (N.D. Cal. 2017).&nbsp; In this class action suit, the Plaintiff (Dennis M. Lorenz) asserted claims under ERISA against the &ldquo;Safeway 401(K) Plan&#39;s&rdquo; fiduciaries. Lorenz alleged, amongst other things, that the Defendants breached their fiduciary duty by selecting and investing the plan&rsquo;s assets with funds that charged higher fees than comparable, readily-available funds, and which had no meaningful record of performance so as to indicate that higher performance would offset this difference in fees.&nbsp; Why does this scare me?&nbsp; I am scared because we could just as easily take this lawsuit (and the many like it) and replace the players with members of our own industry. &nbsp;Health benefit plans routinely spend plan assets to pay medical bills and compensate providers that may be more costly &ldquo;than comparable, readily-available [providers], and which had no meaningful record of performance so as to indicate that higher performance would offset this difference in fees.&rdquo;&nbsp; Ouch!&nbsp; If I am a member of a self-funded health plan, and my administrator is taking my money, and using it to pay for a $3,000 colonoscopy, when a facility down the road would do it for $750&hellip; and the more expensive facility has an &ldquo;as good&rdquo; or &ldquo;worse&rdquo; record when it comes to quality and outcomes&hellip; wouldn&rsquo;t I say: &ldquo;Hey!&nbsp; It looks like that fiduciary isn&rsquo;t prudently managing my assets.&rdquo;&nbsp; I truly believe that, for anyone that is a fiduciary of these plans, the day participants turn on us may not be a matter of &ldquo;if,&rdquo; but rather, &ldquo;when.&rdquo;</p> <p style="text-align: justify;">Consider also the recently filed, <em>McCorvey v. Nordstrom</em>, <em>Inc</em>. filed in the California Central District Court on November 6, 2017.&nbsp; In this case, a former participant in the Nordstrom Inc. 401(K) Plan sued plan executives alleging breaches of fiduciary duties in the management of the plan, and is seeking class action status for their claim.&nbsp; The basis of the claim, similar to the Safeway case discussed above, challenges the reasonableness of fees paid with plan assets, and further, that the plan fiduciaries failed to take advantage of cost-cutting alternatives.&nbsp; The lawsuit literally contends that the defendant failed to adequately and prudently manage the plan, by allowing plan funds to be used in the payment of unreasonable fees and not acting prudently to lower costs.</p> <p style="text-align: justify;">It doesn&rsquo;t take a rocket scientist to see the parallels between these lawsuits, and out of control spending by health plans.&nbsp; Whether you are someone offering better care for less cost, or someone who can revise the plan&rsquo;s methodologies to maximize benefits while minimizing costs, these trends in fiduciary exposure should galvanize us all to either offer help, or seek it, when it comes to prudent use of plan assets.</p> <p style="text-align: justify;">&ldquo;But Ron,&rdquo; you say, &ldquo;even if we (or the TPA and broker) are fiduciaries of the plan, the decision to contract with over-priced facilities, agree to their fees, and pay these claims, is ultimately a decision made by the plan sponsor (employer) &ndash; right?&nbsp; So, while your previous comments about self-funded employers leaving the market when they realize they&rsquo;ve been taken for a ride may be true, we are at least safe from liability for fiduciary breach.&nbsp; Right?&rdquo;&nbsp; Maybe not.&nbsp; Consider <em>Longo v. Trojan Horse Ltd</em>., 208 F. Supp. 3d 700, 712 (E.D.N.C. 2016).&nbsp; In this case, the plaintiff employees of Trojan Horse and Glen Burnie Hauling filed a putative class action against defendant Ascensus Trust.&nbsp; In this case, the Defendant was collecting contributions, submitting them for investment, and keeping a fee for themselves.&nbsp; There is some dispute regarding what happened to the investments, but ultimately it appears the funds weren&rsquo;t properly invested.&nbsp; The Defendant argued that they did their job, and the issues about which the complaint was filed was outside their immediate control.&nbsp; Yet, the court held that Defendant had a fiduciary duty in regard to the contributions, and that they failed to take affirmative steps to investigate.&nbsp; In other words, pursuant to 29 U.S.C. &sect; 1132(a)(2), fiduciaries are responsible to ensure the plan&rsquo;s welfare is priority number one, even when the actions in question may be taken by another entity or fiduciary.&nbsp; So&hellip; following that line of logic&hellip; if a TPA, broker, or other advisor is a fiduciary of the plan, and we are aware (or should reasonably be aware) of actions being taken by another fiduciary, that are detrimental to the plan &hellip; or options that available to the plan to contain costs, but we knowingly allow another fiduciary to ignore them&hellip; we may be on the hook too!</p> <p style="text-align: justify;">So &ndash; in summary &ndash; I believe it is proper and necessary for any and all fiduciaries of these self-funded plans to step back, look for wasteful or imprudent behavior &ndash; both by the fiduciary itself, and other fiduciaries of the plan &ndash; and determine whether there is any action, option, or alternative that would constitute a more prudent use of plan assets.&nbsp; Likewise, those who seek to help these fiduciaries and the plan reduce their expenditures without harming the plan need to raise their voices and warn their prospective clients of the cost of not working with them.&nbsp; In other words, fiduciaries need to stop clinging to the status quo, and the onus is on all of us to help them do so.</p> </div> </div> 695Empowering Plans: P34 – Loopholes, Untouchables, and An Unlikely Allyhttps://www.phiagroup.com/Media/Posts/PostId/691/empowering-plans-p34-loopholes-untouchables-and-an-unlikely-allyPodcastsFri, 23 Mar 2018 13:38:14 GMT<p>In this episode of Empowering Plans, Adam, Ron, and Brady go around the horn discussing a few hot button topics; from exposing what could be a significant loophole affecting health plans to explaining how certain age groups face unique barriers to obtaining health coverage. Finally, they discuss Idaho&rsquo;s recent attempts&nbsp; to thwart Obamacare and the Trump Administration&rsquo;s surprising reaction.</p> <p><br /> <a href="https://youtu.be/EJKvb60x5HU">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/EJKvb60x5HU">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 691Transparency: Using it to Your Advantagehttps://www.phiagroup.com/Media/Posts/PostId/689/transparency-use-it-to-your-advantageWebinarsTue, 20 Mar 2018 18:34:40 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/WV1mh72CWG4" width="100%"></iframe></p> <p> </p> <p>This industry is full of “regular” agreements, complex multi-party arrangements, handshake deals, and everything in between. For years The Phia Group has preached that transparency is a best practice for everyone from medical providers to TPAs to stop-loss carriers; that is still by far our prevailing opinion, but recently we have begun to see that transparency can also have some potentially  damaging effects on the industry as a whole, stemming primarily from changes in patient behavior.</p> <p> </p> <p>Join The Phia Group’s legal team as they discuss the need for, and effects of, contractual and price transparency on the self-funded industry – and how health plans, TPAs, and brokers can use transparency to their advantage.</p> <p><a href="https://youtu.be/WV1mh72CWG4">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 689Empowering Plans: P33 - Partners in Empowerment – A Prescription for Savingshttps://www.phiagroup.com/Media/Posts/PostId/685/empowering-plans-p33-partners-in-empowerment-a-prescription-for-savingsPodcastsFri, 16 Mar 2018 15:19:19 GMT<p style="text-align: justify;">In this episode Ron and Brady are thrilled to interview LG Hanzel of Rx Results.&nbsp; LG digs deep on topics ranging from Specialty Drugs to PBMs, and what benefit plans can do to curb the cost of drugs in America &ndash; an issue that is big, and getting bigger every day.</p> <p style="text-align: justify;"><a href="https://youtu.be/nkZgJPHJUW0">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/nkZgJPHJUW0">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)</p> 685Empowering Plans: P32 - Red Cross Blood Drive Special Episodehttps://www.phiagroup.com/Media/Posts/PostId/681/empowering-plans-p32-red-cross-blood-drive-special-episodePodcastsThu, 01 Mar 2018 17:45:32 GMT<p>Today The Phia Group in partnership with the Red Cross hosted an on-site blood drive.&nbsp; Join Ron Peck as he interviews members of The Phia Group staff and Red Cross leadership as we discuss the event, personal experiences, and the ever present need for donors.&nbsp; This moving and important episode will hopefully drive you to action!<br /> <br /> <a href="https://youtu.be/gmmsplrECY4">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/gmmsplrECY4">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!)</p> 681Evolve or Dissolve – Responding to Today’s Tax Law to Save the Health Benefit Plan Industry Tomorrowhttps://www.phiagroup.com/Media/Posts/PostId/679/evolve-or-dissolve-responding-to-todays-tax-law-to-save-the-health-benefit-plan-industry-tomorrowWebinarsTue, 27 Feb 2018 20:57:10 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/owgNJMRDHK8" width="100%"></iframe></p> <p> </p> <p>You either keep moving, or get out of the way. As changes in the tax law threaten all benefit plans, removing the individual mandate and making enrollment optional, the threat of economic unviability looms. To remain intact, benefit plans must maintain their risk pools, and to maintain their risk pools they must attract low risk lives. Without an individual mandate, how is this achieved? With passion and determination, solutions exist for benefit plans that choose to empower themselves. Those that are unwilling to sacrifice the security of the "status quo" face financial ruin. Instead, today you can take the challenging steps needed to make benefit plans attractive to all participants, and thereby protect plan assets.</p> <p> </p> <p>Join The Phia Group's Adam Russo, Ron Peck, and Brady Bizarro as they discuss what you need to know about the new law, and how to navigate the treacherous path that lies ahead.</p> <p><a href="https://youtu.be/owgNJMRDHK8">Click Here to View Our Full Webinar on YouTube</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 679Empowering Plans: P31 - 3 Scoops of Knowledgehttps://www.phiagroup.com/Media/Posts/PostId/678/empowering-plans-p31-3-scoops-of-knowledgePodcastsMon, 26 Feb 2018 16:52:10 GMT<p><span class="pre_wrap">In this episode, Adam, Ron and Brady celebrate the forthcoming change in seasons and warming weather, by each selecting a unique topic that is bugging them, and offering their opinions regarding how we should react. This is one cool sampling of self-funded flavor you won’t want to miss.</span><span class="pre_wrap">In this episode, Adam, Ron and Brady celebrate the forthcoming change in seasons and warming weather, by each selecting a unique topic that is bugging them, and offering their opinions regarding how we should react. This is one cool sampling of self-funded flavor you won’t want to miss.</span><span class="pre_wrap">In this episode, Adam, Ron and Brady celebrate the forthcoming change in seasons and warming weather, by each selecting a unique topic that is bugging them, and offering their opinions regarding how we should react. This is one cool sampling of self-funded flavor you won’t want to miss.</span></p> <p style="text-align: justify;">In this episode, Adam, Ron and Brady celebrate the forthcoming change in seasons and warming weather, by each selecting a unique topic that is bugging them, and offering their opinions regarding how we should react.&nbsp; This is one cool sampling of self-funded flavor you won&rsquo;t want to miss.</p> <p><a href="https://youtu.be/Gkm2Qf4cy3s">Click here to check out the podcast!</a>&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/Gkm2Qf4cy3s">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!)</p> 678Keeping it Under Wraps: What the Networks Don’t Advertisehttps://www.phiagroup.com/Media/Posts/PostId/677/keeping-it-under-wraps-what-the-networks-dont-advertiseWebinarsThu, 22 Feb 2018 19:41:15 GMT<p style="text-align: justify;">It’s 2018, and the importance of cost-containment is at an all-time high. Everywhere you look in the self-funded industry is a vendor trying to help health plans control costs; as can be expected, some methods are effective and maximize savings, whereas others…well…not so much.</p> <p style="text-align: justify;">Join The Phia Group’s legal team as they discuss wrap networks – both in theory and in practice – and what alternatives might be available to modern self-funded health plans.</p> <p><a href="https://youtu.be/gR69vZPe8X4">Click Here to View Our Full Webinar on YouTube</a></p> <p><a href="/Portals/phiagroup/webinars/February%202018/Keeping_it_Under_Wraps_What_the_Networks_Don_t_Adv.mp3">Click Here to Download Webinar Audio Only</a></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 677Empowering Plans: P30 - Fireside Chat with The Presidenthttps://www.phiagroup.com/Media/Posts/PostId/675/empowering-plans-p30-fireside-chat-with-the-presidentPodcastsFri, 16 Feb 2018 14:46:58 GMT<p style="text-align: justify;">This is it!&nbsp; Our first Empowering Plans guest, and it&rsquo;s a doozy.&nbsp; In this episode none other than the Self-Insurance Institute of America&rsquo;s CEO and President, Michael Ferguson, sits down with Adam, Ron and Brady to discuss everything &ndash; from past wins and losses, to plans for 2018.&nbsp; From conflicts within the industry, to threats from beyond&hellip; Mike doesn&rsquo;t hold back, and you &ndash; like we &ndash; get to enjoy the results.</p> <p style="text-align: justify;"><a href="https://youtu.be/8YabHWyQkGU">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!)</p> 675Empowering Plans Segment 29 - Disruption or Not? https://www.phiagroup.com/Media/Posts/PostId/671/empowering-plans-segment-29-disruption-or-notPodcastsWed, 07 Feb 2018 16:12:55 GMT<p>In this episode, our hosts discuss the recent announcement that Amazon, Berkshire Hathaway and JPMorgan are looking to collaborate on &ldquo;health care.&rdquo;&nbsp; Is this just a new way to supply medical goods, deliver care, or handle the entire exchange (including enrollment and payment)?&nbsp; How can broker/advisors, plan administrators, and other members of the industry benefit from this change?&nbsp; And who should be most concerned?&nbsp; This and more await you in &ldquo;Empowering Plans.&rdquo;</p> <p><a href="https://youtu.be/2-jWc-G9Uy0">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/2-jWc-G9Uy0">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!)</p> 671Plan on Saving by Saving Your Plan – Applying Lessons Learned to Create the Perfect Plan Document https://www.phiagroup.com/Media/Posts/PostId/669/plan-on-saving-by-saving-your-plan-applying-lessons-learned-to-create-the-perfect-plan-documentWebinarsTue, 30 Jan 2018 16:46:31 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/A3dgBBd_GzE" width="100%"></iframe></p> <p> </p> <p style="text-align: justify;">Many of you are familiar with the plan drafting conundrum: multiple options are available for plan document verbiage on a given topic, but your client either can’t decide, can’t tell the difference, or simply doesn’t have a preference. In response to Phia Document Management (PDM) user requests, we have simplified the plan document checklist by creating a new template with fewer variables, called the Flagship.<br /> <br /> Unlike our traditional major medical template where the user is given ten variables for which workers’ compensation exclusion to choose, the Flagship template incorporates The Phia Group’s “best practices” approach to plan drafting; there must always be variables when drafting a plan document, but far fewer in the Flagship, making the user experience a more streamlined and intuitive one.<br /> <br /> Join The Phia Group’s legal team as they explain the Flagship template, differences from the existing template, and why the Flagship may be right for you.<br /> <br /> <a href="https://youtu.be/A3dgBBd_GzE">Click Here to View Our Full Webinar on YouTube</a><br /> <a href="/Portals/phiagroup/webinars/Jan 2018/Plan_on_Saving_by_Saving_Your_Plan_Applying_Lesson.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> <p> </p> 669Empowering Plans Segment 28 - Game-changershttps://www.phiagroup.com/Media/Posts/PostId/668/empowering-plans-segment-28-game-changersPodcastsMon, 29 Jan 2018 16:44:41 GMTThis week, our hosts discuss Adam&rsquo;s recent travels and review events.&nbsp; We are not alone in our attitudes and desires to change the industry for the better, and now we have proof of that fact!&nbsp; What ideas and concepts were shared with Adam, and how can we add fuel to the fire?<br /> <br /> <a href="https://youtu.be/mHnvH6_JPcY">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w?view_as=subscriber">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!) <br />668The Phia Group's 1st Quarter 2018 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/667/the-phia-groups-1st-quarter-2018-newsletterNewslettersThu, 25 Jan 2018 21:38:43 GMT<meta content="text/html; charset=UTF-8" http-equiv="Content-Type" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #FFF; } 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> <link href="moz-extension://48639557-5d9e-4653-b057-e24770eb7b08/css/emoji.css" rel="stylesheet" type="text/css" /> <table align="center" border="0" cellpadding="5" cellspacing="5" width="650"> <tbody> <tr> <td colspan="2" style="background-color: #4a85d3;"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext" style="text-align: right; background-color: #4a85d3;" 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 alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/header2018.jpg" /></td> </tr> <tr> <td colspan="2"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/icons2018.png" /></td> </tr> <tr> <td style="width: 312px;" valign="top"><a href="#p2"><img alt="" height="210" src="/Portals/phiagroup/Newsletter%20Q1%202018/b1a.png" width="325" /></a></td> <td style="width: 323px;" valign="top"><a href="#p2a"><img alt="" height="209" src="/Portals/phiagroup/Newsletter%20Q1%202018/b2a.png" width="325" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" height="466" width="663"> <tbody> <tr> <td style="width: 51%;" valign="middle"><img alt="" height="371" src="/Portals/phiagroup/Newsletter Q1 2018/adam.jpg" width="325" /></td> <td style="width: 49%;" valign="top"> <p class="bodytext"><br /> <span class="heading1" style="font-size: 14px; font-weight: bold; color: #000000;">The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">About six months ago I decided to start a project at The Phia Group focusing on how we can ensure the future viability of my company. The strategy for doing this was based on focusing on the young professional, also known as the millennial population, and attempting to figure out what makes them tick. How can I attract these folks to join Phia and make them want to stay with us throughout their career? The first thing that we did was survey the many young professionals that we have here at Phia in order to identify their thoughts, and what we found out truly opened my eyes. These workers want to understand why our company exists and not just what it is that we do.<br /> <br /> Ron Peck, Matt Painten, and I spent months just getting back to the basics. After many focus groups and back-and-forth, I believe that we figured it out. This is the core essence of Phia and how we will attract, obtain, and retain not only employees, but clientele as well. I would love your feedback on what we came up with, so here it is: </span></p> </td> </tr> </tbody> </table> <p class="bodytext"><span style="color: #000000;"><span style="text-decoration: underline;"><strong>The Problem</strong></span><br /> Health care costs too much and the price is increasing; employers are forced to offset costs onto employees through higher co-pays and deductibles.</span></p> <p class="bodytext"><span style="color: #000000;"><span style="text-decoration: underline;"><strong>The Phia Group&rsquo;s Purpose</strong></span><br /> To make health benefits affordable for employers and employees<br /> <br /> <span style="text-decoration: underline;"><strong>Why is this The Phia Group&rsquo;s Purpose?</strong></span><br /> Hard working Americans deserve access to high quality, affordable health care.<br /> <br /> <span style="text-decoration: underline;"><strong>What does it mean to &ldquo;Empower Plans?&rdquo;</strong></span><br /> To help employers maximize benefits, minimize costs, and take control of their own plans.<br /> <br /> <span style="text-decoration: underline;"><strong>How do we &ldquo;Empower Plans?&rdquo;</strong></span><br /> We start by promoting and educating employers about self-funding. Then, we invent and implement cost containment services while delivering custom solutions to meet specific client needs.<br /> <br /> I truly hope that 2018 is an amazing year for you and yours.&nbsp; Happy reading my friends.</span><br /> &nbsp;</p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> </table> </td> </tr> <tr> <td class="toc" colspan="2" style="background-color: #eeeeee;" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p class="tocbkgd"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/inthisissue.png" /><br /> <a href="#p1">Service Focus of the Quarter: Plan Document/Summary Plan Description Risk Assessment</a><br /> <a href="#p3">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group&rsquo;s 2017 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia&rsquo;s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a id="p1" name="p1"></a> <p class="heading1"><br /> <span style="color: #000000;">Service Focus of the Quarter: Plan Document/Summary Plan Description Risk Assessment</span></p> <p class="bodytext"><span style="color: #000000;">In case you hadn&rsquo;t heard, a new tax bill has been signed into law. Amongst other things, it appears the individual mandate ushered in by the ACA (aka ObamaCare) is being eliminated. The initial impact will be on the individual market, but we foresee healthy (low risk) individuals performing a cost benefit analysis and eventually choosing to drop out of their employer&rsquo;s group health insurance. The first people likely to drop from such plans are likely those who are paying an arm and a leg to be enrolled in expensive, traditional, &ldquo;fully funded&rdquo; insurance. Yet, we fear that &ndash; soon after &ndash; the most desirable lives (healthy, low risk lives) will drop from their employers&rsquo; self funded plans&hellip; leaving only high risk / high cost lives. No plan &ndash; fully funded or self funded &ndash; can withstand losing those lives. It therefore behooves every self funded plan sponsor to figure out ways to offer more for less, and thus make plan enrollment attractive for all members &ndash; low and high risk, healthy and unhealthy alike. To do this, you must innovate and implement new benefits and cost containment tools. To do that, start with the plan document. </span></p> <p class="bodytext"><span style="color: #000000;">One of the benefits of self-funding is that the employer has the freedom and flexibility to design a benefit plan that truly meets the needs of its employees; making it attractive to the low risk healthy lives we need to fund the plan, and to whom we need to make the plan attractive (now that they aren&rsquo;t &ldquo;required&rdquo; to enroll). The employer also has the ability to structure the plan so as to prudently manage the assets of the plan; this can be done, in particular, through innovative plan language meant to proactively tackle potential issues such as risk and cost. </span></p> <p class="bodytext"><span style="color: #000000;">Our Plan Document/Summary Plan Description Risk Assessments will identify areas the employer may want to consider for additional review, as well as provide a brief explanation of why certain items are important. </span></p> <p class="bodytext"><span style="color: #000000;">Once completed, plan sponsors can implement new measures to make their plans very attractive to even the healthiest folks. Things like new payment methodologies of out of network claims, medical tourism, and more can result in benefit plans offering more for less &ndash; and thus remaining a &ldquo;must have&rdquo; for those important healthy participants &ndash; even when enrollment is optional &ndash; but it all starts with the plan document. </span></p> <p class="bodytext"><span style="color: #000000;">Contact Tim Callender at</span> <a href="mailto:tcallendar@phiagroup.com">tcallender@phiagroup.com</a> <span style="color: #000000;">or 781-535-5631 to learn more about how a Plan Document/Summary Plan Description Risk Assessment can help you.</span></p> <span style="color: #000000;"> <a id="p2" name="p2"></a> </span> <p class="bodytext"><span style="color: #000000;"><strong>Protect Your ASA: Update Your Agreements Today!</strong></span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group is privileged to work with so many different players in the self-funded industry and health insurance field in general. As a result, we often see issues developing and devise solutions before they have a chance to seriously impact our allies. </span></p> <p class="bodytext"><span style="color: #000000;">One such issue that has become a bigger problem of late, negatively impacting third party administrators, plan sponsors, brokers and stop-loss carriers, occurs when a self funded benefit plan or their broker-advisor wishes to utilize a stop-loss carrier that the TPA has neither vetted nor placed. Despite the fact that the TPA played no role in selecting the carrier, that TPA - more often than not - is still targeted by the plan sponsor if and when the carrier subsequently refuses to reimburse the plan or some other conflict arises. </span></p> <p class="bodytext"><span style="color: #000000;">For those TPAs utilizing The Phia Group&#39;s best-in-class template administrative services agreement (ASA), language is included that generally addresses this issue, but as the problem has escalated - it now requires special attention. With that in mind, The Phia Group has developed a form, which is signed by the plan sponsor and TPA, and is added to existing ASAs as an exhibit. </span></p> <p class="bodytext"><span style="color: #000000;">This addendum can be revised to fit with any ASA. Please contact Garrick Hunt at</span> <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> <span style="color: #000000;">or call him at (781) 535-5644 to learn how you can obtain access to this very important form. </span></p> <p class="bodytext">&nbsp;</p> <hr class="horiz" />  <p>&nbsp;</p> <p class="bodytext"><strong><span style="color: #000000;">Cutting back on Questionnaires: </span></strong></p> <span style="color: #000000;"> <a id="p2a" name="p2a"></a> </span> <p class="bodytext"><span style="color: #000000;">It is The Phia Group&rsquo;s mission to reduce the cost of healthcare through the use of innovative legal techniques and the most sophisticated technology. In keeping with this goal The Phia Group is always taking steps to improve all of our services, including our earliest: subrogation. Recent upgrades to The Phia System&trade; and advancements in our investigational techniques have led to faster identification of third party liability claims and quicker engagement by The Phia Group&rsquo;s team, without relying upon or otherwise communicating with the plan participants. These new resources allow us to identify opportunities more often and more effectively, while at the same time reducing the volume of accident questionnaires we send to plan participants. While accident questionnaires are still a useful tool when investigating and collecting accident details &ndash; they are no longer the only tool. As such, we are pleased to now provide all of our subrogation clients with the ability to increase, decrease, or cease the use of plan participant accident questionnaires. Clients can also opt to utilize their own letters, or have the employer communicate directly with plan participants. The choice is yours! </span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group is committed to ensuring you and your clients are provided with nothing but the highest quality service, best-in-class performance, and a member first approach. That is why we are continuously improving our services to provide the best performance (and most options) possible. </span></p> <p class="bodytext"><span style="color: #000000;">To discuss these new customization capabilities, or our other services, please contact Trevor Schramn at</span> <a href="mailto:tschramn@phiagroup.com">tschramn@phiagroup.com</a> <span style="color: #000000;">or call (781) 535-5692.</span></p> <p>&nbsp;</p> <hr class="horiz" /> <p class="heading1"><a id="p3" name="p3"></a><br /> <span style="color: #000000;">Phia Group Case Study: Retroactive Plan Amendments</span></p> <p class="bodytext"><span style="color: #000000;">A self-funded group&rsquo;s broker approached The Phia Group&rsquo;s consulting department (via PGCReferral@phiagroup.com) and asked us to help respond to a provider&rsquo;s appeal of a large dialysis claim. The provider was out-of-network, so thankfully there were no PPO contract concerns &ndash; but at the time the services were rendered, the SPD defined its payment rate as the prevailing charge in the area. One month after receiving the final claims for which the Plan was responsible, the Plan chose to effect an amendment that limited payment for all dialysis claims to 145% of the Medicare rate, and the amendment was back-dated to the beginning of the year (before the member began dialysis treatments). </span></p> <p class="bodytext"><span style="color: #000000;">The Plan desired to use its new carve-out amendment to reprice the existing claims, but had received negative feedback on that proposition from its TPA, since the TPA felt that the language in the SPD at the time the claims were incurred is the language that must be adhered to. The broker asked The Phia Group for advice, and our advice was identical to that of the TPA &ndash; that a retroactive carve-out is not a valid way to price the already-incurred claims. Regardless, the Plan chose to pay all past claims based on that new amendment, despite the language not being in the SPD when the services were rendered. </span></p> <p class="bodytext"><span style="color: #000000;">As expected, the provider pushed back against the lower-than-expected reimbursement, and commenced a lawsuit over the balance of $500,000. The Phia Group provided the Plan assistance with settling the claims to avoid litigation, since litigation almost certainly would have resulted in the Plan paying the prevailing charges in the area&hellip;plus interest&hellip;plus penalties. </span></p> <p class="bodytext"><span style="color: #000000;">The moral of the story is that self-funded plans, their TPAs, and their brokers should be proactive in making sure the SPD contains the proper protections &ndash; since once a claim comes in, it is sometimes too late to contain costs. In other words, if you think you may need to carve out high dollar claims (like dialysis) in the future, fix your plan document now! Don&rsquo;t wait, until it&rsquo;s too late; (The Phia Group&rsquo;s Phia Document Management service &ndash; including the Flagship Template &ndash; can help make sure that SPDs say what you need them to say). </span></p> &nbsp; <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p4" name="p4"></a><br /> <span style="color: #000000;">Fiduciary Burden of the Quarter: Strictly Following the Plan Document!</span></span></p> <p class="bodytext"><span style="color: #000000;">Plan Administrators owe a fiduciary duty to strictly follow the terms of the governing plan documents. The SPD is the &ldquo;supreme law of the land&rdquo; for a health plan, and violating even one minor exclusion is technically a violation of the Plan Administrator&rsquo;s considerable fiduciary duty. Since we&rsquo;ve been warning the industry about this for years, it didn&rsquo;t shock us when we heard that the Department of Labor had filed a lawsuit against a benefit plan for paying claims based on Medicare rates, without having included the proper language within the SPD. </span></p> <p class="bodytext"><span style="color: #000000;">We understand that Plan Documents are complex, and amending them is not exactly an enjoyable process. But if the health plan wants to implement procedures to save money, there are some deal-breakers &ndash; such as making sure the SPD affords the Plan the right to do what the plan is going to do. </span></p> <p class="bodytext"><span style="color: #000000;">ERISA empowers a plan sponsor to put almost any language of its choosing into its SPD. That&rsquo;s a great thing, and plans that take advantage have experienced novel savings and have had remarkable self-funding experiences. If a benefit plan wants to pay claims differently from what is currently in the SPD, it can certainly do so &ndash; but not until the SPD reflects it, and not until the SPD is altered at the appropriate time.</span></p> <p class="bodytext"><a href="#top">Back to top ^</a><br /> &nbsp;</p> <hr class="horiz" /> <p>&nbsp;</p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a><span style="color: #000000;">Phia Fit to Print:</span></p> <p class="bodytext"><span style="color: #000000;">&bull; Self-Insurers Publishing Corp. &ndash; </span><a href="https://www.sipconline.net/files/The Future of Self-Funding-An Insider's Take by Adam V_ Russo%2C Esq.pdf">The Future of Self-Funding - An Insider&#39;s Take</a> <span style="color: #000000;">&ndash; October 3, 2017</span></p> <p class="bodytext"><span style="color: #000000;">&bull; Money Inc. &ndash;</span> <a href="http://moneyinc.com/self-funding-amid-obamacare-uncertainty/">Self-funding Amid Obamacare Uncertainty</a><span style="color: #000000;"> &ndash; November 2, 2017</span></p> <p class="bodytext"><span style="color: #000000;">&bull; Self-Insurers Publishing Corp. &ndash; </span><a href="https://www.sipconline.net/files/Interim Final Rules Update by Krista Maschinot.pdf">Interim Final Rules Update</a><span style="color: #000000;"> &ndash; November 4, 2017</span></p> <p class="bodytext"><span style="color: #000000;">&bull; Self-Insurers Publishing Corp. &ndash;</span> <a href="https://www.sipconline.net/files/Managing Plan Communication During a Time of Legislative Uncertainty by Corrie Cripps.pdf">Managing Plan Communication During a Time of Legislative Uncertainty</a> <span style="color: #000000;">&ndash; December 1, 2017</span></p> <p class="bodytext"><span style="color: #000000;">&bull; HealthLeaders Magazine &ndash;</span> <a href="http://www.healthleadersmedia.com/health-plans/insurers-facing-impossible-scenario-cover-everyone-no-individual-mandate">Insurers Facing Impossible Scenario: Cover Everyone, But No Individual Mandate</a><span style="color: #000000;"> &ndash; December 13, 2017</span></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><br /> <span style="color: #000000;">From the Blogosphere:</span></p> <p class="bodytext"><span style="color: #000000;">&bull;</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/635/an-appealing-option">An Appealing Option.</a> <span style="color: #000000;">Facing a final appeal.</span></p> <p class="bodytext"><span style="color: #000000;">&bull;</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/640/phia-undercover-two-chargemasters-at-addiction-centers">Phia Undercover: Two Chargemasters at Addiction Centers.</a> <span style="color: #000000;">Dealing with a high rate biller.</span></p> <p class="bodytext"><span style="color: #000000;">&bull;</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/646/welcome-to-the-fiduciary-jungle">Welcome to the Fiduciary Jungle!</a> <span style="color: #000000;">The writing is on the wall; what will you do about it?</span></p> <p class="bodytext"><span style="color: #000000;">&bull;</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/652/sacrificing-the-individual-mandate-on-the-alter-of-tax-reform">Sacrificing the Individual Mandate on the Alter of Tax Reform.</a> <span style="color: #000000;">The glue holding all of Obamacare together. </span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;">To stay up to date on other industry news, please</span> <a href="https://www.phiagroup.com/Media/Blog.aspx">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a><br /> <span style="color: #000000;">Webinars</span></span></p> <p class="bodytext"><span style="color: #000000;"><strong>Plan on Saving by Saving Your Plan</strong></span></p> <p class="bodytext"><span style="color: #000000;">On January 30, 2017, The Phia Group will present &ldquo;Plan on Saving by Saving Your Plan,&rdquo; where our legal team will explain the Flagship template, differences from the existing template, and why the Flagship may be right for you.</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;"><a href="https://register.gotowebinar.com/register/8354714256140621827">Click HERE to Register!</a></p> <p class="bodytext"><span style="color: #000000;">On January 18, 2018, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Webinars">A Taxing Time: The Tax Bill&rsquo;s Impact on Self-Insurance</a><span style="color: #000000;">,&rdquo; where we discussed the latest tax law. </span></p> <p class="bodytext"><span style="color: #000000;">On December 19, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/655/with-great-cost-containment-power-comes-great-fiduciary-responsibility">With Great (Cost-Containment) Power Comes Great (Fiduciary) Responsibility</a><span style="color: #000000;">,&rdquo; where we describe various ways to cut costs, what must be done to ensure that fiduciary duties are being met, and what happens if they are not. </span></p> <p class="bodytext"><span style="color: #000000;">On November 14, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/645/living-in-the-now-prepare-for-2018">Living in the Now: Prepare for 2018</a><span style="color: #000000;">,&rdquo; where we discussed where the market is heading and what you need to do to keep up with it.</span></p> <p class="bodytext"><span style="color: #000000;">On October 17, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/636/best-practices-for-todays-plan-documents">Best Practices for Today&#39;s Plan Documents</a><span style="color: #000000;">,&rdquo; where our legal team discussed best and worst plan document practices, provide some creative ideas for plan formation, and suggest some concepts to help perfect plan document drafting.</span></p> <p class="bodytext"><span style="color: #000000;">Be sure to check out all of our past webinars! </span></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a><br /> <span style="color: #000000;">Podcasts:</span></span></p> <p class="bodytext"><span style="color: #000000;">&bull; On December 21, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/656/empowering-plans-segment-25-a-taxing-time">Breaking Down the GOP Tax Bill and How It Affects You</a><span style="color: #000000;">,&rdquo; where The Phia Group&#39;s CEO Adam Russo and Attorney Brady Bizarro discuss the new GOP tax bill in depth. </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On December 18, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/654/empowering-plans-segment-24-protect-your-asa">Protect Your ASA</a><span style="color: #000000;">,&rdquo; where Adam Russo, Ron Peck, and Jen McCormick discuss the rising trend in stop-loss insurance being placed by entities other than the TPA, yet the TPA is held responsible if things go sour. </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On December 6, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/651/empowering-plans-segment-23-plans-and-conspiracy">Plans and Conspiracy</a><span style="color: #000000;">,&rdquo; where our legal team discussed the recent news regarding CVS purchasing Aetna, as well as a new opportunity to customize plan document reviews to address different levels of need. </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On November 21, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/647/empowering-plans-segment-22-the-biggest-threats-to-self-funding-a-lightning-round">The Biggest Threats to Self-Funding: A Lightning Round</a><span style="color: #000000;">,&rdquo; where Adam Russo, Ron Peck, and Brady Bizarro discuss the biggest threats to the self-funded industry. </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On November 3, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/641/empowering-plans-segment-21-planning-for-stormy-seas-ahead">Planning for Stormy Seas Ahead</a><span style="color: #000000;">,&rdquo; where Adam Russo, Ron Peck, and Jennifer McCormick discuss all of the many issues creating waves as it relates to benefit plan documents, and what steps we can all take to safely navigate those waters &ndash; including setting sail on The Phia Group Flagship Template! </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On October 19 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/638/empowering-plans-segment-20-trumping-costs-and-climbing-the-hill">Trumping Costs and Climbing the Hill</a><span style="color: #000000;">,&rdquo; where Adam Russo, Ron Peck, and Brady Bizarro discussed discuss the wild and crazy happenings in DC. </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On October 13, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/634/empowering-plans-segment-19-the-man-with-the-plan">The Man with the Plan</a><span style="color: #000000;">,&rdquo; where Adam Russo and Ron Peck discuss the often overlooked but &ndash; in their opinion &ndash; all important plan document. </span></p> <p class="bodytext"><span style="color: #000000;">&bull; On September 28, 2017, The Phia Group presented &ldquo;</span><a href="https://www.phiagroup.com/Media/Posts/PostId/627/empowering-plans-segment-18-responsibility-beyond-the-contract">Responsibility - Beyond the Contract</a><span style="color: #000000;">,&rdquo; where Adam Russo and Ron Peck discuss trends impacting health plans, employers, and employees.</span></p> <p><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;">Be sure to check out all of</span> <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext"><img alt="" src="/Portals/phiagroup/Newsletter%202018%20Q2/itunes.png" style="width: 251px; height: 78px;" title="" /></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a><br /> <span style="color: #000000;">The Phia Group&rsquo;s 2017 Charity</span></span></p> <p class="bodytext"><span style="color: #000000;">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.<br /> <br /> The Phia Group&#39;s 2018 charity is the Boys &amp; Girls Club of Brockton. </span></p> <p><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/bandgclub.png" /></span></p> <p class="bodytext"><span style="color: #000000;">The mission of The Boys &amp; Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment. </span></p> <p class="bodytext"><span style="color: #000000;">The Boys &amp; Girls Club of Brockton (BGCB) 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 &amp; Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club. </span></p> <p class="bodytext"><span style="color: #000000;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming. </span></p> <p><span style="color: #000000;">&nbsp;</span></p> <p><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/brockton2018.jpg" /></span></p> <p class="bodytext"><span style="color: #000000;">On Wednesday, December 21st, CEO of The Phia Group, Adam Russo, made a special visit to The Boys &amp; Girls club of Brockton. During his visit, Adam handed out over 200 gifts that were purchased and wrapped by The Phia Group. It is truly a pleasure to see the look on their faces when Santa brings them exactly what they asked for on their wish list. </span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/brockton22018.jpg" /></span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group invites its staff to donate various items for the benefit of The Boys and Girls Club of Brockton. For more information or to get involved, visit </span><a href="http://www.bgcbrockton.org/">www.bgcbrockton.org</a><span style="color: #000000;">.</span></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a><br /> <span style="color: #000000;">The Stacks</span></span></p> <p class="bodytext" style="font-weight: bold;"><span style="color: #000000;">Managing Plan Communication During a Time of Legislative Uncertainty </span></p> <p class="bodytext" style="font-weight: normal;"><em><span style="color: #000000;">By: Corrie Cripps &ndash; December 2017 &ndash;</span> <a href="https://www.sipconline.net/files/Managing Plan Communication During a Time of Legislative Uncertainty by Corrie Cripps.pdf">Self-Insurers Publishing Corp.</a></em></p> <p><br /> <span class="bodytext"><span style="color: #000000;">While the congressional efforts to repeal and replace the Affordable Care Act (ACA) in 2017 have failed, the Trump administration is now taking executive and regulatory action to modify various aspects of the ACA. In addition, other guidance that may affect group health plans in 2018 is still pending. The following is a summary of the recent regulatory actions that will affect self-insured plans in 2018. </span></span></p> <p><span class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/666/the-stacks-1st-quarter-2018">Click here to read the rest of this article </a></span></p> <p><br /> <span style="color: #000000;"><span class="bodytext" style="color: #000000;"><strong>Interim Final Rules Update</strong></span></span></p> <p>&nbsp;</p> <p class="bodytext" style="font-weight: normal;"><em><span style="color: #000000;">By: Krista Maschinot, Esq. &ndash; November 2017 &ndash;</span> <a href="https://www.sipconline.net/files/Interim Final Rules Update by Krista Maschinot.pdf">Self-Insurers Publishing Corp.</a></em><br /> &nbsp;</p> <p class="bodytext"><span style="color: #000000;">On October 6, 2017, the Trump Administration issued two Interim Final Rules (IFR) related to the Affordable Care Act&rsquo;s (ACA) contraceptive mandate. These rules apply to all employers and create additional considerations for employers sponsoring self-funded plans and their third-party administrators (TPAs). </span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/666/the-stacks-1st-quarter-2018">Click here to read the rest of this article. </a></p> <p>&nbsp;</p> <p class="bodytext"><br /> <strong><span style="color: #000000;">The Future of Self-Funding-An Insider&#39;s Take</span></strong></p> <p class="bodytext"><em><span style="color: #000000;">By: Adam V. Russo, Esq. &ndash; October 2017 &ndash;</span> <a href="https://www.sipconline.net/files/The Future of Self-Funding-An Insider's Take by Adam V_ Russo%2C Esq.pdf">Self-Insurers Publishing Corp.</a></em></p> <p><br /> <span class="bodytext"><span style="color: #000000;">According to the 2016 Milliman Medical Index, the typical family of four costs $25,826 annually in premium and out of pocket expenses and 57% of costs are borne by the employer. Self-funding the right way can reduce these figures significantly and we as an industry must focus on this. At our company, a single employee pays $127.62 for health insurance a month. This compares to the $554 average in the state of Massachusetts, based on the 2017 UBA survey. </span></span><strong> </strong></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/666/the-stacks-1st-quarter-2018" target="_blank">Click here to read the rest of this article.</a></p> <p>&nbsp;</p> <p class="bodytext"><span style="color: #000000;">To stay up to date on other industry news,</span> <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a><br /> <span style="color: #000000;">Phia&rsquo;s Q4 Speaking Events:</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Phia&rsquo;s Speaking Engagements:</strong></span></p> <p class="bodytext"><span style="color: #000000;">Adam Russo&rsquo;s 2018 Speaking Engagements: </span></p> <p class="bodytext"><span style="color: #000000;">&bull; 1/23/18 &ndash; Q4 Intelligence Conference &ndash; Tampa, FL </span></p> <p class="bodytext"><span style="color: #000000;">&bull; 2/2/2018 &ndash; Benefit Intelligence School District Conference &ndash; Phoenix, AZ </span></p> <p class="bodytext"><span style="color: #000000;">&bull; 2/7/2018 &ndash; CGI Business Solutions Seminar &ndash; Manchester, NH </span></p> <p class="bodytext"><span style="color: #000000;">&bull; 3/7/2018 &ndash; SIIA Self-Insured Health Plan Executive Forum &ndash; Charleston, NC</span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Ron Peck&rsquo;s 2017 Speaking Engagements:</strong></span></p> <p class="bodytext"><span style="color: #000000;">&bull; 1/25/2018 &ndash; HealthFirst TPA Client Conference &ndash; Tyler, TX </span></p> <p class="bodytext"><span style="color: #000000;">&bull; 3/6/2018 &ndash; SIIA National Conference &ndash; Charleston, SC </span></p> <p class="bodytext"><span style="color: #000000;">&bull; 3/7/2018 &ndash; CGI Business Solutions Seminar &ndash; Manchester, NH </span></p> <p>&nbsp;</p> &nbsp; <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a><br /> <span style="color: #000000;">Get to Know Our Employee of the Quarter:<br /> Brady Bizarro</span></span></p> <p class="bodytext"><span style="color: #000000;">Congratulations to Brady Bizarro, The Phia Group&rsquo;s Q4 2017 Employee of the Quarter! </span></p> <p class="bodytext"><span style="color: #000000;">Brady joined The Phia Group, LLC as an attorney in early 2016. As a member of The Phia Group&#39;s in-house legal team, he focuses on contract review, ERISA, ACA, and HIPAA compliance, claim negotiation, and providing general consultative advice on matters involving the health insurance industry and employee benefits law.</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/brady2018.jpg" /></span></p> <p class="bodytext"><span style="color: #000000;">Congratulations Brady and thank you for your many current and future contributions.</span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Get to Know Our Employees of the Year: Amanda Grogan &amp; Hemant Dua</strong></span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/check2018.jpg" /></span></p> <p class="bodytext"><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext"><span style="color: #000000;">Amanda: An attorney&rsquo;s office sent the following to Amanda&rsquo;s manager: &ldquo;I wanted to take a moment to tell you what a professional, courteous, knowledgeable, and helpful employee Amanda Grogan is. Besides her helping me with a very difficult file she understands how her industry and her desk works, including the language we need in order to do these files and that is something that should be applauded.&rdquo; </span></p> <p class="bodytext"><span style="color: #000000;">Hemant: &ldquo;What more can be said about the man that came to our company and within 3 months deployed a brand new claims system that was in development for 2 years, within 6 months rewrote 75% of the logic code to ensure proper processing of our clients&rsquo; claims data in TPS, within 9 months stabilized TPS and pioneered ground breaking performance improvements that were unfathomable with EZD and most recently trained Zach, our new Principal Developer, and on-boarded our new offshore development team, Hitachi. He has been an integral part to this year&rsquo;s success and his drive to resolve every issue for the TPS users is commendable. He has been a great mentor to many Phia employees that have been with the company for years, showing his business acumen to learn our processes quickly and apply them. His ability to provide solutions, teach the user how the solution was achieved and encourage the user to utilize the newly learned skills in their future endeavors makes Hemant a true sensei. Phia is lucky to have such an amazing individual working to make Phia great again!&rdquo; </span></p> <p class="bodytext"><span style="color: #000000;">Congratulations Amanda &amp; Hemant and thank you for your many current and future contributions.</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a><br /> <span style="color: #000000;">Phia News</span></span></p> <p class="bodytext"><span style="color: #000000;">&bull; Rock Stars of Health Award o The Phia Group was recently awarded the &ldquo;Rock Stars of Health GOLD Award&rdquo; during The Rock Stars of Health Summit held in Missoula, Montana on September 29, 2017. The award recognizes innovation in the implementation of employee health initiatives that unify expertise in wellness, employee health, safety, risk management, and employee benefits.</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/rockstar2018.jpg" /></span></p> <p class="bodytext"><span style="color: #000000;">&bull; Year Up at Phia! o The Phia Group has been beyond thrilled with our talented, dedicated members who have come to us through Year Up. Sheyla and Josh have become such essential members of our team &ndash; we feel truly blessed to call them a part of the Phia Family. We sat down with them to hear their thoughts and experiences.</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/650/phia-participating-in-the-year-up-program">Find out what they had to say!</a></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/yearup2018.jpg" /></span></p> <p><span class="boldtext" style="color: #000000;">Job Opportunities: </span></p> <p class="bodytext"><span style="color: #000000;">&bull; Consultant I </span></p> <p class="bodytext"><span style="color: #000000;">&bull; Health Benefit Plan Administration &ndash; Attorney </span></p> <p class="bodytext"><span style="color: #000000;">&bull; IT Technologist </span></p> <p class="bodytext"><span style="color: #000000;">&bull; Administrative Assistant &ndash; Recovery </span></p> <p class="bodytext"><span style="color: #000000;">&bull; Case Analyst </span></p> <p class="bodytext"><span style="color: #000000;">See the latest job opportunities, here:</span> <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong><span style="color: #000000;">Promotions </span></strong></p> <p class="bodytext"><span style="color: #000000;">&bull; Keith McMahon was promoted from Claim Recovery Specialist IV &ndash; WC to Claim Recovery Specialist IV &ndash; BI<br /> <br /> &bull; Casey Balchunas was promoted from Claim Recovery Specialist III to Claim Recovery Specialist IV<br /> <br /> &bull; Joseph Bacon was promoted from Legal Assistant to Claim Recovery Specialist<br /> <br /> &bull; Sabrina Centeio was promoted from Case Handler to Claims Recovery Specialist III<br /> <br /> &bull; Jillian Painten was promoted from Claim Recovery Specialist IV to Team Leader<br /> <br /> &bull; Cori DeCristoforo was promoted from Customer Service to Case Evaluation<br /> <br /> &bull; Jiyra Martinez was promoted from a part-time employee to a full-time employee</span><br /> &nbsp;</p> <p class="bodytext"><span style="color: #000000;"><strong>New Hires</strong></span></p> <p class="bodytext"><span style="color: #000000;">&bull; Harry Horton was hired as an Attorney<br /> <br /> &bull; Rea Kostopulos was hired as a Talent Acquisition Specialist<br /> <br /> &bull; Dixie Hayenga was hired as a Consultant<br /> <br /> &bull; Kerry Brennan was hired as a Legal Assistant</span><br /> &nbsp;</p> <p class="bodytext">&nbsp;</p> <p class="bodytext"><strong><span style="color: #000000;">Fun at Phia:</span></strong></p> <p class="bodytext"><span style="color: #000000;">Our Phia Family is so festive! Our &ldquo;Ugly Sweater Day&rdquo; was a hit and we thank all those who participated; congratulations to Josh (pictured below sporting a little red number, complete with a reindeer puppy, plus bells and ornaments) for winning &ldquo;Ugliest Sweater&rdquo;! </span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/sweater2018.jpg" /></span></p> <p class="bodytext"><span style="color: #000000;">How great are these costumes? This year the Phia Halloween Costume Contest was truly a nail-biter. Who would win? The Cowardly Lion? The clown? The fan favorite &ldquo;Orange Blob,&rdquo; bravely worn by Sheyla ultimately took home the gold. Thank you to all who participated, you truly made it a stellar Halloween! </span></p> <p>&nbsp;</p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/sweater22018.jpg" /></span></p> <p><span style="color: #000000;">&nbsp;</span></p> <p class="bodytext" style="text-align: center;"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q1%202018/footerlogo.png" /></span><br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center;">&nbsp;</p> <ul> </ul> </td> </tr> <tr> <td colspan="2" style="background-color: #4a85d3;"> <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> 667The Stacks - 1st Quarter 2018https://www.phiagroup.com/Media/Posts/PostId/666/the-stacks-1st-quarter-2018NewslettersThu, 25 Jan 2018 17:47:46 GMT<strong>Managing Plan Communication During a Time of Legislative Uncertainty<br /> </strong>By: Corrie Cripps<br /> <strong><br /> </strong>For many employer-sponsored group health plans, this is open enrollment season.&nbsp; This normally busy time of year, coupled with the general public&rsquo;s uncertainty about potential health care policy changes, has produced a more stressful environment than usual. &nbsp;<br /> <br /> <strong>What&rsquo;s happening at the federal level</strong><br /> <br /> While the congressional efforts to repeal and replace the Affordable Care Act (ACA) in 2017 have failed, the Trump administration is now taking executive and regulatory action to modify various aspects of the ACA. In addition, other guidance that may affect group health plans in 2018 is still pending. The following is a summary of the recent regulatory actions that will affect self-insured plans in 2018.<br /> <br /> <span style="text-decoration: underline;">Accommodation/exemption from the ACA&rsquo;s contraceptive mandate</span><br /> On October 6, 2017, the Department of Labor (DOL) issued interim final rules (effective immediately) on religious and moral exemptions and accommodations to the ACA&rsquo;s contraceptive mandate.<sup>1,2</sup> <br /> <br /> These interim final rules allow a much broader group of employers and insurers to exempt themselves from covering contraceptives such as birth control pills on religious or moral grounds. While the interim final regulations do maintain the existing accommodations process, the process is now optional. In other words, employers could choose not to request an accommodation, or choose to revoke their current accommodation and instead claim exemption status. The key difference in an accommodation versus an exemption essentially impacts the third party administrator (TPA). Under the exemption, the TPA would no longer be responsible for providing the contraceptive coverage. The rules outline the process if an employer now chooses to revoke its current accommodation (which includes notifying the TPA and plan participants). <br /> <br /> <span style="text-decoration: underline;">DOJ memo on gender identity/orientation</span><br /> In a memorandum issued on October 4, 2017, to agency heads and US attorneys, Attorney General Jeff Sessions issued guidance to agency heads and US attorneys concluding that transgender individuals are not automatically protected from discrimination under Title VII of the Civil Rights Act of 1964.<sup>3</sup> <br /> &nbsp;<br /> It is important to note that the Department of Justice&rsquo;s (DOJ) recent guidance conflicts with the Equal Employment Opportunity Commission&rsquo;s (EEOC), an independent commission, stance that transgender employees are protected under Title VII.<br /> &nbsp;<br /> The December 31, 2016, U.S. District Court injunction (applicable nationwide) on certain parts of the ACA Section 1557&mdash;the prohibitions against discrimination on the basis of gender identity and termination of pregnancy&mdash;is still in effect.<sup>4</sup>&nbsp; The DOJ&rsquo;s recent guidance does not specifically address ACA Section 1557. The U.S. Department of Health and Human Services (HHS) is expected to issue a new proposed rule on ACA Section 1557, which will likely include a religious exemption.<br /> &nbsp;<br /> <span style="text-decoration: underline;">Disability claims and appeals rules may be delayed until April 1, 2018</span><br /> Last December the Employee Benefits Security Administration at the DOL issued a final rule on disability benefit plans claims procedures changes, which are slated to become effective on January 1, 2018.<sup>5</sup>&nbsp; There is now a proposed rule to move the compliance date to April 1, 2018 for these regulations.<sup>6</sup>&nbsp; <br /> <br /> These regulations are applicable to all Employee Retirement Income Security Act (ERISA) plans that offer disability benefits. The regulations generally align procedures for disability claims with those for group health plans under the ACA.<br /> <br /> <span style="text-decoration: underline;">HIPAA administrative simplification rules</span><br /> On October 4, 2017, HHS withdrew the January 2, 2014 proposed rule that would have required a controlling health plan (CHP) to submit information certifying compliance with certain Health Insurance Portability and Accountability Act (HIPAA) electronic transaction operating rules and standards.<sup>7</sup> <br /> <br /> The withdrawal of this proposed rule does not remove the requirements for covered entities to comply with any of those regulations codified at 45 CFR parts 160 and 162. The other HIPAA Administration Simplification requirement to obtain and use Health Plan Identifiers (HPIDs) has been delayed since October 2014, with no new guidance issued.<sup>8</sup> <br /> <br /> <span style="text-decoration: underline;">ACA emergency room regulations</span><br /> The American College of Emergency Physicians (ACEP) filed suit in May 2016 against the Departments of Health and Human Services, Labor and the Treasury (the Departments) regarding the ACA regulation for emergency services, applicable to non-grandfathered plans. Specifically, ACEP is concerned with the part of the rule that sets forth how much insurers/plans are required to pay out-of-network physicians for emergency health care services.<br /> <br /> On August 31, 2017, a federal court ruled that the Departments acted arbitrarily and capriciously in adopting final regulations under the patient protections provisions for emergency services.<sup>9</sup>&nbsp; The court stated that the Departments did not "seriously respond" to the transparency and manipulation concerns raised in comments by providers and advocacy groups to the interim final rules. The court&rsquo;s ruling does not invalidate the final regulations; instead the ruling sends the regulations back to the Departments and requires them to respond to ACEP&rsquo;s concerns and proposals in a substantive manner.<br /> <br /> <span style="text-decoration: underline;">EEOC wellness regulation review</span><br /> On August 22, 2017, the U.S. District Court for the District of Columbia concluded that the U.S. Equal Employment Opportunity Commission&rsquo;s (EEOC) interpretation of a &ldquo;voluntary&rdquo; wellness program in its regulations is arbitrary and capricious, and has sent the regulations back to the EEOC for reconsideration.<sup>10</sup>&nbsp; <br /> <br /> In AARP v. EEOC, the AARP filed a lawsuit against the EEOC regarding its wellness program rules, which state that employers can cap incentives to participate in the wellness programs at 30% of an employee&rsquo;s health insurance costs. The AARP argued that these incentives are so high that they are not truly &ldquo;voluntary&rdquo;, which means that older plan participants would have to incur financial penalties if they chose not to participate or divulge sensitive medical information in cases where the incentive requirement is that a health risk assessment be completed.<br /> <br /> The court ruled in AARP's favor, determining that the EEOC did not justify its conclusion that the 30% incentive level is a reasonable interpretation of voluntariness. However, instead of vacating the regulations the court remanded them to the EEOC for reconsideration. <br /> <br /> The EEOC has stated in its status report to the Court that it will need until August 2018 to reconsider its regulations on employer wellness programs and expects to issue a new final rule by October 2019.<sup>11</sup>&nbsp; AARP is expected to respond to the EEOC&rsquo;s status report and argue that revised regulations should be issued sooner. <br /> <br /> <span style="text-decoration: underline;">Executive order on health care</span><br /> On October 12, 2017, the President issued an executive order on health care, which directs the Departments of Health and Human Services (HHS), Labor, and Treasury (the Departments) to develop regulations and guidance that could permit new health insurance options for employers and consumers.<sup>12</sup> <br /> <br /> The executive order seeks to allow the Departments to look for ways to make it easier for small businesses to join Association Health Plans, expand on the availability and use of Health Reimbursement Arrangements (HRAs), as well as allow the sale of insurance across state lines.<br /> <br /> The executive order does not specify a date in which a proposed rule from the Departments will be released. <br /> <br /> <span style="text-decoration: underline;">IRS will reject individual tax returns that are silent on health coverage question</span><br /> The Internal Revenue Service (IRS) announced it will not accept electronically filed tax returns, and may suspend paper returns, where the individual does not answer the health coverage question.<sup>13</sup> &nbsp; Employers will need to ensure they are furnishing the Form 1095-B or the Form 1095-C, whichever is applicable, to certain employees by January 31, 2018.<br /> <br /> <em><span style="text-decoration: underline;"><strong>What are the public&rsquo;s concerns</strong></span></em><br /> Two recent studies show that Americans rank health care policy changes as one of their biggest concerns.<sup>14,15</sup>&nbsp; <br /> <br /> The Transamerica Center for Health Studies study found that more than two-thirds (67 percent) of Americans reported having at least one chronic health condition, and 42 percent say losing health care because of a pre-existing condition is among their biggest fears.<br /> <br /> The uncertain political environment around health care and the rising costs of health care undoubtedly cause stress, which ultimately affects the individual&rsquo;s health status. In addition, many individuals are not taking advantage of the incentive programs and/or wellness programs offered by their employers, even though more employers are offering such programs.<sup>16,17</sup> &nbsp; <br /> <br /> <strong><span style="text-decoration: underline;"><em>How to communicate plan changes and spread awareness of incentives</em></span></strong><br /> In order to neutralize the impact of uncertainty on plan participants, plans will need to engage more authentically with plan participants. For example, if a plan is removing coverage of a benefit, the plan administrator, or representative, should articulate the reason for the change, and be responsive to the plan participants&rsquo; feedback. And if new benefits or programs are being added to the plan, those should be communicated as well. As the results from the Transamerica Center study indicate, while employers might believe that their wellness and incentive programs are clear as day to their employees, many employees aren&rsquo;t even aware that these programs exist in their employer-sponsored health plans.<br /> <br /> In addition, there are notice requirements under ERISA and the ACA that plans need to follow when making plan changes. A recent lawsuit from the DOL reiterates the importance of complying with the ERISA documentation requirements. The DOL filed suit against Macy&rsquo;s and two of its TPAs alleging violations of ERISA&rsquo;s fiduciary duties.<sup>18</sup> &nbsp; The DOL states that at some point the plan changed the formula to calculate reimbursement of out-of-network claims, but Macy&rsquo;s did not update its plan documents to notify plan participants of this change. The lawsuit states that this caused plan participants to overpay on certain claims.<br /> <br /> This lawsuit shows the continued importance of keeping ERISA plan documentation up-to-date and ensuring that plan administration is consistent with the written terms of the plan.<br /> <br /> <em><strong>Conclusion</strong></em><br /> <br /> For plans and TPAs, being well-informed on regulatory developments is always of the upmost importance, but is particularly important for this renewal and open enrollment season due to rapid changes in the regulatory landscape. In addition to keeping plan documents updated, employers and plans should also clearly communicate any changes to help ease the transition for plan participants and avoid liability landmines. <br /> <br /> Corrie Cripps is a plan drafter/compliance consultant with The Phia Group.&nbsp; 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.<strong> &nbsp;<br /> ---------------------------------------------------------------<br /> </strong><sup>1</sup>Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 26 CFR Part 54, 29 CFR Part 2590, 45 CFR Part 147, October 13, 2017, https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21851.pdf, (last visited November 6, 2017).<br /> <sup>2</sup>Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 26 CFR Part 54, 29 CFR Part 2590, 45 CFR Part 147, October 13, 2017,&nbsp; https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21852.pdf, (last visited November 6, 2017).<br /> <sup>3</sup>Office of the Attorney General, Revised Treatment of Transgender Employment Discrimination Claims Under Title VII of the Civil Rights Act of 1964, October 4, 2017, https://www.documentcloud.org/documents/4067437-Sessions-memo-reversing-gender-identity-civil.html, (last visited November 6, 2017).<strong><br /> </strong><sup>4</sup>Section 1557 of the Patient Protection and Affordable Care Act, https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html, (last visited November 6, 2017).<br /> <sup>5</sup>Claims Procedure for Plans Providing Disability Benefits, 29 CFR Part 2560, https://www.gpo.gov/fdsys/pkg/FR-2016-12-19/pdf/2016-30070.pdf, (last visited November 6, 2017).<br /> <sup>6</sup>Claims Procedure for Plans Providing Disability Benefits; Extension of Applicability Date, 29 CFR Part 2560, https://www.gpo.gov/fdsys/pkg/FR-2017-10-12/pdf/2017-22082.pdf, (last visited November 6, 2017).<br /> <sup>7</sup>Administrative Simplification: Certification of Compliance for Health Plans; Withdrawal, 45 CFR Parts 160 and 162, https://www.gpo.gov/fdsys/pkg/FR-2017-10-04/pdf/2017-21424.pdf, (last visited November 6, 2017).<br /> <sup>8</sup>HPID, https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Unique-Identifier/HPID.html, (last visited November 6, 2017).<strong><br /> </strong><sup>9</sup>United States District Court for the District of Columbia, American College of Emergency Physicians v. Thomas E. Price, MD., https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2016cv0913-23, (last visited November 6, 2017).<br /> <sup>10</sup>United States District Court for the District of Columbia, AARP v. United States Equal Employment Opportunity Commission, https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2016cv2113-47, (last visited November 6, 2017).<br /> <sup>11</sup>AARP v. United States Equal Employment Opportunity Commission, Defendant&rsquo;s Status Report, https://gallery.mailchimp.com/582bc250bf108dcead582e3b8/files/c23461a4-8a49-4bad-b6b4-36e8f9fbb615/2017_09_21.EEOC_wellness_regs_status_report.pdf, (last visited November 6, 2017).<strong><br /> </strong><sup>12</sup>Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States. https://www.whitehouse.gov/the-press-office/2017/10/12/presidential-executive-order-promoting-healthcare-choice-and-competition, October 12, 2017, (last visited November 6, 2017).<br /> <sup>13</sup>ACA Information Center for Tax Professionals, https://www.irs.gov/tax-professionals/aca-information-center-for-tax-professionals, (last visited November 6, 2017).<br /> <sup>14</sup>Transamerica Center for Health Studies, Healthcare Consumers in a Time of Uncertainty: Fifth Annual Nationwide TCHS Survey, https://www.transamericacenterforhealthstudies.org/docs/default-source/research/healthcare-consumers-in-a-time-of-uncertainty.pdf?sfvrsn=2, November 1, 2017, (last visited November 6, 2017).<br /> <sup>15</sup>American Psychological Association, Stress in America&trade;: The State of Our Nation, http://www.apa.org/news/press/releases/stress/2017/state-nation.pdf, November 2017, (last visited November 6, 2017).<br /> <sup>16</sup>Transamerica Center for Health Studies, Healthcare Consumers in a Time of Uncertainty: Fifth Annual Nationwide TCHS Survey, https://www.transamericacenterforhealthstudies.org/docs/default-source/research/healthcare-consumers-in-a-time-of-uncertainty.pdf?sfvrsn=2, (last visited November 6, 2017).<br /> <sup>17</sup>Fidelity Investments&reg; and the National Business Group on Health&reg;, Embracing a Broader Definition of Well-Being: Eighth Annual Employer-Sponsored Health and Well-being Survey,<strong> <br /> </strong>https://workplace.fidelity.com/sites/default/files/NBGH%20Fidelity_2017_WellbeingWebinar_Presentation05022017.pdf, March 2017, (last visited November 6, 2017).<br /> <sup>18</sup>Acosta v. Macy&rsquo;s Inc., S.D. Ohio, No. 1:17-cv-00541<strong><br /> _____________________________________________________________________________________________________________<br /> Interim Final Rules Update<br /> </strong>By: Krista Maschinot, Esq.<br /> <br /> With the calendar year coming to a close, plan sponsors and plan administrators had been breathing a sigh of relief that renewal season will go smoothly as Congress failed to pass any major legislation affecting the Affordable Care Act this year.&nbsp; As with years past, however, a last-minute curveball was thrown at them that proves this year will be no different than previous years. &nbsp;<br /> &nbsp; <br /> On October 6, 2017, the Trump Administration issued two Interim Final Rules (IFR) related to the Affordable Care Act&rsquo;s (ACA) contraceptive mandate.&nbsp; These rules apply to all employers and create additional considerations for employers sponsoring self-funded plans and their third-party administrators (TPAs).&nbsp; These new Department of Health and Human Services (HHS) regulations, the &ldquo;Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act&rdquo; and the &ldquo;Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act,&rdquo; allow for an exemption to the contraceptive mandate for a broader spectrum of companies and organizations.&nbsp; Specifically, the rule expands the types of entities that can claim an exemption or an accommodation from the contraceptive mandate on the grounds of religious beliefs or for moral reasons. &nbsp;<br /> <br /> <strong><span style="text-decoration: underline;">Background</span></strong><br /> This is not a new discussion.&nbsp; In 2012, the contraceptive mandate in the ACA required all employers to provide contraceptive coverage to participants on a no cost-sharing basis, in-network.&nbsp; Religious employers, such as churches, were exempt from the mandate and were not required to file any documentation with the government.&nbsp; There was also an accommodation process put into place for religious organizations that opposed covering contraceptive services for their employees and students. In 2013, a self-certification form, EBSA Form 700, was created and required for self-funded health plans claiming a religious accommodation from the mandate.&nbsp; Multiple lawsuits were filed during this time resulting in a split among the circuits as to which entities could claim exemption from the mandate. &nbsp;<br /> <br /> In 2014, the Supreme Court weighed in and, in Burwell v. Hobby Lobby, held that requiring closely-held corporations to abide by the HHS regulations requiring no-cost access to contraceptives being made available to female employees violated the Religious Freedom Restoration Act (RFRA) in situations where the owners&rsquo; religious beliefs were contrary to the regulations.<sup>1</sup> &nbsp; In addition to Hobby Lobby, there was another Supreme Court case, Zubik v. Burwell, regarding the accommodation process.&nbsp; The Supreme Court decided not to issue a decision in the consolidated cases challenging the accommodation process for the contraceptive mandate for employers with religious objections to contraceptives. <br /> <br /> Under the Trump Administration&rsquo;s new rules, the pool of employers that will be able to opt out of the contraceptive mandate is greatly expanded as the rules allow for employers that have a sincerely-held religious or moral objection to the provision of all or a subset of contraceptives or sterilization items, procedures, or services, or related patient education and counseling, to opt out of the women&rsquo;s preventive care mandate.&nbsp; The expanded group of entities with religious objections includes:<br /> <br /> &bull;&nbsp;&nbsp; <span>&nbsp;Churches, integrated auxiliaries, and religious orders;<br /> &bull;&nbsp;&nbsp; &nbsp;Nonprofit organizations;<br /> &bull;&nbsp;&nbsp; &nbsp;For-profit entities;<br /> &bull;&nbsp;&nbsp; &nbsp;Non-governmental employers;<br /> &bull;&nbsp;&nbsp; &nbsp;Institutions of higher education;<br /> &bull;&nbsp;&nbsp; &nbsp;Individuals with employer sponsored or individual market coverage; and<br /> &bull;&nbsp;&nbsp; &nbsp;Issuers that provide coverage to plan sponsors or individuals that are exempt.<sup>2</sup></span> <br /> <br /> As you can see from the list, this change will permit a much larger pool of companies to carve-out certain women&rsquo;s preventive care benefits under their health plans. <br /> <br /> While these interim final rules allow a much broader group of employers and insurers to exempt themselves from covering contraceptives such as birth control pills on religious or moral grounds, they do not alter the rules regarding the TPA&rsquo;s/insurer&rsquo;s role once the employer has opted out of providing the contraceptive coverage.&nbsp; In other words, the regulations still require TPAs who administer the self-funded medical plan for those entities who opt out of the mandate to otherwise arrange for these women&rsquo;s preventive benefits. While the interim final regulations do maintain the existing accommodations process, the process is now optional. Employers could choose not to request an accommodation, or choose to revoke their current accommodation, which would mean that the TPA would no longer be responsible for providing contraceptive coverage. The rules outline the process if an employer now chooses to revoke its current accommodation (which includes notifying the TPA and plan participants). <br /> <br /> <strong><span style="text-decoration: underline;">Process</span></strong><br /> Under Burwell, closely-held corporations that chose to opt out of contraceptive coverage could send a letter to HHS stating that they objected to offering contraceptive coverage in their health plans or they could complete EBSA Form 700, if they preferred.&nbsp; Under the new rules, the accommodation is now an optional process and employers can choose whether or not to provide any sort of notice or self-certification in order to inform the government of their intent to no longer provide coverage under the mandate.&nbsp; Employers are still responsible for notifying plan participants of any changes in coverage.<br /> <br /> <strong><span style="text-decoration: underline;">Pending Action </span></strong><br /> Upon issuance, the rules were questioned.&nbsp; For example, Maura Healey, the Attorney General for the Commonwealth of Massachusetts, filed a lawsuit in federal court on Friday, October 6th, in an attempt to block the new rules from taking effect.&nbsp; According to the Complaint, the IFR will result in thousands of women in Massachusetts being substantially harmed should the contraception mandate of the ACA be nullified by allowing employers to block contraceptive care and services based upon the employers&rsquo; religious and moral objections to contraception.<sup>3</sup> &nbsp; The Complaint further states that implementation of the IFR will &ldquo;jeopardize the health care of women in Massachusetts and nationwide, promote the religious freedom of corporations over the autonomy of women, and leave the states to bear additional health care costs both with regard to contraceptive and prenatal care as well as other services associated with unintended pregnancies and related negative health outcomes for both women and their children.&rdquo;<sup>4</sup> &nbsp; As of the date of this article, an Answer has not been issued by HHS.&nbsp; This creates questions and confusion for how to apply to the IFR.<br /> <br /> <strong><span style="text-decoration: underline;">Next Steps</span></strong><br /> With plan renewal season just around the corner, the applicability of this rule for self-funded plans and their TPAs needs immediate clarification.&nbsp; Under Burwell, the regulations required TPAs who administered the self-funded medical plan for those entities who could opt out of the mandate (via an exemption or accommodation, etc.) to otherwise arrange for these women&rsquo;s preventive benefits.&nbsp; According to the interim final regulations, the accommodations process is still applicable but is now optional.&nbsp; TPAs will want to be on the look-out to ensure they have processes and procedures in place to address this accommodation process, or a revocation of a current accommodation, internally. <br /> <br /> Should a plan decide to no longer offer contraceptives, the plan must still abide by the reporting and disclosure rules of the Employee Retirement Income Security Act (ERISA).&nbsp;&nbsp; As this would be a reduction of benefits, the Summary of Material Reduction (SMR) rules would apply. A plan has to disclose a material reduction sixty (60) days after the adoption of the change.&nbsp; However, this post-change notification may not necessarily align with fiduciary duties and it is best to give as much warning about a change as possible. The Summary of Benefits and Coverage (SBC) rules also include distribution requirements and, in short, if a change to the plan creates the need to change or update the SBC and the change is made mid-plan year, the plan must give sixty (60) days&rsquo; advance notice.&nbsp; When changes are made at plan renewal, the SBC distribution requirement for open enrollment is generally thirty (30) days&rsquo; notice before the start of the plan year.&nbsp;&nbsp; These requirements may create a significant amount of administrative work and potentially be costly for the plan. Plans will need to consider the administrative burdens that will arise if coverage is no longer available, the notification requirements, and how changes could possibly affect their stop loss coverage.<br /> <br /> As a result of this regulation, there are many questions that we hope to have resolved with future guidance.&nbsp; Employers considering the exemption and/or accommodation will need to take into consideration the lack of guidance provided and the potential effect these unanswered questions may have on the plan and the plan participants.&nbsp; Employers and interested parties can submit their comments to HHS regarding the new rules throughout the comment period, which closes on December 5, 2017.<br /> ----------------------------------------------------------------<br /> <sup>1</sup>Burwell v. Hobby Lobby Stores, Inc., 573 U.S. 22 (2014)<br /> <sup>2</sup>Departments of Health and Human Services, Fact Sheet: Religious and Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act (2017), https://www.hhs.gov/sites/default/files/fact-sheet-religious-exemptions-and-accommodations-for-coverage.pdf.<br /> <sup>3</sup>Commonwealth v. U.S Dep&rsquo;t of Health and Human Services et al., No. 1:2017cv11930 (D. Mass. Filed Oct. 6, 2017).&nbsp; <br /> <sup>4</sup>Id.<br /> __________________________________________________________________________________________________________________<br /> <strong>The Future of Self-Funding - An Insider's Take<br /> </strong>By: Adam V. Russo, Esq. <br /> <br /> According to the 2016 Milliman Medical Index, the typical family of four costs $25,826 annually in premium and out of pocket expenses and 57% of costs are borne by the employer. Self-funding the right way can reduce these figures significantly and we as an industry must focus on this. At our company, a single employee pays $127.62 for health insurance a month. This compares to the $554 average in the state of Massachusetts, based on the 2017 UBA survey.<br /> <br /> <a href="https://www.sipconline.net/files/The%20Future%20of%20Self-Funding-An%20Insider's%20Take%20by%20Adam%20V_%20Russo%2C%20Esq.pdf">Click here to read the rest of this article.</a>666Empowering Plans Segment 27 - Mandate? We don’t need no stinking mandate!https://www.phiagroup.com/Media/Posts/PostId/664/empowering-plans-segment-27-mandate-we-dont-need-no-stinking-mandatePodcastsMon, 22 Jan 2018 15:39:56 GMT<p style="text-align: justify;">In this episode, Adam, Ron, and regular co-hose &ndash; Brady Bizarro &ndash; address the new tax law, elimination of the individual mandate, and how it may impact benefit plans of all types.&nbsp; In particular, they examine the psyche of low risk lives and ask the all-important question &ndash; how do we keep them enrolled without the mandate?<br /> <br /> <a href="https://youtu.be/cvWR4MlcMFI">Click here to check out the podcast!&nbsp;</a>&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w?view_as=subscriber">YouTube </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!) <br /> <br /> </p>664A Taxing Time: The Tax Bill’s Impact on Self-Insurancehttps://www.phiagroup.com/Media/Posts/PostId/663/a-taxing-time-the-tax-bills-impact-on-self-insuranceWebinarsThu, 18 Jan 2018 14:56:09 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/JQWKmdCXC6w" width="100%"></iframe></p> <p> </p> <p style="text-align: justify;">On December 22nd, President Trump signed a $1.5 trillion tax bill. Among other things, it effectively ends the Affordable Care Act’s individual mandate. It will have a major impact on individual and employer-sponsored health insurance. Millions of Americans may be without health insurance coverage in the coming years.<br /> <br /> For self-funded plans, this bill may lead to higher costs due to ripple effects across the entire health insurance market while also opening doors to increased cost-containment opportunities. There are other legislative proposals and agency action which could impact our industry, and many states are considering proposals of their own.<br /> <br /> Listen to The Phia Group’s legal team as they discuss this sweeping tax law.<br /> <br /> <a href="https://www.youtube.com/watch?v=JQWKmdCXC6w&feature=youtu.be">Click Here to View Our Full Webinar on YouTube</a><br /> <a href="/Portals/phiagroup/webinars/Jan 2018/MP3 A_Taxing_Time_The_Tax_Bill_s_Impact_on_Self-Insura.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> <p> </p> 663Empowering Plans Segment 26 - Lightning Strikes Twice – Top 2017 Issues Impacting 2018https://www.phiagroup.com/Media/Posts/PostId/660/empowering-plans-segment-26-lightning-strikes-twice-top-2017-issues-impacting-2018PodcastsWed, 10 Jan 2018 16:08:50 GMT<p style="text-align: justify;">In this episode, the &ldquo;Phia Group Boys&rdquo; freestyle as they share the issues they felt defined 2017 and are likely to impact 2018.&nbsp; From taxes to law; partnerships to reform&hellip; nothing is safe from their analysis and we all benefit from their warnings!&nbsp; This is an episode you cannot afford to miss.<br /> <br /> <a href="https://youtu.be/iTSrcNmcGbY">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w?view_as=subscriber">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!) <br /> <br /> </p>660Empowering Plans Segment 25 - A Taxing Time https://www.phiagroup.com/Media/Posts/PostId/656/empowering-plans-segment-25-a-taxing-timePodcastsThu, 21 Dec 2017 15:04:19 GMTIn this special edition of the podcast, The Phia Group's CEO Adam Russo and Attorney Brady Bizarro discuss the new GOP tax bill in depth. Specifically, how does the bill affect employers? What does the repeal of the individual mandate mean for the self insured industry and for the future of Obamacare? <br /> <br /> <a href="https://youtu.be/VhAHTGA0wP0">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/VhAHTGA0wP0">YouTube </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!)656With Great (Cost-Containment) Power Comes Great (Fiduciary) Responsibility! https://www.phiagroup.com/Media/Posts/PostId/655/with-great-cost-containment-power-comes-great-fiduciary-responsibilityWebinarsTue, 19 Dec 2017 19:23:00 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/3zDhXm8ym50" width="100%"></iframe></p> <p>Insurance has entered an era of cost-containment. No matter your role in the industry, you are concerned with saving money, whether for yourselves or your clients. Health plans and other entities have begun to adopt various programs that are designed to reduce exposure – but only some of those programs are supported by the Plan Document. This can cause fiduciary headaches for the Plan, such as in the recent Macy’s case.<br /> <br />  Join The Phia Group’s legal team for an hour as they describe various ways to cut costs, what must be done to ensure that fiduciary duties are being met, and what happens if they are not.<br /> <br /> <a href="https://youtu.be/3zDhXm8ym50">Click Here to View Our Full Webinar on YouTube</a><br /> <a href="/Portals/phiagroup/webinars/Dec2017/MP3-With_Great_Cost-Containment_Power_Comes_Great_.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 655Empowering Plans Segment 24 - Protect Your ASAhttps://www.phiagroup.com/Media/Posts/PostId/654/empowering-plans-segment-24-protect-your-asaPodcastsMon, 18 Dec 2017 17:42:14 GMTIn this episode, our hosts (including repeat guest host Vice President of Consulting, Attorney Jennifer McCormick) discuss the rising trend in stop-loss insurance being placed by entities other than the TPA, yet the TPA is held responsible if things go sour.&nbsp; Listen in to see how everyone can proactively avoid issues from emerging.<br /> <br /> <a href="https://youtu.be/6-Ix8jMmU2k">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://youtu.be/6-Ix8jMmU2k">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!)654Empowering Plans Segment 23 - Plans and Conspiracyhttps://www.phiagroup.com/Media/Posts/PostId/651/empowering-plans-segment-23-plans-and-conspiracyPodcastsWed, 06 Dec 2017 16:25:50 GMTBring your tin foil hats, folks!&nbsp; With today's episode, our hosts (including guest host, VP of Consulting, Attorney Jennifer McCormick) discuss the recent news regarding CVS purchasing Aetna as well as a new opportunity to customize plan document reviews to address different levels of need.<br /> <br /> <a href="https://youtu.be/ydFel131VEM">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w">YouTube </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!) <br />651Empowering Plans Segment 22 - The Biggest Threats to Self-Funding: A Lightning Round https://www.phiagroup.com/Media/Posts/PostId/647/empowering-plans-segment-22-the-biggest-threats-to-self-funding-a-lightning-roundPodcastsTue, 21 Nov 2017 20:35:46 GMTIn this episode, The Phia Group&rsquo;s CEO, Adam Russo, Sr. VP, Ron Peck, and Attorney Brady Bizarro discuss the biggest threats to the self-funded industry. From expanded fiduciary liability to stop-loss denials to a real threat to the ACA&rsquo;s individual mandate, our experts give their thoughts in a fast-paced discussion.<br /> <br /> <a href="https://www.youtube.com/watch?v=I3DVHET-wq8">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!) <br />647Living in the Now: Prepare for 2018 https://www.phiagroup.com/Media/Posts/PostId/645/living-in-the-now-prepare-for-2018WebinarsTue, 14 Nov 2017 19:51:00 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/4ItKDWeO4WI" width="100%"></iframe></p> <p> </p> <p>A new year is approaching, and we are in the middle of renewal season; meaning it’s time for some serious preparation. Making sure your clients are cared for is no easy task; are you prepared to protect your plans, save them money, and grow your own business in 2018?<br /> <br /> Join The Phia Group’s legal team discuss where the market is heading and what you need to do to keep up with it.<br /> <br /> <a href="https://youtu.be/4ItKDWeO4WI">Click Here to View Our Full Webinar on YouTube</a><br /> <a href="/Portals/phiagroup/webinars/Nov 2017/MP3_Living_in_the_Now_Prepare_for_2018_1_.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> <p> </p> 645Empowering Plans Segment 21 - Planning for Stormy Seas Ahead https://www.phiagroup.com/Media/Posts/PostId/641/empowering-plans-segment-21-planning-for-stormy-seas-aheadPodcastsFri, 03 Nov 2017 13:40:37 GMTIn this episode, Adam, Ron, and their guest star &ndash; VP of Consulting Jennifer McCormick, Esq. &ndash; discuss all of the many issues creating waves as it relates to benefit plan documents, and what steps we can all take to safely navigate those waters &ndash; including setting sail on The Phia Group Flagship Template!<br /> <br /> <a href="https://www.youtube.com/watch?v=kqtArvrdrxk">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w">YouTube </a>and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes </a>Channels!) <br />641Empowering Plans Segment 20 - Trumping Costs and Climbing the Hillhttps://www.phiagroup.com/Media/Posts/PostId/638/empowering-plans-segment-20-trumping-costs-and-climbing-the-hillPodcastsThu, 19 Oct 2017 20:31:07 GMTWith this episode, Adam and Ron welcome back a fan favorite &ndash; guest star Brady Bizarro &ndash; and discuss the wild and crazy happenings in DC.&nbsp; From contraceptives to cost containment; the impact of fully insured subsidies on self funded plans; and everything in between &ndash; this is one lively podcast you cannot afford to miss.<br /> <br /> <a href="https://www.youtube.com/watch?v=IT4HFxaRl2U&amp;t=8s">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our <a href="https://www.youtube.com/channel/UC19nCE2rXmyRMbbAEctAn6w">YouTube</a> and <a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2">iTunes</a> Channels!)638Best Practices for Today's Plan Documents https://www.phiagroup.com/Media/Posts/PostId/636/best-practices-for-todays-plan-documentsWebinarsTue, 17 Oct 2017 18:37:00 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/G4n3qb8YKik" width="100%"></iframe></p> <p> </p> <p> </p> <p>There’s a reason the law governs how plan documents must be formed and distributed – and it’s that the plan document remains the be-all-end-all of the plan’s and member’s rights. For this reason, it is crucial to ensure that the plan document is compliant to a T, is clear and comprehensible, and is able to contain costs.<br />  <br /> A plan document can, however, also be a tool that employers can use to improve their businesses as a whole, and a way for TPAs and brokers to distinguish themselves in the marketplace. Join The Phia Group’s legal team as they discuss best and worst plan document practices, provide some creative ideas for plan formation, and suggest some concepts to help perfect plan document drafting.<br /> <br /> <a href="/Portals/phiagroup/webinars/October 2017/Best Practices for Today_s Plan Documents.mp4">Click Here to Download our Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/October 2017/MP3 Best_Practices_for_Today_s_Plan_Documents.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span><br /> <a href="https://youtu.be/G4n3qb8YKik">Click Here to View our Webinar on YouTube</a></p> 636Empowering Plans Segment 19 - The Man with the Planhttps://www.phiagroup.com/Media/Posts/PostId/634/empowering-plans-segment-19-the-man-with-the-planPodcastsFri, 13 Oct 2017 20:40:28 GMTIn this episode Adam and Ron discuss the oft overlooked but &ndash; in their opinion &ndash; all important plan document.&nbsp; From its purpose to best practices, they discuss why legal compliance, interaction with third parties, and cost containment efforts all start (and end) with the plan terms.&nbsp; Bring a pen and paper &ndash; these tips cannot be missed.<br /> <br /> <a href="https://www.youtube.com/watch?v=xCoWOsqltqs">Click here to check out the podcast!</a>&nbsp;&nbsp; (Make sure you subscribe to our YouTube and iTunes Channels!) <br />634The Phia Group's 4th Quarter 2017 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/633/the-phia-groups-4th-quarter-2017-newsletterNewslettersFri, 13 Oct 2017 19:36:00 GMT<meta content="text/html; charset=UTF-8" http-equiv="Content-Type" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #FFF; } 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 colspan="2" style="background-color: #4a85d3;"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext" style="text-align: right; background-color: #4a85d3;" valign="bottom"> <p>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 alt="" height="303" src="/Portals/phiagroup/Newsletter%20Q2%202017/mainimage.jpg" width="667" /></td> </tr> <tr> <td colspan="2"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/phia_icons.png" /></td> </tr> <tr> <td style="width: 312px;" valign="top"><a target="_blank"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/b1a.png" /></a></td> <td style="width: 323px;" valign="top"><a href="https://www.phiagroup.com/Media/Posts/PostId/633/the-phia-groups-4th-quarter-2017-newsletter#p2" target="_blank"><img alt="" height="214" src="/Portals/phiagroup/Q4%202017%20Newsletter/b2a.png" width="325" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td style="width: 51%;" valign="middle"><img alt="" height="374" src="/Portals/phiagroup/Newsletter%20Q2%202017/adam.jpg" width="323" /></td> <td style="width: 49%;" valign="top"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold; color: #000000;"><br /> <span style="font-size: 18px;"></span></span><span class="heading1" style="font-size: 18px; color: #000000;">The Book of Russo:</span><span class="heading1" style="font-weight: bold; font-size: 18px; color: #000000;"> </span><br /> <span class="heading1" style="font-size: 18px; color: #000000;">From the Desk of the CEO</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">The fall season is here and that means cooler weather, shorter days, changing leaves… and lots of travel for those of us in the self funding space.  The airport terminal is starting to get to me, but as we all know, once October ends, we have a few months at home before the spring events.   But that doesn't mean that it's not busy; in fact, with the amount of new business that so many of you are bringing to the table, it's busier than ever here at The Phia Group. <br /> <br /> We are talking about new plan documents to write, new stop loss policies to assess, more data to scrub for recovery opportunities, and more claims to review.  But all of this growth comes with potential land mines. We cannot take our eyes off the ball and must continue to innovate while being cautious of not overstepping.  There are so many ways we can empower our plans but we need to ensure that we do it right.</span></p> </td> </tr> <tr> <td colspan="2" style="text-align: justify;" valign="top"><span class="bodytext" style="color: #000000;">Speaking of right, I am excited about the release of our flagship template.  I spoke to our clients and one thing you wanted was our full template plan document, but with the variables pre-selected… a best practices plan document that had our chosen provisions in place already, saving you 75% of your time filling out long checklists.  Consider it done!  That’s just one example of the news we have to share.  So, without further ado, enjoy the season and happy reading.<br /> <br /> <span style="font-size: 18px;">Reducing Questionnaires:</span><br /> <br /> Thanks to evolving technology and new resources, The Phia Group can identify subrogation opportunities without sending questionnaires to plan participants.  These recent upgrades to The Phia System™ and advancements in our investigational techniques lead to faster identification of third party liability claims and quicker engagement by The Phia Group’s team, without communicating with the plan participants – identifying opportunities more often, while reducing the volume of accident questionnaires we send to plan participants.  While accident questionnaires are still a useful tool – they are no longer the only tool.  That’s why I am pleased to provide you with the ability to decrease or cease the use of accident questionnaires.  To discuss these new customization capabilities, or our other services, please contact Garrick Hunt at ghunt@phiagroup.com or call (781) 535-5644.</span><br />  </td> </tr> </tbody> </table> </td> </tr> <tr> <td class="toc" colspan="2" style="background-color: #eeeeee;" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p> </p> <p class="tocbkgd"><img alt="" height="29" src="/Portals/phiagroup/Q4%202017%20Newsletter/inthisissue.png" width="166" /><br /> <br /> <a href="#p1">Service Focus of the Quarter: The Phia Group Flagship Template</a><br /> <a href="#p2">New Services and Offerings</a><br /> <a href="#p3">Phia Group Case Study</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group’s 2017 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia’s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"><a id="p1" name="p1"></a> <p class="heading1" style="text-align: justify;"><span style="color: #000000;"><br /> Service Focus of the Quarter: The Phia Group Flagship Template</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">Our plan document can now be yours in a fraction of the time. Taking the guesswork out of best practices and utilizing optimal provisions, The Phia Group Flagship Template offers an unrivaled plan document, with time and cost effectiveness in mind.<br /> <br /> Let us make your life easier and your plan document drafting experience more accurate. With minimal time or monetary investment, you can now take advantage of the industry's most thorough yet efficient plan document production tool. Despite having 75% fewer questions than any other customizable plan document template, The Phia Group Flagship Template is both compliant with federal law, as well as innovative in its use of cost-containment tools and participant incentivizing provisions.<br /> <br /> It should therefore come as no surprise that following in-depth review and assessment, The Phia Group Flagship Template is supported by many leading stop loss carriers.<br /> <br /> Contact Garrick Hunt at <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> or 781-535-5644 to learn more about how The Phia Flagship Template can help you.</span><br />  </p> <hr class="horiz" /> <p class="heading1" style="text-align: justify;"><a id="p2" name="p2"></a><span style="color: #000000;">New Services and Offerings:</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;"><strong>New Phia Tableau Reporting Portal Tool now available: </strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">At The Phia Group, we value transparency and customer satisfaction above all else. In recognition of those priorities, we routinely improve our client facing reports and reporting capabilities. To that end, we are proud to announce that we will be further expanding our reporting service features. Through the use of Tableau</span> (<a href="https://www.tableau.com/">https://www.tableau.com/</a>)<span style="color: #000000;">, reports will now offer a new level of customization, enabling you and The Phia Group to collaborate like never before. These features are not only available to our Subrogation and Third Party Claim Recovery clients, but also customers utilizing any of our Provider Relations services (such as Phia Unwrapped, Balance Bill Support, and Claim Negotiation and Signoff). </span><br /> <br /> <span style="color: #000000;">For more information regarding the new Phia Tableau Reporting Tool and pricing, please contact Garrick Hunt at</span> <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> <span style="color: #000000;">or call him at (781) 535-5644</span></p> <hr class="horiz" /> <strong></strong> <p class="bodytext" style="text-align: justify;"><span style="font-size: 18px; color: #000000;">Cutting back on Questionnaires:</span><strong><span style="font-size: 18px; color: #000000;"> </span></strong></p> <p style="text-align: justify;"><span style="color: #000000;"> <a id="p2a" name="p2a"></a> </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">It is The Phia Group’s mission to reduce the cost of healthcare through the use of innovative legal techniques and the most sophisticated technology. In keeping with this goal The Phia Group is always taking steps to improve all of our services, including our earliest: subrogation. Recent upgrades to The Phia System™ and advancements in our investigational techniques have led to faster identification of third party liability claims and quicker engagement by The Phia Group’s team, without relying upon or otherwise communicating with the plan participants. These new resources allow us to identify opportunities more often and more effectively, while at the same time reducing the volume of accident questionnaires we send to plan participants. While accident questionnaires are still a useful tool when investigating and collecting accident details – they are no longer the only tool. As such, we are pleased to now provide all of our subrogation clients with the ability to increase, decrease, or cease the use of plan participant accident questionnaires. Clients can also opt to utilize their own letters, or have the employer communicate directly with plan participants.<br /> <br /> The Phia Group is committed to ensuring you and your clients are provided with nothing but the highest quality service, best-in-class performance, and a member first approach. That is why we are continuously improving our services to provide the best performance (and most options) possible.<br /> <br /> To discuss these new customization capabilities, or our other services, please contact Garrick Hunt at</span> <a href="mailto:ghunt@phiagroup.com">ghunt@phiagroup.com</a> <span style="color: #000000;">or call (781) 535-5644.</span></p> <p> </p> <hr class="horiz" /> <p class="heading1" style="text-align: justify;"><a id="p3" name="p3"></a><span style="color: #000000;">Phia Group Case Study: </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">The Phia Group was presented with a case where a self-funded health plan paid a claim based on a network rate; the billed charges were $211,500, and the network rate was 51% of billed charges – netting payment of $107,865. When submitted to stop-loss the group’s carrier denied a portion of the claim paid, citing the stop-loss policy exclusion of all amounts in excess of Usual and Customary amounts, as determined by the carrier.<br /> <br /> The kicker: that was all the stop-loss policy’s exclusion said - Usual and Customary was not defined anywhere within the policy.<br /> <br /> The carrier was of the opinion that 150% of the Medicare rate was Usual and Customary, and upon that basis allowed only $22,000 – denying reimbursement of nearly $87,000 that the Plan paid pursuant to its PPO contract. The group attempted to appeal the denial, but the carrier stood firm; the group was all but ready to give up the fight, when the group changed brokers and the new broker’s first order of business was to consult The Phia Group.<br /> <br /> The Phia Group got in touch with the stop-loss carrier on the group’s behalf and attempted to explain the group’s position. The existence of the PPO contract and required payment amount combined with the carrier’s lack of explicit, supporting policy language in the stop-loss policy (along with other arguments – legal and common sense) formed the basis of our position. After many rounds of discussions, the carrier agreed to reimburse the entire claim paid except for $2,073 in “ineligible” charges.<br /> <br /> The plan’s liability for the denied stop-loss claim was $87,000, and The Phia Group’s intervention helped save $85,000.</span><br />  </p> <hr class="horiz" /> <p class="bodytext" style="text-align: justify;"><span class="heading1"><a id="p4" name="p4"></a><span style="color: #000000;">Fiduciary Burden of the Quarter: </span></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">Traditionally, we have discussed fiduciary burdens in terms of companies that perform “plan” functions– such as repricing claims or administering appeals – but this quarter has seen certain instances in which those that perform “settlor” functions (most prominently a broker placing stop-loss or network coverage) have encountered some fiduciary issues. For example: a recent dispute between a plan, its broker, a network administrator, and stop-loss carrier in which the broker apparently placed inadequate or insufficient stop-loss coverage to support a network’s standard policies. The issue is that the network contract required payment of claims that the carrier did not cover; caught in the cross-fire is the broker, who placed this business, and who allegedly should have been aware of the potential discrepancy.<br /> <br /> The allegation? That the broker simply provided bad guidance regarding the choice of which network/carrier combination the plan should use. It is a very easy mistake to make and one that can potentially be made by anyone placing business. Our advice to brokers, TPAs, and other advisors, is to make sure you are as diligent as possible when making decisions for, or even making suggestions to, your clients. Self-funded plan sponsors and plan administrators rely heavily on their advisors; when they are given questionable advice, the backlash can be huge – and it can be unexpected.<br /> <br /> Our popular services: plan document review, stop loss policy review, and Gap-Free Analysis  (which compares the stop-loss policy to a plan document, network contract, or other materials), can help identify issues and potential “gaps” in coverage before they happen. This can mean the difference between spending $120,000 on a new Maserati, and spending $120,000 to indemnify your client from an unexpected stop-loss denial.</span><br />  </p> <p class="bodytext"><a href="#top">Back to top ^</a><br />  </p> <hr class="horiz" /> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a><span style="color: #000000;">Phia Fit to Print:</span></p> <p class="bodytext"><span style="color: #000000;">• Money Inc. –</span> <a href="http://moneyinc.com/affordable-health-insurance-is-not-affordable-health-care/">“Affordable” Health Insurance Is Not “Affordable” Health Care</a> <span style="color: #000000;">– May 11, 2017</span></p> <p class="bodytext"><span style="color: #000000;">• Boston Voyager –</span> <a href="http://bostonvoyager.com/interview/meet-ron-e-peck-phia-group-braintree/">Meet Ron E. Peck of The Phia Group in Braintree</a> <span style="color: #000000;">– August 7, 2017 </span></p> <p class="bodytext"><span style="color: #000000;">• Money Inc. –</span> <a href="http://moneyinc.com/one-one-not-case-single-payer-system/">All Against One and One Not for All: A Case Against a Single Payer System</a> <span style="color: #000000;">– August 21, 2017</span></p> <p class="bodytext"><span style="color: #000000;">• Bloomberg –</span> <a href="https://www.bna.com/employers-taking-action-n73014464063/">Employers Taking Action to Control Health-Care Costs</a> <span style="color: #000000;">– September 5, 2017</span></p> <p class="bodytext"><span style="color: #000000;">• California Broker Magazine –</span> <a href="https://issuu.com/californiabrokermagazine/docs/california_broker_september_2017_2">Even as “Repeal and Replace” Falters Self-funding Remains Strong</a> <span style="color: #000000;">–</span> <span style="color: #000000;">September 7, 2017</span></p> <p class="bodytext"><span style="color: #000000;">• Self-Insurers Publishing Corp. –</span> <a href="https://www.sipconline.net/files/State-mandated Continuation of Coverage and ERISA Preemption by Brady Bizarro%2C Esq.pdf">State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know</a> <span style="color: #000000;">– August 4, 2017</span></p> <p class="bodytext"><span style="color: #000000;">• Self-Insurers Publishing Corp. –</span> <a href="https://www.sipconline.net/files/Taking Health Care International-The Growing Trends of Importing Care and Exporting Patients by Andrew Silverio.pdf">Taking Health Care International - The Growing Trends of Importing Care and Exporting Patients</a> <span style="color: #000000;">– July 3, 2017</span></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><span style="color: #000000;">From the Blogosphere:</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/623/stop-loss-and-my-infinite-sadness">Stop Loss and My Infinite Sadness.</a> <span style="color: #000000;">You get what you pay for.</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/620/uncertainty-prevails-in-the-health-care-debate">Uncertainty Prevails in the Health Care Debate.</a> <span style="color: #000000;">The dog days of summer have come and gone.</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/611/reverse-medical-tourism">Reverse Medical Tourism.</a> <span style="color: #000000;">US patients are seeking services abroad to obtain services and care at more affordable rates. </span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/PostId/601/spinning-the-web-of-the-plan-document">Spinning the Web of the Plan Document.</a> <span style="color: #000000;">No, this isn’t about spiders. </span></p> <p class="bodytext"> </p> <p class="bodytext"><span style="color: #000000;">To stay up to date on other industry news, please</span> <a href="https://www.phiagroup.com/Media/Blog.aspx">visit our blog</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a><span style="color: #000000;">Webinars</span></span></p> <p class="bodytext" style="text-align: center;"><span style="color: #000000;"><strong>Best Practices for Today's Plan Documents</strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On October 17, 2017, The Phia Group will present “Best Practices for Today's Plan Documents,” where our legal team will discuss best and worst plan document practices, provide some creative ideas for plan formation, and suggest some concepts to help perfect plan document drafting.</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #039;"><a href="https://register.gotowebinar.com/register/565483611825896195">Click HERE to Register!</a></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On September 21, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/625/its-time-to-renew-revisiting-stop-loss-trends">It’s Time To Renew – Revisiting Stop Loss Trends</a><span style="color: #000000;">,” where we discussed understanding procedures preemptively, reviewing a plan document side-by-side with the stop loss policy, and agreeing upon language interpretations. </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On August 22, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/618/a-true-impact-on-the-bottom-line-identifying-current-issues-implementing-solutions-seeing-results">A True Impact on the Bottom Line – Identifying Current Issues, Implementing Solutions & Seeing Results</a><span style="color: #000000;">,” where we discussed the biggest issues impacting the health benefits industry today.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On July 13, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/606/consulting-headlines-the-hottest-topics-in-benefit-plan-administration">Consulting Headlines – The Hottest Topics in Benefit Plan Administration</a><span style="color: #000000;">,” where our legal team discussed how laws are changing, regulations are shifting, and benefit plans are scrambling to keep up.</span></p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a><span style="color: #000000;">Podcasts:</span></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On September 11, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/622/cutting-out-conflict">Cutting Out Conflict</a><span style="color: #000000;">,” where our legal team explained what plan administrators can do to cut out conflict and tie up loose ends before they suffer a costly loss. </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On August 21, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/617/empowering-plans-segment-16-in-reference-to-reference-based-pricing">In Reference to reference Based Pricing</a><span style="color: #000000;">,” where Adam Russo and Ron Peck picked apart the method for containing costs, identified the pros and cons of an “RBP” plan, and discussed options to customize such a program.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On August 11, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/615/stopping-the-bleeding">Stopping the Bleeding</a><span style="color: #000000;">,” where The Phia Group’s CEO, Adam Russo and Attorney Brady Bizarro interviewed Garrick Hunt, Phia’s Sales Executive.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On August 7, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/612/empowering-plans-segment-14-repeal-replace-fails-whats-next">Repeal & Replace Fails: What’s Next</a><span style="color: #000000;">,” where The Phia Group's CEO, Adam Russo, Sr. VP, Ron Peck, and Attorney Brady Bizarro discussed the dramatic events on Capitol Hill and the shocking failure of Senate Republicans to repeal and replace Obamacare.</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On July 17, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/607/empowering-plans-p13-your-friendly-neighborhood-provider">Your Friendly Neighborhood Provider</a><span style="color: #000000;">,” where Ron Peck, Jon Jablon and Andrew Silverio shared stories and examples of providers working with payers to preserve the private employer based group health plan industry. </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On July 10, 2017, The Phia Group presented “</span><a href="https://www.phiagroup.com/Media/Posts/PostId/603/empowering-plans-segment-12-the-cost-of-care">The Cost of Care</a><span style="color: #000000;">,” where The Phia Group's CEO, Adam Russo and Sr. VP, Ron Peck, interviewed Attorney Jon Jablon - Director of Provider Relations</span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">Be sure to check out all of</span> <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a></p> <p class="bodytext" style="text-align: left;"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/itunes.png" /><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a><span style="color: #000000;">The Phia Group’s 2017 Charity</span></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">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.<br /> <br /> The Phia Group's 2017 charity is the Boys & Girls Club of Brockton.<br /> <br /> <img alt="" height="77" src="/Portals/phiagroup/Q4%202017%20Newsletter/bandgclub.png" width="279" /></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">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. </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">The Boys & Girls Club of Brockton (BGCB) 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. </span></p> <p class="bodytext" style="text-align: justify;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.<br /> <br /> <img alt="" height="297" src="/Portals/phiagroup/Q4%202017%20Newsletter/vol.jpg" width="508" /></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">On Friday, August 24th, employees of The Phia Group participated in the annual volunteer day at The Boys & Girls club of Brockton. Employees of The Phia Group hosted a number of activities that all of the children truly enjoyed. This year, The Phia Group collected and donated $4,500 to help keep this program running and enjoyable for years to come!  </span></p> <br /> <img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/boysandgirls.jpg" /> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">The Phia Group invites its staff to donate various items for the benefit of The Boys and Girls Club of Brockton. For more information or to get involved, visit</span> <a href="http://www.bgcbrockton.org/">www.bgcbrockton.org</a>.</p> <p class="bodytext"><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a><span style="color: #000000;">The Stacks</span></span></p> <p class="bodytext" style="font-weight: bold;"><span style="color: #000000;">Aid-in-dying Laws and the Implications for Self-Funded Plans</span></p> <p class="bodytext" style="font-weight: normal;"><em><span style="color: #000000;">By: Maribel E. McLaughlin, Esq. – September 2017 -</span> <a href="https://www.sipconline.net/files/Aid-in-dying laws and the Implications for Self-Funded Plans by Maribel E_ McLaughlin Esq.pdf" target="_blank">Self-Insurers Publishing Corp</a>.</em></p> <p style="text-align: justify;"><span class="bodytext"><br /> <span style="color: #000000;">Two years ago, a woman close to my mother was diagnosed with an aggressive form of brain cancer. Along with her two daughters, she went through the various treatment options presented to her and determined that she was going to try all of them. She wanted to put her best foot forward for her daughters and her granddaughter, and she found the strength to fight the cancer with every cell in her body. </span></span></p> <p><span class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/632/the-stacks-4th-quarter-2017">Click here to read the rest of this article </a></span></p> <p><span style="color: #000000;"><span class="bodytext" style="color: #000000;"><br /> <strong>State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know</strong></span></span></p> <p class="bodytext" style="font-weight: normal;"><em><span style="color: #000000;">By: Brady Bizarro, Esq. – August 2017 - </span><a href="https://www.sipconline.net/files/State-mandated Continuation of Coverage and ERISA Preemption by Brady Bizarro%2C Esq.pdf">Self-Insurers Publishing Corp</a>.</em><br />  </p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">According to one prominent health law attorney, “Although in its text ‘hospital’ appears only once and ‘physician’ not all, ERISA may be the most important law [prior to the Affordable Care Act] affecting health care in the United States.” William Sage, “Health Law 2000”: The Legal System and the Changing Health Care Market, 15(3) Health Aff. 9 (Aug. 1996). Understanding the intricacies of the Employee Retirement Income Security Act of 1973 (“ERISA”) and its preemption clause can be a challenge for even the most assiduous attorney. The statute supersedes any and all state laws insofar as they “relate to” any employee benefit plan. It also contains a “savings clause” which preserves the state’s traditional role of regulating insurance. That clause is then qualified by the “deemer clause,” which acts as a kind of escape hatch through the savings clause. For employers, that escape hatch is key because it allows them to avoid state insurance regulations by self-funding their health plans rather than by purchasing health insurance. Increasingly, however, states are testing the limits of preemption by passing leave laws which mandate that employers continue health insurance coverage for eligible employees out on leave. </span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/632/the-stacks-4th-quarter-2017">Click here to read the rest of this article. </a></p> <p class="bodytext"><strong><br /> <span style="color: #000000;">Taking Health Care International – The Growing Trends of Importing Care and Exporting Patients </span></strong></p> <p class="bodytext"><em><span style="color: #000000;">By: Andrew Silverio, Esq. – July 2017 –</span> <a href="https://www.sipconline.net/files/Taking Health Care International-The Growing Trends of Importing Care and Exporting Patients by Andrew Silverio.pdf" target="_blank">Self-Insurers Publishing Corp.</a></em></p> <p style="text-align: justify;"><span class="bodytext"><br /> <span style="color: #000000;">Esteemed physicist Richard Feynman is remembered by many for the phrase “If you think you understand quantum mechanics, you don’t understand quantum mechanics.” This sentiment rings true for the continually evolving landscape of our healthcare system as well, and the problems facing all of us, particularly as insurers, employers, and patients. For those of us within the healthcare or health risk industries, the more we learn about the problems we face and what is causing them, the more we realize just how complex the landscape is and what an impossible task it would be for any single solution to reel in the cost of care. </span></span><strong> </strong></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/PostId/632/the-stacks-4th-quarter-2017" target="_blank">Click here to read the rest of this article.</a><br />  </p> <p class="bodytext"><span style="color: #000000;">To stay up to date on other industry news,</span> <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a><span style="color: #000000;">Phia’s Q4 Speaking Events:</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Phia’s Speaking Engagements:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 7/12/17 – Montana Captive Conference – Whitefish, MT “High Performing Self-Insured Health Plans – The Key to Successful Stop-loss Captive Programs” </span></p> <p class="bodytext"><span style="color: #000000;">• 8/9/17 – NAHU Region 1 Meeting – Stamford, CT “The Best gets Better: Getting the Most out of Your Self-Funded Plans” </span></p> <p class="bodytext"><span style="color: #000000;">• 9/19/17 – Custom Design Benefits – Cincinnati, OH “The Top 10 Innovations in Self-Funding” </span></p> <p class="bodytext"><span style="color: #000000;">• 9/27/17 – TABA’s 2017 Fall Conference and Membership Meeting - The Woodlands, TX “Gap Traps: Avoiding Variances between the Employee Handbook and the Plan Document” </span></p> <p class="bodytext"><span style="color: #000000;">• 10/3/17 – NHAHU – Bedford, NH “Top 10 Do’s & Don’ts of Self-Funding”</span></p> <p class="bodytext"><span style="color: #000000;"> • 10/4/17 – Hewitt Coleman Broker Meeting – Greenville, SC “The Future of Self-Funding & Reference Based Pricing”</span></p> <p class="bodytext"><span style="color: #000000;">• 10/16/17 – Captivated Health Membership Meeting – Woburn, MA “Empower & Engage Through Your Handbook”</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Ron Peck’s 2017 Speaking Engagements:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 9/19/17 – CIC-DC 2017 Annual Conference – Washington, D.C. “Cost Containment Strategies” </span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Tim Callender’s 2017 Speaking Engagements:</span><br /> • 7/17/17 – Health Care Administrator’s Association TPA Summit – St. Louis, MO “Conference Emcee” </span></p> <p class="bodytext"><span style="color: #000000;">• 8/17/17 – FMMA 2017 Annual Conference – Oklahoma City, OK “Critical Strategies in Self-Funding to Promote the Free Market”</span></p> <p class="bodytext"><span style="color: #000000;">• 9/21/17 – Metro Detroit Association of Health Underwriters, Annual Conference – Troy, MI “The Real Causes of High Healthcare Costs & True Cost-Containment Strategies to Combat Cost.”</span></p> <p class="bodytext"><span style="color: #000000;">• 10/10/17 – SIIA, National Educational Conference & Expo – Phoenix, AZ “Through the Looking Glass – a Non-Vendor Take on Reference Based Pricing” </span></p> <p class="bodytext"><span style="color: #000000;"> <span class="boldtext">Brady Bizarro's 2017 Speaking Engagements:</span><br /> • 7/18/17 – HCAA TPA Summit 2017 – St. Louis, MO “Ethics”<br /> <br /> • 8/9/17 – TPAC 2017 Conference – Philadelphia, PA “Most Common Mistakes Employers Make in Their Plan Documents.”<br /> <br /> • 9/26/17 – TABA’s 2017 Fall Conference and Membership Meeting - The Woodlands, TX “Gap Traps: Avoiding Variances between the Employee Handbook and the Plan Document” </span></p> <p> </p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a><span style="color: #000000;">Get to Know Our Employee of the Quarter:<br /> Kerri Sherman</span></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">Congratulations to Kerri Sherman, The Phia Group’s Q3 2017 Employee of the Quarter! </span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">“Kerri consistently goes above and beyond to help all of us when help is needed. Kerri is always around to provide assistance and help out wherever she can! Whether it be training, or making sure we have all the tools we need to complete our work. She has been in the training room at times working with new people, but always keeps us informed of where she will be and what she is doing, so if any issues arise, we know how to proceed. We think she is a fantastic multi-tasker and is always supportive. She always provides quick feedback if something requires immediate attention and always provides detailed explanations of everything that needs to be done in order to solve the issue. We have appreciated all the hard work she has done to help me keep my case load at bay especially while we were preparing to go on vacation. We think she has been phenomenal and we are happy to have her on our team. She is reasonable and fair, while maintaining professionalism.”</span></p> <p class="bodytext"> </p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/kerri.jpg" /><br /> <br /> Congratulations Kerri and thank you for your many current and future contributions.</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a><span style="color: #000000;">Phia News</span></span></p> <p class="bodytext" style="text-align: left;"><span style="color: #000000;"><strong>Catherine Dowie’s Latest Win</strong></span></p> <p class="bodytext" style="text-align: justify;"><span style="color: #000000;">We would like to congratulate Catherine Dowie on her latest win! Phia’s own Catherine Dowie won a $25,000 prize in the Philip Shawe Scholarship Competition, tying for second place in a pool of 240 applicants who submitted briefs to the crowd sourcing contest. We are proud to have you on our team. Get all of the details in recent article published by </span><a href="http://suffolk.edu/law/explore/73687.php#.WdfHsLVrxpj">Suffolk University Law School</a>.</p> <span class="boldtext" style="color: #000000;"><br /> Job Opportunities: </span> <p class="bodytext"><span style="color: #000000;">• Customer Service Representative</span></p> <p class="bodytext"><span style="color: #000000;">• Claims Specialist</span></p> <p class="bodytext"><span style="color: #000000;">• Medical Bill Negotiator</span></p> <p class="bodytext"><span style="color: #000000;">• Health Benefit Plan Consultant I</span></p> <p class="bodytext"><span style="color: #000000;">• Health Benefit Plan Administration – Attorney II</span></p> <p class="bodytext"><span style="color: #000000;">• Product Development Manager</span></p> <p class="bodytext"><span style="color: #000000;">See the latest job opportunities, here:</span> <a href="https://www.phiagroup.com/About-Us/Careers">https://www.phiagroup.com/About-Us/Careers</a></p> <p class="bodytext"> </p> <p class="bodytext"><strong><span style="color: #000000;">Babies </span></strong></p> <p class="bodytext"><span style="color: #000000;">• Jamie Johnson gave birth to Miles and Kaia on 7/10/2017 </span></p> <p class="bodytext"><span style="color: #000000;"><strong><br /> Promotions </strong></span></p> <p class="bodytext"><span style="color: #000000;">• Ulyana Bevilacqua was promoted from Consultant to Supervisor, PGC<br /> <br /> • Elizabeth Pels was promoted from Legal Assistant to Claim Recovery Specialist<br /> <br /> • Joseph Bacon was promoted from Legal Assistant to Claim Recovery Specialist</span><br /> <br /> <span style="color: #000000;">• Vourneen O’Donovan was promoted from Legal Assistant to Claim Recovery Specialist<br /> <br /> • Cheyenne Fonseca was promoted from Legal Assistant to Claim Recovery Specialist</span><br />  </p> <p class="bodytext"><span style="color: #000000;"><strong>New Hires</strong></span></p> <p class="bodytext"><span style="color: #000000;">• Joseph Bacon was hired as a Legal Assistant<br /> <br /> • Naveen Omkar was hired as an IT Technologist<br /> <br /> • Trevor Schramn was hired as a Sales and Accounts Coordinator</span><br /> <br /> <span style="color: #000000;">• Jeff Booth was hired as a Training and Development Manager<br /> <br /> • Jen Montalto was hired as a Case Investigator/Stop Loss<br /> <br /> • Mike Mears was hired as a Claim Analyst<br /> <br /> • Gordon Glenn was hired as an IT Technologist<br /> <br /> • Olesya Avramenko was hired as a Consultant I</span><br /> <br /> <span style="color: #000000;">• Michelle Rowland was hired as a Consultant I<br /> <br /> • Alexandra Simboski was hired as a Consultant I<br /> <br /> • Patrick Ouellette was hired as a Juris Doctor<br /> <br /> • Andrew Fine was hired as an Intake Specialist<br /> <br /> • Erin Hussey was hired as an Attorney I<br /> <br /> • Catina Griffiths was hired as a Case Investigator<br /> <br /> • Samad Khan was hired as a Contract Administrator</span><br /> <br /> <span style="color: #000000;">• Zackery McLaren was hired as a Case Investigator<br /> <br /> • Kaley Dennison was hired as a Case Investigator<br /> <br /> • Ekta Gupta was hired as an ETL Specialist<br /> <br /> • Kathy baker was hired as a Claim Recovery Specialist IV-WC<br /> <br /> • Annie Heskin was hired as a Talent Acquisition Specialist</span><br />  </p> <p class="bodytext"><strong><span style="color: #000000;">Fun at Phia:</span></strong></p> <p class="bodytext"><span style="color: #000000;">Solar Eclipse of 2017</span></p> <p class="bodytext"> </p> <p class="bodytext" style="text-align: justify;"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/solar.jpg" /><br /> <br /> <span style="color: #000000;"><br /> <strong> Rock Star Recognition:</strong><br /> <br /> The Phia Group was recently awarded the “Rock Stars of Health GOLD Award” during The Rock Stars of Health Summit held in Missoula, Montana on September 29, 2017.</span><strong><br /> <br /> <img alt="" height="420" src="/Portals/phiagroup/Q4%202017%20Newsletter/RockStarAward.JPG" width="349" /></strong><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext" style="text-align: center;"> </p> <p class="bodytext" style="text-align: center;"><img alt="" src="/Portals/phiagroup/Q4%202017%20Newsletter/footerlogo.png" /></p> <ul> </ul> </td> </tr> <tr> <td colspan="2" style="background-color: #4a85d3;"> <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> 633The Stacks - 4th Quarter 2017https://www.phiagroup.com/Media/Posts/PostId/632/the-stacks-4th-quarter-2017NewslettersTue, 10 Oct 2017 18:55:40 GMT<p style="text-align: justify;"><strong>Aid-in-dying laws and the Implications for Self-Funded Plans</strong><br /> By: Maribel E. McLaughlin, Esq. <br /> <br /> Two years ago, a woman close to my mother was diagnosed with an aggressive form of brain cancer. Along with her two daughters, she went through the various treatment options presented to her and determined that she was going to try all of them.&nbsp; She wanted to put her best foot forward for her daughters and her granddaughter, and she found the strength to fight the cancer with every cell in her body.&nbsp; After sixteen months of treatment, losing her hair, the inability to eat properly, and her body being riddled with the toxins that were used to fight the cancer, she decided that she wanted to end her life; her way, on her own terms.&nbsp; She had a lengthy discussion with her daughters about her choice, and as sad as they were that they would soon be losing their mother, they understood that their mother wanted to live every moment to its fullest, but, when she was ready, she would make the decision to die on her own terms.&nbsp; One particularly difficult night, she pushed herself to take one last walk through the Newport Cliff Walk with her daughters and granddaughter, enjoyed her last Del&rsquo;s lemonade, savored the final clam chowder she was going to have, and decided that this was her chance to end her life on a high note.&nbsp; That night, she took a higher dose of the medicine that she had been taking for the last sixteen months, and never woke up.&nbsp; She purposely overdosed; or, as many would call it, she committed suicide.<br /> <br /> <strong>D.C.&rsquo;s New Death with Dignity Act</strong><br /> The Death with Dignity Act went into effect on February 18, 2017 in Washington D.C., and last month, doctors were able to begin the process of prescribing life-ending drugs to terminally ill patients; adding the District to six states that currently authorize that practice. &nbsp;<br /> <br /> The D.C. Health Department launched a website where physicians can register to participate in the &ldquo;Death with Dignity&rdquo; program, where doctors, pharmacists, and patients can learn about the law&rsquo;s requirements and patients and doctors can download required forms.&nbsp; Patients must be older than eighteen with a prognosis of less than six months to live in order to be eligible. In addition, they must have made two requests at least fifteen days apart for life-ending medications. They must ingest the drugs themselves, and two witnesses must attest that the patient is making the decision voluntarily. <br /> <br /> <strong>Affordable Cara Act &amp; Physician-Assisted Suicide</strong><br /> According to Section 1553 of the Affordable Care Act (&ldquo;ACA&rdquo;) , a health plan may not discriminate against an individual or institutional healthcare entity because the entity does not provide any healthcare item or service that causes, or assists in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.&nbsp; Put another way, if terminally ill patient requests that his doctor help him end his life, and the doctor refuses for moral or other reasons, that doctor is protected against discrimination by federal law.&nbsp; This protects the doctor that may be targeted by insurance company because of their refusal to help patients end their lives. <br /> <br /> <strong>California&rsquo;s Election of Death of Dignity Law</strong><br /> In California, one of the six states, the law does not make it easy for a patient to elect death with dignity; the patient must be terminally ill to request a doctor&rsquo;s prescription for medications intended to end their lives peacefully.&nbsp; The End of Life Option Act creates a long list of administrative obstacles that both patients and doctors must overcome. At the time of the law&rsquo;s enactment, it became the fifth state to implement an aid-in-dying law, and it is currently also the most stringent.&nbsp; Patients must get a prescription from a participating physician.&nbsp; This is not as easy as it may seem A coordinator may connect the patient with a physician that participates; but, if the patient is a U.S. military veteran that receives healthcare from the U.S. Department of Veterans Affairs, that patient will not be able to utilize this state law since federal law prohibits the use of federal funds for this purpose.&nbsp; Additionally, the forty-eight Catholic and Catholic-affiliated hospitals located in California will not provide patients with the option to end their lives.&nbsp; &nbsp;<br /> <br /> <strong>Cost of Death vs. Cost of Healthcare</strong><br /> Another obstacle that patients may come across is the cost of the drugs involved with the assisted suicide practice.&nbsp; The patient&rsquo;s health plan may not cover them - and the states that have allowed the practice of assisted suicide do not require health insurers to cover the medications.&nbsp; Under The Employee Retirement Income Security Act of 1974 (ERISA), there are minimum standards for voluntarily established health plans in private industry to provide protection for individuals in these plans; plans must provide participants with information about plan features and funding, and furnish information regularly and free of charge.&nbsp; Nothing about the Acts requires that a self-funded plan under ERISA, cover the cost of the death-with-dignity practice. Luckily under ERISA, a Plan still has the liberty to create their health benefits. A health plan, when drafting their Plan Document, can choose to either allow this practice, or not. The ACA prohibits the discrimination of a provider that does not provide assisted suicide services.&nbsp; The Act does not require health plans to allow the practice. The option is left to the Plan. <br /> <br /> Healthcare costs in the United States have risen astronomically over the past decade and many people fear that insurance companies may look to assisted suicide as a way for a health plan to save money of expensive medical care.&nbsp; One report concluded that it would save approximately $627 million dollars in 1995.&nbsp;&nbsp; Some, who oppose assisted suicide, argue that insurance companies may begin to limit expensive procedures for patients who are suffering from terminal illnesses such as cancer, AIDS, and multiple sclerosis.&nbsp; Others argue that even though the aggregate savings is small, the impact on an individual company or an individual family would be a powerful enough financial incentive to encourage the practice even where it was not intended.&nbsp;&nbsp; Many fear that patients would be more likely to consider physician-assisted suicide as a better alternative with the added bonus of saving their family money and the burden of prolonged, expensive care. Insurance companies may try to exclude life-saving or life-extending drugs and pressure people into thinking about the practice of physician assisted suicide.<br /> <br /> <strong>Collins and the Suicide Exclusion</strong><br /> Health plans are permitted to include a suicide exclusion that would enable the plan administrator to deny claims associated with the suicide. In Collins v. Unum Life Insurance Co., 185 F. Supp.3d 860 (2016),&nbsp; the Supreme Court held that &ldquo;Unum reasonably interpreted the suicide exclusion to encompass insane suicide, [and that] Mr. Collins' sanity at death has no bearing on the outcome.&rdquo;&nbsp; The issue in this case involved a state law which stated that a suicide exclusion would be only be valid if liability was limited to an insured &ldquo;who, whether sane or insane, dies by his own act.&rdquo;&nbsp; Former Navy SEAL David M. Collins served this country for seventeen years, during which he was deployed to Iraq, Afghanistan, and Kuwait. He served in dangerous and stressful situations, many of which exposed him to enemy gunfire and blasts from mortar fire.&nbsp;&nbsp; Despite seeking treatment, Mr. Collins was found dead in the driver's seat of his car with a gunshot wound to his head on March 12, 2014. The death was ruled a suicide.&nbsp; Prior to his death, Mr. Collins had been working for Blackbird Technologies, where he participated in an employee benefit plan that provided basic and supplemental life insurance through group policies funded and administered by Unum Life Insurance Company of America.&nbsp; When Mr. Collins died, his widow, Jennifer Mullen Collins, applied for benefits under both policies. Unum granted benefits under the basic policy, but denied benefits under the supplemental policy's suicide exclusion.&nbsp; In addition, the Court held that it found &ldquo;substantial evidence in the administrative record to support Unum's conclusion that the suicide exclusion applied.&rdquo; <br /> <br /> <strong>Option to Elect or Exclude Suicide</strong><br /> Plan administrators can take the position of either excluding assisted-suicide claims or paying them.&nbsp; They can allow the practice, and give the power to the patient to make the decision for themselves, and ultimately save the Plan money for care that the patient would have ultimately not wanted; or, they can exclude the practice and have the peace of mind that everything that should have been covered was covered.&nbsp; Whether you&rsquo;re a broker, a health plan sponsor, third-party administrator, or reinsurer, this is something that should not only spike an interest, but also it should worry you if you have health plans in the states that allow physician assisted suicide practices.&nbsp; Specialists in plan document drafting can provide assistance in reviewing your plan document and ensuring that the plan document addresses this issue specifically. <br /> _________________________________________<br /> <sup>1</sup> HHS Office of the Secretary &amp; Office for Civil Rights (OCR), Section 1553 - Refusal to provide assisted suicide services HHS.gov (2015), https://www.hhs.gov/civil-rights/for-individuals/refusal-provide-assisted-suicide-services/index.html (last visited Aug 9, 2017).<br /> <sup>2</sup> 42 U.S. Code &sect; 18113 (2010)<br /> <sup>3</sup> AB-15 End of life.(2015-2016), Bill Text - ABX2-15 End of life. (2015), https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520162AB15 (last visited Aug 9, 2017).<br /> <sup>4</sup> Id. <br /> <sup>5</sup> Emily Bazar, Aid-In-Dying: Not So Easy Kaiser Health News (2017), http://khn.org/news/aid-in-dying-not-so-easy/ (last visited Aug 9, 2017).<br /> <sup>6</sup> 29 U.S.C. 18 &sect; 1001<br /> <sup>7</sup> Physician Assisted Suicide and Health Care Costs, Low Fat Diet Plan, http://lowfatdietplan.com/weight-loss-routine/end-of-life-care/physician-assisted-suicide-and-health-care-costs (last visited Aug 9, 2017).<br /> <sup>8</sup> Id<br /> <sup>9</sup> Id. <br /> <sup>10</sup> Collins v. Unum Life Insurance Co., 185 F. Supp.3d 860 (2016)<br /> <sup>11</sup> Id. at 882<br /> <sup>12</sup> Id. at 871<br /> <sup>13</sup> Id. at 863<br /> <sup>14</sup> Id. at 864<br /> <sup>15</sup> Id. at 863<br /> <sup>16</sup> Id. at 865<br /> <sup>17</sup> Id. at 880<br /> ________________________________________________________________________________________________________________________<br /> <strong>State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know</strong><br /> By: Brady Bizarro, Esq.<br /> <br /> According to one prominent health law attorney, &ldquo;Although in its text &lsquo;hospital&rsquo; appears only once and &lsquo;physician&rsquo; not all, ERISA may be the most important law [prior to the Affordable Care Act] affecting health care in the United States.&rdquo; William Sage, &ldquo;Health Law 2000&rdquo;: The Legal System and the Changing Health Care Market, 15(3) Health Aff. 9 (Aug. 1996). Understanding the intricacies of the Employee Retirement Income Security Act of 1973 (&ldquo;ERISA&rdquo;) and its preemption clause can be a challenge for even the most assiduous attorney. The statute supersedes any and all state laws insofar as they &ldquo;relate to&rdquo; any employee benefit plan. It also contains a &ldquo;savings clause&rdquo; which preserves the state&rsquo;s traditional role of regulating insurance. That clause is then qualified by the &ldquo;deemer clause,&rdquo; which acts as a kind of escape hatch through the savings clause. For employers, that escape hatch is key because it allows them to avoid state insurance regulations by self-funding their health plans rather than by purchasing health insurance. Increasingly, however, states are testing the limits of preemption by passing leave laws which mandate that employers continue health insurance coverage for eligible employees out on leave.<br /> <br /> Perhaps the best known leave law is the federal Family and Medical Leave Act of 1993 (&ldquo;FMLA&rdquo;). The statute, like most other federal laws, applies regardless of the source of insurance. It requires employers to provide twelve weeks of unpaid, job-protected leave for an employee&rsquo;s own serious health condition, for the birth or adoption of a child, or to care for a spouse, parent, or child with an illness. Significantly, the law also requires employers to maintain group health benefits for employees who take FMLA leave. Even though this continuation of coverage requirement clearly impacts self-funded ERISA plans, federal laws such as the FMLA are outside the scope of ERISA preemption. <br /> <br /> At the state level, five states have now passed laws to address a perceived gap in the FMLA, granting eligible employees paid family leave: California, New Jersey, Rhode Island, Washington, and New York. Rhode Island law requires four weeks of paid leave, California and New Jersey each offer six weeks of paid leave, and Washington offers up to twelve weeks per year. New York&rsquo;s Paid Family Leave Act (&ldquo;PFL&rdquo;), scheduled to take effect on January 1, 2018, offers one of the longest and most comprehensive paid family leave laws in the country. What makes the PFL unique is not just that it requires employers to provide twelve weeks of paid family leave; it also requires employers to continue health insurance coverage to employees out on leave. While this state-mandated employer obligation would seem to fall squarely under the purview of ERISA preemption, it turns out that determining the scope of ERISA preemption is an arduous task.<br /> <br /> The key question to answer is whether the state law at issue &ldquo;relates to&rdquo; an ERISA plan.&nbsp; The U.S. Supreme Court has said that a state law &ldquo;relates to&rdquo; an employee benefit plan covered by ERISA if it refers to or has a connection with that plan, even if the law is not designed to affect the plan or the effect is only indirect. See, e.g., Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139 (1990). This implies that there is no relevant distinction between obligations imposed on the employer versus on the employee benefit plan for purposes of determining whether ERISA preemption applies. Simply put, state laws which impose obligations on employers, and not specifically plans, may still be preempted. In addition, the Court has held that ERISA does not preempt state laws which have only a tenuous, remote, or peripheral connection with an ERISA plan, as is typically the case with laws of general applicability.<br /> <br /> The Court directly addressed ERISA preemption and a state law which mandated the extension of health insurance coverage in District of Columbia v. Greater Washington Bd. of Trade, 506 U.S. 125 (1992). In Greater Washington, the Court reviewed a Washington, D.C. law which required employers who provided health insurance for their employees to provide equivalent health insurance coverage for employees eligible for workers&rsquo; compensation benefits. The Court explained that when a state law specifically refers to benefit plans regulated by ERISA, that provides a sufficient basis for preemption. It made no difference to the Court that the law also related to ERISA-exempt worker-compensation plans or non-ERISA plans. Once it is determined that a state law relates to ERISA plans, this is sufficient irrespective of whether the law also relates to ERISA-exempt plans.<br /> &nbsp;<br /> In earlier cases, petitioners argued that ERISA preemption should be construed to require a two-step analysis: if the state law &ldquo;related to&rdquo; an ERISA-covered plan, they argued, it may still survive preemption if employers could comply with the law through separately administered plans exempt from ERISA (making the distinction between a plan requirement and an employer requirement). See generally Metropolitan Life Ins. Co. v. Massachusetts, 471 U.S. 724 (1985). In Greater Washington, the U.S. Supreme Court dismissed that analysis, stating, &ldquo;We cannot engraft a two-step analysis onto a one-step statute.&rdquo; See Greater Washington, at 133. Despite the Court&rsquo;s rulings, the breadth of the &ldquo;relate to&rdquo; clause remained unclear and the question of state-mandated continuation of coverage was not directly addressed.<br /> <br /> In 2005, the Department of Labor (&ldquo;DOL&rdquo;) seemed to put this issue to rest in an advisory opinion on the applicability of leave substitution provisions of the Washington State Family Care Act (&ldquo;FCA&rdquo;) to employee benefit plans. The FCA permits employees entitled to sick leave or other paid time off to use that paid time off to care for certain relatives of the employee who had health conditions or medical emergencies. As part of its analysis, the DOL analyzed section 401(b) of the FMLA, which provides that state family leave laws at least as generous as the FMLA are not preempted by &ldquo;this Act or any amendment made by this Act.&rdquo; 29 U.S.C. &sect; 2651(b). Further, the DOL cited to a 1993 Senate report which recounts a colloquy between Senators Chris Dodd (D-CT) and Russ Feingold (D-WI). The discussion involved the leave substitution provisions of the Wisconsin FMLA and ERISA preemption. The record revealed that Senator Dodd, the chief sponsor of the FMLA, remarked, &ldquo;The authors of this legislation intend to prevent ERISA and any other [f]ederal law from undercutting the family and medical leave laws of States that currently allow the provision of substitution of accrued paid leave for unpaid family leave&hellip;&rdquo; The DOL relied on this exchange as additional support for the notion that state family leave laws at least as generous as the FMLA (including leave laws that provide continuation of health insurance or other benefits) are not preempted by ERISA or any other federal law. <br /> <br /> As a result of the department&rsquo;s guidance, it appeared as if state family leave laws enjoyed special protections from ERISA preemption. In 2014, the Sixth Circuit Court of Appeals considered the same issue and reached the opposite conclusion. In Sherfel v. Newson, 768 F.3d 561 (2014), the Court found that the leave substitution provisions of Wisconsin&rsquo;s FMLA sufficiently &ldquo;related to&rdquo; an ERISA plan such that they were preempted by ERISA. Specifically, the Court held that the state law would &ldquo;mandate the payment of benefits contrary to the [written] terms of an ERISA plan,&rdquo; thus undermining one of ERISA&rsquo;s chief purposes; achieving a uniform administrative scheme for employers. Newson, at 564. As part of its analysis of the preemption issue, the Court also dismissed the legislative history relied upon by the DOL in an uncommonly blunt (and borderline satirical) manner. Considering whether legislators intended to preclude the preemption of state family leave laws by ERISA, the Court observed, &ldquo;[T]he idea that this colloquy ever passed the lips of any Senator is an obvious fiction. Colloquies of this sort get inserted into the Congressional Record all the time, usually at the request of a lobbyist&hellip;&rdquo; Newson, at 570.<br /> <br /> By ruling that a state family leave law was preempted by ERISA, the Sixth Circuit Court of Appeals aligned itself with the U.S. Supreme Court&rsquo;s earlier jurisprudence on preemption. It remains to be seen how other Circuit Courts will address similar challenges to state leave laws; especially those that mandate continuation of coverage. The conservative approach for employers would be to continue health coverage when required by state law; however, the Sixth Circuit is the highest court to address this issue to date, and self-funded employers would be on solid footing to use ERISA preemption as a shield against state-mandated continuation of coverage.<br /> <br /> Paid family leave is one of the few policies in Washington, D.C. that has bipartisan support, and employers should expect to see more states pass laws akin to New York&rsquo;s Paid Family Leave Act. The President explicitly referred to paid family leave in a speech to a joint session of Congress on February 28, and his 2018 budget proposes six weeks of federal paid parental leave. While it remains unclear if that policy will become law, the trend is likely to continue at the state level, and as those laws impact self-funded health plans, the issue of continuation of coverage and ERISA preemption will increasingly attract the scrutiny of the courts.<br /> <br /> Brady Bizarro, Esq. is an attorney with The Phia Group, LLC.<br /> ________________________________________________________________________________________________________________________<br /> <strong>Taking Health Care International &ndash; The Growing Trends of Importing Care and Exporting Patients</strong><br /> By: Andrew Silverio, Esq.<br /> <br /> Esteemed physicist Richard Feynman is remembered by many for the phrase &ldquo;If you think you understand quantum mechanics, you don&rsquo;t understand quantum mechanics.&rdquo;&nbsp; This sentiment rings true for the continually evolving landscape of our healthcare system as well, and the problems facing all of us, particularly as insurers, employers, and patients.&nbsp; For those of us within the healthcare or health risk industries, the more we learn about the problems we face and what is causing them, the more we realize just how complex the landscape is and what an impossible task it would be for any single solution to reel in the cost of care. <br /> <br /> In tow with the cost of care, health premiums as well as per capita healthcare spending in America steadily increase every year.&nbsp; This should not be news to anyone, and countless strategies have been proposed to slow and eventually reverse this inflation.&nbsp; But, for many, the immediate objective isn&rsquo;t to &ldquo;fix&rdquo; healthcare or undo the decades of developments which brought us here.&nbsp; For many, the immediate goal is just to get care for their employees and families in an affordable way.&nbsp; Although this problem is not uniquely American, we spend more of our GDP on healthcare than any other country (by a wide margin), and care is more expensive here than anywhere else.&nbsp; As such, several newer strategies for cost containment are reaching beyond our borders into the international market &ndash; and doing so with impressive results.<br /> <br /> One strategy aims to avoid the exceedingly high prices of some prescription medications in America by simply getting them from elsewhere.&nbsp; Countries designated as &ldquo;Tier 1&rdquo; countries (including Canada, the UK, Australia, and New Zealand) have safety and efficacy standards which equal or exceed American standards, and enjoy significantly lower prices for drugs which are often chemically identical.&nbsp; So, why hasn&rsquo;t the American prescription drug market self-corrected due to this international competition?&nbsp; The simple answer, and the reason many employers are hesitant to take advantage of this option, is that the practice is illegal.&nbsp; Under federal law, drugs which are manufactured for sale outside the country are not FDA approved, as there is no potential for oversight in the manufacturing process.&nbsp; Additionally, even if the foreign version of the drug is chemically identical in every respect, FDA guidelines address more than just the chemical makeup of the drug &ndash; they relate to labeling, storage, and transportation as well.&nbsp; So, even a drug manufactured within the United States for sale outside of the country would be considered illegal if it was later re-imported into the country. <br /> <br /> So, if importing foreign drugs is illegal, how is it a viable option for cost containment?&nbsp; It&rsquo;s possible, under the right circumstances, due to a well documented FDA policy of &ldquo;enforcement discretion&rdquo;.&nbsp; Under this policy, the FDA does not prosecute individuals who import a limited quantity of prescription medications from abroad for personal use.&nbsp; This discretion is based on several factors, including that the drug is for personal use only and that the amount imported is no more than a 3 month supply. So, if a program is set up correctly, the savings on many costly medications can be huge, with very minimal risk to the employer.&nbsp; Two important things to consider, though, are safety and plan document design.&nbsp; Regarding safety, it&rsquo;s important to remember that just because a drug comes from a &ldquo;Tier 1&rdquo; country does not mean it is safe.&nbsp; Just as you (probably) wouldn&rsquo;t buy prescription drugs from someone out of a suitcase on the street, it&rsquo;s important to ensure that you are working with reputable people and pharmacies abroad when dealing with this type of program.&nbsp; There have been incidents involving drugs which were imported from Tier 1 countries after being manufactured in other countries with more lax standards, as well as incidents were drugs were found to be outright counterfeits.&nbsp; Regarding plan document design, any given plan document likely has some existing barriers to making a seamless transition into reimbursing for expenses such as these.&nbsp; Any exclusions or language which would conflict must be removed, and these changes should be approved by the plan&rsquo;s stop-loss carrier and TPA (and ideally the PBM as well).&nbsp; But again, when set up and run properly, this type of program can generate significant savings with minimal risk to the employer or patient.<br /> <br /> Another trend picking up steam is specialized medical tourism.&nbsp; Medical tourism is certainly nothing new, both within the country and internationally, but we are seeing a new trend &ndash; providers gearing their business model to specifically target medical tourism, and sometimes even specific conditions/illnesses.&nbsp; When a facility specializing in a certain surgical procedure or implant, or treating a disease with particularly costly treatment, sets up shop just over the boarder or just offshore, it&rsquo;s surely no coincidence. <br /> <br /> A prime example of this is Health City Cayman Islands. Health City is a brand new facility (they took their first patient in 2014) that offers a broad spectrum of healthcare services, but none illustrate the savings potential better than their hepatitis C program.&nbsp; Of course, a medical tourism offering only helps an employer save money if patients want to utilize it.&nbsp; Health City seems to understand this &ndash; along with the appeal of their tropical location they offer travel planning assistance, transportation, and concierge services including arranging local activities and excursions.&nbsp; The leading prescription hepatitis C medications can cost nearly $100,000 in the United States for a single 12 week course of treatment.&nbsp; Many employers may be surprised to hear that in light of this, as compared to simply purchasing the drug at the local pharmacy, it can actually be significantly less expensive to put a patient on a plane (with a companion) and fly them to the Caribbean for treatment, including all ancillary services and testing and prescription medications dispensed onsite, all as part of what is essentially a free vacation.&nbsp; The same concept is being applied with increasing regularity to other treatment, including surgical procedures. <br /> <br /> Just as with drug importation, there are some practical house cleaning tasks a plan must take care of before introducing any sort of medical tourism benefit, particularly if patients will be traveling internationally.&nbsp; A common barrier could be any existing plan exclusions for international treatment.&nbsp; This and any other conflicting exclusions must be removed and cleared with interested parties, just as with an importation reimbursement benefit.&nbsp; Another consideration with a medical tourism benefit is potential conflicts with the employer&rsquo;s network agreement.&nbsp; Many such agreements require that the in-network incentive be the &ldquo;best&rdquo; available, so if the in-network coinsurance is 20%, and the plan offers a &ldquo;zero out-of-pocket&rdquo; option to incentivize patients to use the new program, there could be trouble.&nbsp; By that same token, the limitation could only apply within the network&rsquo;s service area, which would mean there is no problem.&nbsp; It is important to have a professional review these agreements to make sure the employer isn&rsquo;t creating any liability for itself. <br /> <br /> While many great minds continue to grapple with the puzzle of bringing American health costs down, many patients and employers simply cannot afford to wait for a complete solution.&nbsp; These globally-minded strategies are just a few of the creative ways employer plans, vendors, and providers are attempting to make care more affordable and accessible.&nbsp; The potential for savings is huge, and the quality of care can be just as high as or higher than comparable treatment domestically. Ultimately, those who reap the benefits will be those who are willing to innovate, and utilize new methods and strategies outside of the traditional employee benefit playbook. <br /> <br /> </p>632The Phia Group, LLC is pleased to announce the integration of its Flagship Templatehttps://www.phiagroup.com/Media/Posts/PostId/630/the-phia-group-llc-is-pleased-to-announce-the-integration-of-its-flagship-templatePress ReleasesFri, 06 Oct 2017 14:17:32 GMTFor Immediate Release <br /> October 6, 2017<br /> &nbsp;<br /> Braintree, MA &ndash; The Phia Group, LLC is pleased to announce the integration of its Flagship Template into its acclaimed Phia Document Management (&ldquo;PDM&rdquo;) software, and support for The Phia Group Flagship Template by many leading stop loss carriers. &nbsp;<br /> &nbsp;<br /> Recognizing that delays in plan drafting cause many plans to administer old plans &ndash; or in some cases &ndash; no plan, early in 2017 The Phia Group announced that it had compiled decades of experience servicing various types of plans to develop its Flagship Template.&nbsp; The Phia Group&rsquo;s Flagship Template is a complete version of its industry acclaimed, fully customizable plan document template, but users&rsquo; time commitment is substantially reduced thanks to The Phia Group having already created a nearly complete plan document.&nbsp; By populating the document with what it deems to be the best provisions in every regard and applying best practices to create an almost-complete SPD, users enjoy a compliant and innovative plan in comparatively no time at all.&nbsp; All that remains is for the plan sponsor or its named administrator to fill in their biographical information, insert their selected schedule of benefits, eligibility criteria, and review the language already provided to request edits or revisions. &nbsp;<br /> &nbsp;<br /> Building upon this foundation, The Phia Group is now proud to announce that its Flagship Template has been uploaded to its acclaimed Phia Document Management (&ldquo;PDM&rdquo;) software, ensuring subscribers can now use and offer The Phia Group Flagship Template to their clientele.&nbsp; Further, following in-depth review and assessment, The Phia Group Flagship Template is now supported by many leading stop loss carriers as well. <br /> &nbsp;<br /> &ldquo;We continue to work towards the evolution of benefit plan documents and self-funding.&nbsp; Each step we take in the advancement of The Phia Group Flagship Template is also a step forward for our industry.&nbsp; We will not allow time constraints to limit the quality of our clients&rsquo; plan documents.&nbsp; With The Phia Group Flagship Template, speed and quality are both possible.&nbsp; Our mission was to reduce the number of questions users need to answer, and we did that &ndash; reducing them by 75%.&rdquo; Remarked The Phia Group&rsquo;s CEO, Adam V. Russo, Esq. <br /> &nbsp;<br /> Regarding what&rsquo;s next for The Phia Group Flagship Template, Mr. Russo advised, &ldquo;Achieving buy-in from the stop loss industry, as well as adding it to our PDM program, is just the beginning.&rdquo;&nbsp; &nbsp;<br /> &nbsp;<br /> For more information regarding The Phia Group&rsquo;s Flagship Template, or to learn about any of The Phia Group&rsquo;s other services, please contact Tim Callender by email at tcallender@phiagroup.com or by phone at 781-535-5631.<br /> &nbsp;<br /> <strong>About The Phia Group:</strong><br /> &nbsp;<br /> The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.&nbsp; By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.<br /> <br />630Empowering Plans Segment 18 - Responsibility - Beyond the Contracthttps://www.phiagroup.com/Media/Posts/PostId/627/empowering-plans-segment-18-responsibility-beyond-the-contractPodcastsThu, 28 Sep 2017 13:41:34 GMTIn this episode, Adam and Ron discuss trends impacting health plans, employers, and employees. While these issues, such as the opioid epidemic, may not seem like the biggest costs facing benefit plans today, the long term costs are real. More importantly, issues like these can be identified by examining claims data; but most administrators are not contractually responsible to do so. Adam and Ron discuss why these entities should consider adding such services to their offerings &ndash; despite not being the most impactful cost containment option or being a contractual responsibility of the administrator.<br /> <br /> <a href="https://www.youtube.com/watch?v=Jk0wSqJQub0&amp;feature=em-upload_owner">Click here to check out the podcast!</a>&nbsp;&nbsp;<strong> (Make sure you subscribe to our YouTube and iTunes Channels!) </strong><br />627It’s Time To Renew – Revisiting Stop Loss Trends https://www.phiagroup.com/Media/Posts/PostId/625/its-time-to-renew-revisiting-stop-loss-trendsWebinarsThu, 21 Sep 2017 18:51:09 GMT<p><iframe allow="autoplay; encrypted-media" allowfullscreen="" frameborder="0" height="375" src="https://www.youtube.com/embed/OFz5Es5gNWo" width="100%"></iframe></p> <p> </p> <p>It’s that time of year again – renewal season!  What is often overlooked is the type of stop loss carrier to partner with for the next plan year. Stop loss choices are often made just on the premium cost, however plans should look at more than just the price. Stop loss is something most self funded benefit plans rely upon to ensure their financial viability and long term success. Yet, too often plans seek to change benefit structures or implement cost containment programs without coordinating those changes with stop loss. Understanding procedures preemptively, reviewing a plan document side-by-side with the stop loss policy, and agreeing upon language interpretations are some of the important things plans and carriers must do to achieve harmony.<br /> <br /> <a href="/Portals/phiagroup/webinars/Sept 2017/MP4 Sept Webinar.mp4">Click Here to Download our Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/Sept 2017/MP3_Sept_Webinar.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span><br /> <a href="https://youtu.be/OFz5Es5gNWo">Click Here to View our Webinar on YouTube </a></p> 625Empowering Plans Segment 17 - Cutting Out Conflict https://www.phiagroup.com/Media/Posts/PostId/622/cutting-out-conflictPodcastsMon, 11 Sep 2017 13:21:10 GMT<p>When it comes to securing stop-loss, too many benefit plans think the ball is only in the stop loss carrier&rsquo;s court.&nbsp; Today, our hosts explain what plan administrators can do to cut out conflict and tie up loose ends before they suffer a costly loss.&nbsp; Ensuring an ongoing and fruitful relationship between plans and stop loss tomorrow requires intensive work today.&nbsp; Addressing these potential costly issues now will guarantee reimbursements are in the bag later.<br /> <br /> <a href="https://www.youtube.com/watch?v=TCEu_P0HDhk">Click here to check out the podcast!<strong>&nbsp;&nbsp; <span style="color: #000000;">(</span></strong></a><strong>Make sure you subscribe to our YouTube and iTunes Channels!)</strong></p> 622A True Impact on the Bottom Line – Identifying Current Issues, Implementing Solutions & Seeing Results!https://www.phiagroup.com/Media/Posts/PostId/618/a-true-impact-on-the-bottom-line-identifying-current-issues-implementing-solutions-seeing-resultsWebinarsTue, 22 Aug 2017 18:29:09 GMT<p>The Phia Group’s legal team frequently addresses the biggest issues impacting the health benefits industry today. Join them as they dissect the conflicts threatening every entity involved in the business of health benefits, and share real life examples of clients who implemented forward thinking solutions… and those that didn’t. From fiduciary liability to claim re-pricing by stop-loss carriers… from international importation of prescription drugs to handling large out of network costs and resolving balance billing of patients… We will together discuss the biggest trends, solutions, and results.<br /> <br /> <a href="/Portals/phiagroup/webinars/August 2017/MP4 A True Impact on the Bottom Line.mp4">Click Here to Download our Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/August 2017/MP3_A_True_Impact_on_the_Bottom_Line.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 618Empowering Plans Segment 16 - In Reference to Reference Based Pricinghttps://www.phiagroup.com/Media/Posts/PostId/617/empowering-plans-segment-16-in-reference-to-reference-based-pricingPodcastsTue, 22 Aug 2017 14:22:09 GMTThis week, Adam Russo and Ron Peck accept that an answer to the high cost of healthcare won&rsquo;t be coming from D.C., and that health plan administrators (with the help of their partners and advisors) need to address the costs internally.&nbsp; Amongst options to do just that, so-called &ldquo;Reference Based Pricing&rdquo; is a hot topic in our industry.&nbsp; Join Ron and Adam as they pick apart this method for containing costs, identify the pros and cons of an &ldquo;RBP&rdquo; plan, and discuss options to customize such a program.<br /> &nbsp; <br /> <a href="https://www.youtube.com/watch?v=mjFq2BzkGsM">Click here to check out the podcast!</a><br /> <br /> <br />617Stopping the Bleedinghttps://www.phiagroup.com/Media/Posts/PostId/615/stopping-the-bleedingPodcastsFri, 11 Aug 2017 20:22:55 GMTThis week, The Phia Group&rsquo;s CEO, Adam Russo and Attorney Brady Bizarro interviewed Garrick Hunt, Phia&rsquo;s Sales Executive, about some of the most common burdens self-funded employers are facing in our industry. From out-of-network claims to air ambulance to specialty drugs, we explore cost-containment strategies and discuss the potential compliance concerns for employers. Finally, we answer a question from our mail bag regarding best practices for handling overpayments.<br /> <br /> <a href="https://www.youtube.com/watch?v=jSTp1lGKMr4">Click here to check out the podcast!</a><br /> <br />615Empowering Plans Segment 14 - Repeal & Replace Fails: What's Next?https://www.phiagroup.com/Media/Posts/PostId/612/empowering-plans-segment-14-repeal-replace-fails-whats-nextPodcastsMon, 07 Aug 2017 13:26:04 GMTThis week, The Phia Group's CEO, Adam Russo, Sr. VP, Ron Peck, and Attorney Brady Bizarro discuss the dramatic events on Capitol Hill and the shocking failure of Senate Republicans to repeal and replace Obamacare. Despite this serious setback, Republicans are not ready to give up. We'll discuss the path forward.<br /> <br /> <a href="https://www.youtube.com/watch?v=78EgNk7Z7NE&amp;lc=z23cybg4lnzvwrewe04t1aokgdmdcnqkinn2pglwhxklbk0h00410&amp;feature=em-comments">Click here to open the Podcast!</a>612Empowering Plans P13 - Your Friendly Neighborhood Providerhttps://www.phiagroup.com/Media/Posts/PostId/607/empowering-plans-p13-your-friendly-neighborhood-providerPodcastsMon, 17 Jul 2017 18:40:46 GMTTaking a positive view on the industry, Ron Peck, Jon Jablon and Andrew Silverio today share stories and examples of providers working with payers to preserve the private employer based group health plan industry.&nbsp; From price transparency, to direct primary care, to medical tourism &ndash; providers that are willing to innovate and work with payers get their moment in the sun with this episode.<br /> <br /> <a href="https://www.youtube.com/watch?v=za1jDwi9Plg">Click here to open the Podcast!</a>607Consulting Headlines – The Hottest Topics in Benefit Plan Administrationhttps://www.phiagroup.com/Media/Posts/PostId/606/consulting-headlines-the-hottest-topics-in-benefit-plan-administrationWebinarsThu, 13 Jul 2017 18:45:14 GMT<p>Extra!  Extra!  Have you heard the news?  Laws are changing, regulations are shifting, and benefit plans are scrambling to keep up. <br /> <br /> Thank you for joining The Phia Group’s legal team on July 13th, as they discuss the biggest issues and most common questions facing our industry, as well as ideas and solutions to not only survive but thrive in this changing environment.  This is your chance to learn from others’ questions, concerns, mistakes and successes.  Check it out!<br /> <br /> <a href="/Portals/phiagroup/webinars/July 2017/MP4-Consulting Headlines – The Hottest Topics in Benefit Plan Administration.mp4">Click Here to Download our Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/July 2017/MP3 Consulting_Headlines_The_Hottest_Topics_in_Benefit.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 606The Phia Group's 3rd Quarter 2017 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/604/the-phia-groups-3rd-quarter-2017-newsletterNewslettersTue, 11 Jul 2017 17:47:00 GMT<meta content="text/html; charset=UTF-8" http-equiv="Content-Type" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #FFF; } 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 colspan="2" style="background-color: #4a85d3;"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext" style="text-align: right; background-color: #4a85d3;" valign="bottom"> <p>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 alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/mainimage.jpg" /></td> </tr> <tr> <td colspan="2"><img alt="" src="/Portals/phiagroup/images/icons/Learn%20Plan%20Save%20Protect%20Icons%20WITH%20TEXT.png" style="width: 650px; height: 96px;" /></td> </tr> <tr> <td style="width: 312px;" valign="top"><a href="https://www.phiagroup.com/LinkClick.aspx?fileticket=GzQu8IJg5GM=&portalid=586" target="_blank"><img alt="" height="217" src="/Portals/phiagroup/Newsletter%20Q2%202017/b1.png" width="325" /></a></td> <td style="width: 323px;" valign="top"><a href="https://www.phiagroup.com/Portals/phiagroup/Flyers/FlagshipFlier_02-07-17.pdf" target="_blank"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/b2.png" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td style="width: 51%;" valign="middle"><img alt="" height="375" src="/Portals/phiagroup/Newsletter%20Q2%202017/adam.jpg" width="325" /></td> <td style="width: 49%;" valign="top"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold; color: #000000;"><br /> The Book of Russo: From the Desk of the CEO</span></p> <p class="bodytext"><span style="color: #000000;">The heat is on here in Boston with absolutely beautiful weather over the past few weeks with the same expected in the near future. This can also be said for the self-insured industry as a whole as well as what we have seen here at The Phia Group. The summer has not meant a slow down; in fact business is up across the board and interest from brokers, advisors, and employers is at levels I have never seen. So while it’s great news that so many people want to get in on this innovative market, the risk is that employers and others will jump in too quickly without truly understanding the risks involved with self-funding their employee benefit plans. Sure you can lower your costs by self-funding but you also expose yourself to catastrophic claims issues, high priced drug costs that you cannot control and stop loss issues that you had no idea existed. That’s why we are here for the industry – to ensure you can have your cake and eat it too. I hope you enjoy our summer newsletter as we have lots of great info to share. Happy reading!</span></p> </td> </tr> <tr> </tr> <tr> <td class="toc" colspan="2" style="background-color: #eeeeee;" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p><img alt="" height="23" src="/Portals/phiagroup/Newsletter%20Q2%202017/inthisissue.png" width="191" /></p> <p class="tocbkgd"><a href="#p1">Service Focus of the Quarter: Independent Consultation & Evaluation (ICE)</a><br /> <a href="#p2">New Services and Offerings</a><br /> <a href="#p3">Phia Group Case Study: Flagship Plan Document</a><br /> <a href="#p4a">Phia Fit to Print</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group’s 2017 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia’s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><span style="color: #000000;"><a id="p1" name="p1"></a><br /> Service Focus of the Quarter: Independent Consultation & Evaluation (ICE)</span></p> <p class="bodytext"><span style="color: #000000;">You need legal consultation to address regulatory compliance concerns, claim processing queries, and to collaborate on difficult administrative tasks. Having an experienced team of attorneys, compliance specialists, and industry experts on call is a must have. With The Phia Group's Independent Consultation and Evaluation ("ICE") service, unlimited access to The Phia Group's acclaimed team of legal consultants is yours for an affordable pre-paid, per employee per month (“PEPM”) subscription fee. Gone are the days of budgeting on the fly and dealing with mysterious "legal bills." With an ICE subscription fee, clients can preemptively budget for and share the cost of this invaluable resource - allowing The Phia Group and their clients to focus on what is really important - results. </span></p> <p class="bodytext"><span style="color: #000000;">For more information regarding ICE and The Phia Group's many other services, please visit our website or contact The Phia Group's Vice President of Sales & Marketing, Tim Callender by email at</span> <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a> <span style="color: #000000;">or by phone at 781-535-5631.</span></p> <p class="heading1"><a id="p2" name="p2"></a><span style="color: #000000;">New Services and Offerings:</span></p> <p class="bodytext"><span style="color: #000000;"><strong><em>Leave of Absence Review</em></strong></span></p> <p class="bodytext"><span style="color: #000000;">Employers aren't paying attention to their health benefit plan documents. They alter their employee handbooks every year, or sometimes multiple times in a single year. They try to be generous, providing employees with the ability to take leaves of absence, and promising them extended health plan coverage when they take such leaves of absence. Little do they know that their plan documents expel participants from coverage after a fixed period of time if the employee isn't actively working. This means that - per the plan - that person exercising their right to a leave of absence has no health plan coverage. If the employer tries to provide coverage anyway, stop-loss isn't required to reimburse claims over the deductible. </span></p> <p class="bodytext"><span style="color: #000000;">We're seeing this conflict come up with startling frequency, and the time has come to end this problem once and for all. The Phia Group has added a Leave of Absence review to its already popular Gap-Free Analysis service. The Phia Group's team of plan document experts and attorneys will analyze the applicable plan document side-by-side with the employer's handbook and stop-loss policy, to ensure there are no gaps in coverage and that all are in compliance with applicable law. </span></p> <p class="bodytext"><span style="color: #000000;"><em><strong>Flagship Plan Document</strong></em></span></p> <p class="bodytext"><span style="color: #000000;">Every self-funded plan deserves a "Best in Class" plan document, yet - delays in plan drafting cause many plans to administer old plans - or in some cases - no plan. Now there is no excuse for administering a self-funded program with an outdated plan document, or worse, no plan document at all.</span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group has compiled decades of experience servicing various types of plans, and drafting various types of plan documents, to develop its Flagship Template. This plan document "checks all the boxes" when it comes to best practices, regarding everything from cost containment to compliance; offering robust yet effective coverage. </span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group's Flagship Template is a condensed version of its industry acclaimed, fully customizable template. The Phia Group has taken its own plan document (complete with thousands of requisite customization queries), and created a nearly complete plan document - by pre-selecting what it deems to be the best provisions in every regard; applying best practices to create an almost-complete plan. All that remains is for the plan sponsor or its named administrator to fill in their biographical information, insert their selected schedule of benefits, eligibility criteria, and review the language already provided to request edits or revisions. </span></p> <p class="bodytext"><span style="color: #000000;">Our goal is to provide plans with plan documents that we think reflect best practices. The plan sponsor and its administrator no longer need to review countless options or fill in limitless blank spaces. The hard work has already been handled by The Phia Group. We don't want to see any more self-funded employers or plan administrators suffer penalties or face conflicts with their partners, due to an outdated or non-existent plan document. Now, with The Phia Group's Flagship Template, clients can enjoy speedy production of best-in-class plans, with minimal time or monetary investment.</span></p> <p class="bodytext"><span style="color: #000000;">For more information regarding any of The Phia Group’s services, please contact The Phia Group’s Vice President of Sales & Marketing, Tim Callender, by email at</span> <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a> <span style="color: #000000;">or by phone at 781-535-5631.</span></p> <p class="heading1"><a id="p3" name="p3"></a><span style="color: #000000;">Phia Group Case Study: Flagship Plan Document</span></p> <p class="bodytext"><span style="color: #000000;">Not long after The Phia Group introduced its Flagship Template offering as part of its Phia Document Management (PDM) service, one of our long-time clients approached us with an issue they were having. They had a new client prospect – the largest prospect the TPA had ever had, and indeed far larger than the average self-funded group. This particular group was coming from the fully-insured market, so it had never structured its own Plan Document before. As part of the RFP process, the TPA had provided the Plan Sponsor with a checklist from the TPA’s standard template, customized for use with the Phia Document Management software.</span></p> <p class="bodytext"><span style="color: #000000;">The TPA contacted our consulting and plan drafting team and relayed that this formerly-fully insured group was a bit uneasy about the number of variables in the checklist. Although the Plan Sponsor had not yet awarded the TPA its business, the Plan Sponsor indicated that it had absolutely no idea how to choose, for instance, which “illegal acts” or “workers compensation” exclusions it wanted, of the myriad of options within the standard checklist.</span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group’s plan drafting team informed the TPA of the newfound existence of our Flagship Template, which is designed specifically to cut down variables by 75%, instead applying our best-practices approach to definitions and exclusions. The remaining variables are designed to be high-level options, rather than the nitty gritty that plan sponsors may not have the experience or interest to answer.</span></p> <p class="bodytext"><span style="color: #000000;">The TPA showed the Plan Sponsor the Flagship Template checklist, and the Plan Sponsor was pleased with the more manageable number of variables, and subsequently awarded the TPA its considerable block of business.</span></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p4" name="p4"></a><span style="color: #000000;">Fiduciary Burden of the Quarter: Prudent Management of Plan Assets</span></span></p> <p class="bodytext"><span style="color: #000000;">ERISA specifies that all Plan Administrators must be prudent with assets. That means avoiding waste, and securing savings whenever possible. Protecting plan assets, identifying fraud, overpayments, undue costs, as well as taking action to protect the plan, recoup lost funds, and identify savings opportunities, are being treated less like “good ideas” and more like “fiduciary duties.” In the meantime, the Department of Labor has begun to crack down on fiduciary violations more than ever. </span></p> <p class="bodytext"><span style="color: #000000;">As always, we urge TPAs and brokers to do their best to ensure that they, and their clients, are prudent with plan assets in every way possible! Please visit our website or contact The Phia Group's Vice President of Sales & Marketing, Tim Callender by email at</span> <a href="mailto:tcallender@phiagroup.com">tcallender@phiagroup.com</a> <span style="color: #000000;">or by phone at 781-535-5631 to discuss this growing concern and steps you can take to maximize benefits and minimize costs.</span></p> <p class="bodytext"><a href="#top">Back to top ^</a><br />  </p> <p class="heading1"><a id="p3" name="p5"></a><a id="p4a" name="p4a"></a><span style="color: #000000;">Phia Fit to Print:</span></p> <p class="bodytext"><span style="color: #000000;">• Employers Costs Outpace Salaries –</span> <a href="http://digitaleditions.sheridan.com/publication/index.php?i=380118&m=&l=&p=1&pre=&ver=html5#{'page':0,'issue_id':380118}">America's Benefit Specialist,</a> <span style="color: #000000;">Page 28</span></p> <p class="bodytext"><span style="color: #000000;">• </span><span style="color: #000000;">Money Inc. –</span> <a href="http://moneyinc.com/affordable-health-insurance-is-not-affordable-health-care/">“Affordable” Health Insurance Is Not “Affordable” Health Care</a></p> <p class="bodytext"><span style="color: #000000;">• Self-Insurers Publishing Corp. –</span> <a href="https://www.sipconline.net/files/Taking Health Care International-The Growing Trends of Importing Care and Exporting Patients by Andrew Silverio.pdf">Taking Health Care International - The Growing Trends of Importing Care and Exporting Patients</a></p> <p class="bodytext"><span style="color: #000000;">• Self-Insurers Publishing Corp. –</span> <a href="https://www.sipconline.net/files/Held Captive by Appeals by Tim Callender%2C Esq.pdf">Held Captive by Appeals</a></p> <p class="bodytext"><span style="color: #000000;">• Self-Insurers Publishing Corp. –</span> <a href="https://www.sipconline.net/files/Appealing to Reason by Jon A_ Jablon%2C Esq.pdf">Appealing to Reason</a></p> <p class="bodytext"><span style="color: #000000;">• Self-Insurers Publishing Corp. –</span> <a href="https://www.sipconline.net/files/Self-Funded Health Plans May Have a New Ally in the Fight against Specialty Drug Prices authored by Brady Bizarro%2C Esq.pdf">Self-Funded Health Plan May Have a New Ally in the Fight against Specialty Drug Prices</a></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <p> </p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><span style="color: #000000;">From the Blogosphere:</span></p> <p class="bodytext"><span style="color: #000000;">• </span><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/590/the-rules-of-the-game-are-still-changing.aspx">The Rules of the Game are Still Changing.</a> <span style="color: #000000;">What is an Executive Order? </span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/584/dear-stop-loss-a-ballad.aspx">Dear Stop-Loss: A Ballad.</a><span style="color: #000000;"> A blog that can be sung to the tune of “Gilligan’s Island.”</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/583/you-are-not-going-to-sue-us-are-you.aspx">You Are Not Going to Sue us, Are You?</a> <span style="color: #000000;">Claims from providers are “getting high.” </span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/577/transparency-its-not-just-for-ghosts.aspx">Transparency – It’s Not Just for Ghosts.</a> <span style="color: #000000;">What about the costs of standard medical procedures?</span></p> <p class="bodytext"><span style="color: #000000;"><br /> To stay up to date on other industry news, please visit <a href="https://www.phiagroup.com/Media/Blog.aspx">our blog</a>.</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a><span style="color: #000000;">Webinars</span></span></p> <p class="bodytext"><span style="color: #000000;"><strong>Consulting Headlines – The Hottest Topics in Benefit Plan Administration</strong></span></p> <p class="bodytext"><span style="color: #000000;">On July 13, 2017, The Phia Group will present “Consulting Headlines – The Hottest Topics in Benefit Plan Administration,” where our legal team will discuss how laws are changing, regulations are shifting, and benefit plans are scrambling to keep up.</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #003399;"><a href="https://register.gotowebinar.com/register/565483611825896195">Click HERE to Register!</a></p> <p class="bodytext"><span style="color: #000000;">On June 22, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/597/a-network-by-any-other-name.aspx">“A Network by any Other Name,”</a> <span style="color: #000000;">where we discussed various payment methodologies, and what a health plan needs to do to ensure that the Plan Document supports that methodology. </span></p> <p class="bodytext"><span style="color: #000000;">On May 16, 2017, The Phia Group presented </span><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/585/decisions-decisions-which-plan-types-work-best-for-which-groups-and-why.aspx">“Decisions, Decisions: Which Plan Types Work Best for Which Groups, and Why,”</a> <span style="color: #000000;">where we went over some basic types of plans that can be chosen and some benefits and pitfalls of each.</span></p> <p class="bodytext"><span style="color: #000000;">On April 27, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/578/the-double-edged-sword-of-discretion-how-even-great-plan-document-language-can-cause-gaps-in-coverage.aspx">“The Double-Edged Sword of Discretion: How Even Great Plan Document Language Can Cause Gaps in Coverage,”</a> <span style="color: #000000;">where our legal team discussed discretion within Plan Documents and stop-loss policies, and how the two interact.</span></p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a><span style="color: #000000;">Podcasts:</span></span></p> <p class="bodytext"><span style="color: #000000;">On June 22, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/598/the-senate-unveils-its-repeal-replace-bill.aspx">“The Senate Unveils its Repeal & Replace Bill,”</a> <span style="color: #000000;">where Sr. Vice President and General Counsel Ron Peck and Attorney Brady Bizarro give their initial thoughts on the Better Care Reconciliation Act.</span></p> <p class="bodytext"><span style="color: #000000;">On June 19, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/595/empowering-plans-segment-10-plan-tales-the-good-bad-and-really-bad.aspx">“Plan Tales: The Good, Bad, and Really Bad,”</a> <span style="color: #000000;">where Adam Russo and Ron Peck interview two key members of The Phia Group’s consulting division – Vice President of Consulting, Attorney Jennifer McCormick, and Product Developer, Kristin Spath.</span></p> <p class="bodytext"><span style="color: #000000;">On June 5, 2017, The Phia Group presented </span><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/592/empowering-plans-segment-09-in-the-land-of-the-blind.aspx">“In the Land of the Blind,”</a> <span style="color: #000000;">where we discussed the assessment of the American Health Care Act (Version 2.0).</span></p> <p class="bodytext"><span style="color: #000000;">On May 22, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/588/empowering-plans-segment-08-healthcares-alternative-provider-payment-programs.aspx">“Healthcares? Alternative Provider Payment Programs,”</a> <span style="color: #000000;">where Adam Russo and Ron Peck discussed movements within the healthcare provider community. </span></p> <p class="bodytext"><span style="color: #000000;">On May 8, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/582/empowering-plans-segment-07-the-american-health-care-act.aspx">“The American Health Care Act,”</a> <span style="color: #000000;">where Adam Russo, Ron Peck, and Brady Bizarro discussed the American Health Care Act, which passed the House of Representatives on 05/04/2017.</span></p> <p class="bodytext"><span style="color: #000000;">On April 25, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/575/empowering-plans-segment-06-an-employer-call-to-action.aspx">“An Employer Call to Action,”</a> <span style="color: #000000;">where our legal team discussed what employers can do to improve their health plan and plan performance.</span></p> <p class="bodytext"> </p> <p class="bodytext"><br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a><span style="color: #000000;">The Phia Group’s 2017 Charity</span></span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group's 2017 charity is the Boys & Girls Club of Brockton. </span></p> <p><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/bandgclub.png" /></p> <p class="bodytext"><span style="color: #000000;">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. </span></p> <p class="bodytext"><span style="color: #000000;">The Boys & Girls Club of Brockton (BGCB) 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. </span></p> <p class="bodytext"><span style="color: #000000;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming. </span></p> <p class="bodytext"><span style="color: #000000;"><strong>Phia's Wiffle Ball Game</strong></span></p> <p><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/wiffle.png" /></span></p> <p class="bodytext"><span style="color: #000000;">On Saturday, June 24th, employees of the Phia Group participated in the 6th Annual John A. Waldron Wiffle Ball Tournament. The tournament honors the late John Waldron, a former member of the Brockton’s Planning Board and Democratic City Committee and a longtime booster for Brockton High School’s sports and clubs. Phia and the 36 teams competing helped raise over $16,000 for local charities, including the Boys and Girls Club of Brockton, TOPSoccer, Frederick Douglass Neighborhood Association, Brockton Hospital Cancer Walk, and more. For more information, visit the</span> <a href="http://www.justcheckingin.org/">John Waldron Wiffleball Tournament website.</a> </p> <p class="bodytext"> </p> <p class="bodytext"><strong><span style="color: #000000;">Monthly Donations From Phia</span></strong></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/donation3.png" /></span></p> <p class="bodytext"><span style="color: #000000;"> </span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group invites its staff to donate various items for the benefit of The Boys and Girls Club of Brockton. For more information or to get involved, visit</span> <a href="http://www.bgcbrockton.org/">www.bgcbrockton.org</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="p9" name="p9"></a><span style="color: #000000;">The Stacks</span></span></p> <p class="bodytext" style="font-weight: bold;"><span style="color: #000000;">A Year Later . . . Montanile Remembered, Lessons Learned</span></p> <p class="bodytext" style="font-weight: normal;"><em><span style="color: #000000;">By: Christopher M. Aguiar, Esq. – April 2017 –</span> </em><a href="https://www.sipconline.net/files/A%20Year%20Later_%20Montanile%20Remembered%2C%20Lessons%20Learned%20by%20Christopher%20M_%20Aguiar%20Esq.pdf">Self-Insurers Publishing Corp.</a></p> <p><span class="bodytext"><br /> <span style="color: #000000;">Things were going so well. In the game of subrogation cases being heard by the Supreme Court of the United States, self-funded benefit plans under the purview of ERISA were on a roll. First, it was <em>Sereboff v. Mid Atlantic Medical Services, Inc.</em>, 547 U.S. 356 (2006), then U.S. Airways v. <em>McCutchen</em>, 133 S. Ct. 1537 (2013). Some even considered <em>Great West Life & Annuity Ins. Co. v. Knudson</em>, 534 U.S. 204 (2002) to have been unfairly viewed as a loss for the subrogation industry because despite a decision against Great West Life, it provided the blue print followed by Mid Atlantic Medical Services, Inc. to elicit the favorable decision that led to the recovery in <em>Sereboff</em>. As is the case in most games, momentum can be lost in the blink an eye.</span></span></p> <p><span class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/602/the-stacks-3rd-quarter-2017.aspx">Click here to read the rest of this article</a></span></p> <p><span class="bodytext"><br /> <strong><span style="color: #000000;">Don’t Let Your LOAs Leave You DOA</span></strong></span><span style="color: #000000;"></span></p> <p class="bodytext" style="font-weight: normal;"><span style="color: #000000;"><em>By: Kelly E. Dempsey, Esq. – May 2017</em> –</span> <a href="https://www.sipconline.net/files/Don't%20Let%20Your%20LOAs%20Leave%20You%20DOA%20by%20Kelly%20E_%20Dempsey.pdf">Self-Insurers Publishing Corp.</a><br />  </p> <p class="bodytext"><span style="color: #000000;">Imagine a scenario where an employer has a long-time reliable employee that suddenly has a stroke of bad luck and is diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. The employee works with a team of medical professionals to come up with a game plan for beating this terrible disease. The employee quickly begins what will hopefully be life-saving treatment as soon as a game plan is mapped out. The claims start rolling in and the treatment starts taking its toll. The employee starts missing an hour here and there for appointments – and then a few hours for appointments and sickness –and then full days of work during treatment. When the employee is at work, the employee struggles to perform normal job functions and the employee is now unable to work because the rigorous chemotherapy regiment. </span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/602/the-stacks-3rd-quarter-2017.aspx">Click here to read the rest of this article. </a></p> <p> </p> <p class="bodytext"><strong><span style="color: #000000;">Air Ambulance: Heads in the Clouds</span></strong></p> <p class="bodytext"><em><span style="color: #000000;">By: Jon A. Jablon, Esq. – June 2017 –</span> </em><a href="https://www.sipconline.net/files/Air%20Ambulance%20Head%20in%20the%20Clouds%20by%20Jon%20A_%20Jablon%2C%20Esq.pdf">Self-Insurers Publishing Corp.</a></p> <p><span class="bodytext"><br /> <span style="color: #000000;">Health plans, third-party administrators, brokers, consultants, and stop-loss carriers are a bit baffled by air ambulance fees. Many are outraged or appalled or disgusted as well – but it seems that the overwhelmingly common feeling is sheer confusion over how this type of billing is permissible.</span></span><strong> </strong></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/602/the-stacks-3rd-quarter-2017.aspx" 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="heading1"><a id="p10" name="p10"></a>Phia’s Q2 Speaking Events:</p> <p class="bodytext"><strong><span style="color: #000000;">Adam Russo’s 2017 Speaking Engagements:</span></strong></p> <p class="bodytext"><span style="color: #000000;">• 4/24/17 - Berkley Captive Symposium – Grand Cayman Islands<br /> “The Best Gets Better – Getting the Most Out of Your Self-Funded Plan”</span></p> <p class="bodytext"><span style="color: #000000;">• 5/4/17 – Benefest – Westborough, MA<br /> “Multiple Personalities – The Biggest Issues Impacting Plans & Employers, and Instances Where They are Their Own Worst Enemy”</span></p> <p class="bodytext"><span style="color: #000000;">• 5/22/17 – United Benefit Advisors (UBA) Spring Conference – Chicago, IL<br /> “The Best Gets Better – Getting the Most Out of Your Self-Funded Plan”</span></p> <p class="bodytext"><span style="color: #000000;">• 6/27/17 – Leavitt Trustee Conference – Big Sky, MT<br /> “The Best Gets Better – Getting the Most Out of Your Self-Funded Plan”</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Ron Peck’s 2017 Speaking Engagements:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 4/3/17 – Eastern Claims Conference (ECC) – Boston, MA<br /> “The Good, The Bad, and The Ugly: Understanding Reference Based Pricing in the Special Risk Market”</span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Tim Callender’s 2017 Speaking Engagements:</span><br /> • 5/4/17 – BevCap Best Practice Workshop – Orlando, FL<br /> “PACE & ICE with a brief political update on repeal and replace”</span></p> <p class="bodytext"><span style="color: #000000;">• 5/22/17 – Group Underwriters Association of America Annual Conference – Denver, CO<br /> “The Future of Health Plans”</span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Jen McCormick's Speaking Engagements:</span><br /> • 5/20/17 – United Benefit Advisors (UBA) Spring Conference – Chicago, IL<br /> “Self-funding and Compliance Issues”<br /> <br /> <span class="boldtext">Brady Bizarro's 2017 Speaking Engagements:</span><br /> • 5/4/17 – BevCap Best Practice Workshop 2017 – Orlando, FL<br /> “Phia's PACE and ICE Services” </span></p> <p class="heading1"><span style="color: #000000;">Phia’s Upcoming Speaking Events</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Adam Russo’s Upcoming Speaking Engagements in 2017:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 7/12/17 – Montana Captive Conference – Whitefish, MT<br /> “High Performing Self-Insured Health Plans – The Key to Successful Stop-loss Captive Programs”</span></p> <p class="bodytext"><span style="color: #000000;">• 8/9/17 – NAHU Region 1 Meeting – Stamford, CT<br /> “The Best gets Better: Getting the Most out of Your Self-Funded Plans”</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Ron Peck’s Upcoming Speaking Engagements in 2017:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 9/19/17 – CIC-DC 2017 Annual Conference – Washington, D.C.<br /> “Cost Containment Strategies” </span></p> <p class="bodytext"><span style="color: #000000;"><strong>Tim Callender’s Upcoming Speaking Egnagements in 2017:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 7/17/17 – Health Care Administrator’s Association TPA Summit – St. Louis, MO<br /> “Conference Emcee”</span></p> <p class="bodytext"><span style="color: #000000;"><strong>Brady Bizarro’s Upcoming Speaking Engagements in 2017:</strong></span></p> <p class="bodytext"><span style="color: #000000;">• 7/18/17 – HCAA TPA Summit 2017 – St. Louis, MO<br /> “Ethics”</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a><span style="color: #000000;">Get to Know Our Employee of the Quarter:<br /> Zachariah John</span></span></p> <p class="bodytext"><span style="color: #000000;">Congratulations to Zachariah John, the Phia Group’s Q2 2017 Employee of the Quarter! </span></p> <p class="bodytext"><span style="color: #000000;">“Zach constantly exhibits great customer service skills and work ethics, with quick responses and delivery on HelpDesk tickets, questions from other employees, and system enhancement builds. He is also incredibly friendly, and always has a great attitude. Even when something cannot be done as specifically desired by a user, Zach finds ways to meet their requirements through other available options and functionalities. He is a true subject matter expert, a great resource of knowledge, and a dedicated employee. There is no question; if Zach were not part of the Phia team, we would be nowhere near where we are now! His assistance and expertise is invaluable.”</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/zach.png" /> </span></p> <p class="bodytext"><span style="color: #000000;">Congratulations Zach and thank you for your many current and future contributions.</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a><span style="color: #000000;">Phia News</span></span></p> <p class="bodytext"><span style="color: #000000;"><strong>Babies </strong></span></p> <p class="bodytext"><span style="color: #000000;">- Diaina Williams gave birth to Hannah on 4/19/2017</span></p> <p class="bodytext"><span style="color: #000000;">- Sabrina Centeio gave birth to Gia on 5/5/2017.</span></p> <p class="bodytext"><span style="color: #000000;">- Shannon Olson gave birth to Shelby Marie on 5/8/2017 </span></p> <p class="bodytext"><span style="color: #000000;">- Lisamarie DeCristoforo gave birth to Kyrie on 6/20/2017</span></p> <p class="bodytext"><span style="color: #000000;">- Boris Senic’s wife gave birth to Matthew Ryan on 6/27/2017 </span></p> <p class="bodytext"><span style="color: #000000;"><strong>Promotions </strong></span></p> <p class="bodytext"><span style="color: #000000;">- Casey Balchunas was promoted from Claim Investigator to Claim Recovery Specialist III </span></p> <p class="bodytext"><span style="color: #000000;">- Lyneka Hubbert was promoted from Claim Recovery Specialist III to Case Analyst </span></p> <p class="bodytext"><span style="color: #000000;"><strong>New Hires</strong></span></p> <p class="bodytext"><span style="color: #000000;">- Maria Sostre was hired as a Case Investigator</span></p> <p class="bodytext"><span style="color: #000000;">- Dante Tylerbest was hired as a Customer Service Representative </span></p> <p class="bodytext"><span style="color: #000000;">- Cori DeCristoforo was hired as a Customer Service Representative</span></p> <p class="bodytext"><span style="color: #000000;">- Elizabeth Pels was hired as a legal assistant</span></p> <p class="bodytext"><span style="color: #000000;">- Shaiti Alavala was hired as an IT Intern</span></p> <p class="bodytext"><span style="color: #000000;">- Robert Balchunas was hired as a PGC Intern</span></p> <p class="bodytext"><span style="color: #000000;">- Abigail Gatanti was hired as a PGC Intern</span></p> <p class="bodytext"><span style="color: #000000;">- Sandra Przychodzki was hired as a PGC Consultant</span></p> <p class="bodytext"><span style="color: #000000;">- Jess Watsky was hired as a PGC Consultant</span></p> <p class="bodytext"><span style="color: #000000;">- Francesca Russo was hired as a Legal Assistant</span></p> <p class="bodytext"><span style="color: #000000;">- Thadeous Washington was hired as a Plan Document Specialist</span></p> <p class="bodytext"><span style="color: #000000;">- Krishna Malyala was hired as an IT Data Architect</span></p> <p class="bodytext"><span style="color: #000000;">- Hannah Sedman was Hired as a Marketing Intern</span></p> <p class="bodytext"><span style="color: #000000;">- Nubian Gamble was hired as a Case Investigator</span></p> <p class="bodytext"><span style="color: #000000;">- Lennon Johnson III was hired as a Case Investigator</span></p> <p class="bodytext"><span style="color: #000000;">- Colin Patzer was hired as a Legal Assistant</span></p> <p class="bodytext"><span style="color: #000000;">- Jiyra Martinez was hired as a Case Analyst</span></p> <p class="bodytext"><span style="color: #000000;"> </span></p> <p class="bodytext"><span style="color: #000000;"><strong>Fun at Phia:</strong></span></p> <p class="bodytext"><span style="color: #000000;">Phia’s Easter Egg Hunt</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/easter.png" /> </span></p> <p class="bodytext"><span style="color: #000000;">Phia's Backyard Barbeque</span></p> <p class="bodytext"><span style="color: #000000;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/bbq.png" /> </span></p> <p class="bodytext"><span style="color: #000000;"></span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext" style="text-align: center;"><img alt="" src="/Portals/phiagroup/Newsletter%20Q2%202017/footerlogo.png" /></p> <p class="bodytext"> </p> <p> </p> <p> </p> </td> </tr> <tr> <td colspan="2" style="background-color: #4a85d3;"> <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> 604Empowering Plans Segment 12 - The Cost of Care https://www.phiagroup.com/Media/Posts/PostId/603/empowering-plans-segment-12-the-cost-of-carePodcastsMon, 10 Jul 2017 15:53:09 GMTThis week, The Phia Group's CEO, Adam Russo and Sr. VP, Ron Peck, interviewed Attorney Jon Jablon - Director of Provider Relations, regarding the seemingly increasing number of excessive charges being billed by providers to health plans, strategies to cut costs, and importantly - ways to work with providers rather than against them, in an effort to implement an arrangement that works for all involved.<br /> <br /> <a href="https://www.youtube.com/watch?v=anIlEdI7Jf4">Click here to open the Podcast!</a>603The Stacks - 3rd Quarter 2017https://www.phiagroup.com/Media/Posts/PostId/602/the-stacks-3rd-quarter-2017NewslettersFri, 07 Jul 2017 20:41:05 GMT<strong>A Year Later . . . Montanile Remembered, Lessons Learned</strong><br /> By:&nbsp; Christopher M. Aguiar, Esq.<br /> <br /> Things were going so well.&nbsp; In the game of subrogation cases being heard by the Supreme Court of the United States, self-funded benefit plans under the purview of ERISA were on a roll.&nbsp; First, it was Sereboff v. Mid Atlantic Medical Services, Inc., 547 U.S. 356 (2006), then U.S. Airways v. McCutchen, 133 S. Ct. 1537 (2013). Some even considered Great West Life &amp; Annuity Ins. Co. v. Knudson, 534 U.S. 204 (2002) to have been unfairly viewed as a loss for the subrogation industry because despite a decision against Great West Life, it provided the blue print followed by Mid Atlantic Medical Services, Inc. to elicit the favorable decision that led to the recovery in Sereboff.&nbsp; As is the case in most games, momentum can be lost in the blink an eye.<br /> <br /> Often times, when the momentum is heavily in one&rsquo;s favor, the successors eventually let their guard down.&nbsp; Enter Montanile v. Board of Trustees of Nat. Elevator Industry Health Benefit Plan, 136 S. Ct. 651 (2016). Montanile was the victim of an accident with a third party who was driving under the influence of alcohol.&nbsp; Montanile&rsquo;s benefit plan paid approximately $120,000 in medical claims arising from the accident.&nbsp; Following the accident, he sued the driver of the vehicle and obtained a settlement in the amount of $500,000.&nbsp; Settlement negotiations between Montanile and the Plan broke down and his attorney warned the Plan that he intended to disburse the funds to Montanile.&nbsp; The Plan did not respond until almost seven months later when it filed a lawsuit in which the Plan argued that even though Mr. Montanile had spent some or all of the settlement funds, the Plan still had a right to the funds.&nbsp; The Supreme Court disagreed, stating that the Plan would have had an equitable right if it had &ldquo;immediately sued to enforce the lien against the settlement fund then in Montanile&rsquo;s possession&rdquo; and that suing Montanile to attempt to attach his general assets was a legal remedy not available to the Plan under ERISA 502(a)(3).&nbsp; Id. at 658.<br /> <br /> Immediately following the period when the Court announced that it would be granting certiorari and hearing arguments in Montanile, subrogation experts rationalized what they had hoped would be the outcome; mainly, that the highest court in the land would not put forth a decision that effectively allowed plan participants to take the money and run &ndash; but we all knew better, and the Court affirmed our fears; that the Plan&rsquo;s equitable remedy may be extinguished when funds are disbursed.<br /> <br /> In the almost fourteen months since Montanile, there has not been much movement.&nbsp; The case has been cited in several briefs and other cases, but there is nothing of a significant nature to report. That said, in the interest of keeping the issue fresh in everyone&rsquo;s mind and not allowing the importance of a benefit plan&rsquo;s third party recovery rights take a back seat, let us take the opportunity to recall the keys to a successful recovery program and some best practices &ndash; many of which have received favorable treatment in the few cases that have addressed the problem created by Montanile.<br /> <br /> <strong>Plan Language<br /> </strong><br /> Perhaps the most important thing to remember is that Montanile did not actually change the law.&nbsp; Plan language continues to be the most important consideration in determining whether a plan has a right to 100% reimbursement.&nbsp; Regardless of whether the funds have been disbursed to the participant and/or whether they have been spent on non-traceable assets, if a plan&rsquo;s language is inadequate, the plan will not be able to enforce its right to a full reimbursement.&nbsp; Montanile did not change the decision in McCutchen, which clearly stated, &ldquo;In a &sect;502(a)(3) action based on an equitable lien by agreement&mdash;like this one&mdash;the ERISA plan&rsquo;s terms govern. Neither general un-just enrichment principles nor specific doctrines reflecting those principles&mdash;such as the double-recovery or common-fund rules invoked by McCutchen&mdash;can override the applicable contract.&rdquo; 133 S. Ct. at 1540.&nbsp; Ensuring your plan&rsquo;s language is as strong as possible remains imperative to maximizing recoveries.<br /> <br /> <strong>Investigation is the Key<br /> </strong><br /> The Supreme Court in Montanile disagreed with the Plan&rsquo;s assertion that its equitable remedy should be enforceable regardless of the whereabouts of the settlement fund and did not appear to have any pity for the burden on the Plan to protect its right.&nbsp; The Court stated:<br /> &hellip; The Board protests that tracking and participating in legal proceedings is hard and costly, and that settlements are often shrouded in secrecy.&nbsp; The facts of this case undercut that argument.&nbsp; The Board had sufficient notice of Montanile&rsquo;s settlement to have taken various steps to preserve those funds.&nbsp; Most notably, when negotiations broke down and Montanile&rsquo;s lawyer expressed his intent to disburse the remaining settlement funds &hellip;unless the Plan objected &hellip;. The Board could have &ndash; but did not - object.&nbsp; Moreover, the Board could have filed suit immediately, rather than waiting half a year.<br /> <br /> Montanile at 662.<br /> <br /> The Court&rsquo;s statements here seem to indicate a pretty clear burden on plans to engage in their own investigations and take any and all steps necessary to protect their interests though it does seem to leave the door open for some flexibility in its decision in a situation where perhaps the facts are different.&nbsp; For example, would the Court have ruled differently if the Plan did not &ldquo;have sufficient notice&rdquo; of Montanile&rsquo;s settlement?&nbsp; This appears to have been the case in AirTran Airways, Inc. v. Elem, 767 F. 3d 1192 (2014).&nbsp;&nbsp; In Elem, the attorney ultimately obtained a settlement of over $500,000 against the responsible driver but told Air Tran that the settlement had been for the insurance policy limit of $25,000.&nbsp; He then inadvertently sent a copy of the $475,000 check of which he had neglected to advise Air Tran. In this case, there appears to have been overt acts to deceive the Plan with regard to the settlement.&nbsp; Would the Court have ruled the same way if faced with these facts? &nbsp;<br /> <br /> Regardless, to avoid situations like this, the Plan MUST HAVE an effective investigation unit.&nbsp; All too often investigations are halted based on an insufficient self-report.&nbsp; Everyone can agree that a participant that falls down the stairs at home does not present a recovery opportunity; but what if that person&rsquo;s &ldquo;home&rdquo; is a rental apartment and the &ldquo;fall down the stairs&rdquo; resulted from a broken stair and faulty railing in the main hallway?&nbsp; If the investigation unit is ill-equipped to ask the right questions or identify when someone is masterfully crafting answers to avoid the question without lying, a plan will miss recovery opportunities.<br /> <br /> <strong>And the Key to Investigation is Data</strong><br /> <br /> A high quality investigation unit is a pivotal part of any recovery process, but access to a plan&rsquo;s data is where it all begins.&nbsp; The Court&rsquo;s decision in Montanile effectively put a ticking clock on a plan&rsquo;s recovery rights.&nbsp; The earlier a plan is involved, the better chance it will have to be aware of potential recovery opportunities and on top of the availability and whereabouts of the potential recovery funds.&nbsp; The most effective way to do that is to both be able to access claims data and also be able to expertly analyze and identify opportunities in the data.&nbsp; When paired with the most cutting edge technology and resources, data can be utilized to find out about recovery opportunities quickly and put a plan in the best position to succeed.<br /> <br /> <strong>Funds Disbursed? &hellip; All May Not Be Lost &hellip;</strong><br /> <br /> Certainly, Montanile threw subrogation professionals a bit of a curveball, but most of us knew this curveball was in the arsenal.&nbsp; Ensuring that you can trace the funds is always the best option; but since Montanile, some courts have reminded us that even if the funds are disbursed, a plan may still have some options.&nbsp; First, the Supreme Court in Montanile held that a plaintiff can &ldquo;enforce an equitable lien only against specifically identified funds that remain in the defendant&rsquo;s possession or against traceable items that the defendant purchased with the funds.... A defendant&rsquo;s expenditure of the entire identifiable fund on non-traceable items ... destroys an equitable lien.&rdquo; Montanile, at 658.&nbsp; For the Plan to lose its right of recovery, the participant must spend the money on items that cannot be traced.&nbsp; So, if the participant purchases a car, property, or asset of some sort, the plan may still be able to enforce its right. <br /> <br /> Further, even if the funds are disbursed, the Plan may have a claim for accounting or disgorgement of profits.&nbsp; In Homampour v. Blue Shield of California Life and Health Insurance Company, the Northern District of California stated the following:<br /> <br /> Montanile does not entirely foreclose plaintiffs' claim. Plaintiffs have not alleged how or from what funds plaintiffs seek to recover disgorgement of profits. It is possible that plaintiffs will present evidence demonstrating that the profits they seek to disgorge are specifically identifiable and within defendants' possession. <br /> <br /> Slip Copy, 2016 WL 4539480 at 8<br /> <br /> Finally, even in a circumstance where a plan&rsquo;s equitable remedy is completely lost, the plan may still have a legal remedy under a breach of contract theory.&nbsp; In Unitedhealth Grp. Inc. v. MacElree Harvey, Ltd.., the U.S. District Court for the Eastern District of Pennsylvania noted that &ldquo;assuming Ms. Neff had at that point already dissipated the settlement recoveries, then, pursuant to Montanile, the Plan could seek legal redress against Ms. Neff for breach of contract.&rdquo; Slip Copy, 2016 WL 4440358 at 7,<br /> <br /> <strong>Conclusion</strong><br /> <br /> Subrogation, like many cost containment options, is complicated.&nbsp; Understanding the legal framework, the differences between the remedies that may be available, the advantages and drawbacks to the different options and utilization of different remedies, and having all the resources to recover effectively can be incredibly burdensome.&nbsp; It requires experience, technical aptitude with data, and access to legal resources necessary to protect the plan&rsquo;s rights.&nbsp;&nbsp; Montanile served as a painful reminder, but all is not lost.&nbsp; A plan can take steps to protect itself, maximize its recovery dollars, and ensure compliance with its fiduciary duty to enforce the terms of the plan and ensure its viability.<br /> <br /> <strong>Don&rsquo;t Let Your LOAs Leave You DOA</strong><br /> By: Kelly E. Dempsey, Esq.<br /> <br /> Imagine a scenario where an employer has a long-time reliable employee that suddenly has a stroke of bad luck and is diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. The employee works with a team of medical professionals to come up with a game plan for beating this terrible disease. The employee quickly begins what will hopefully be life-saving treatment as soon as a game plan is mapped out. The claims start rolling in and the treatment starts taking its toll. The employee starts missing an hour here and there for appointments &ndash; and then a few hours for appointments and sickness &ndash;and then full days of work during treatment. When the employee is at work, the employee struggles to perform normal job functions and the employee is now unable to work because the rigorous chemotherapy regiment. <br /> <br /> The employee decides it&rsquo;s time to take a leave of absence to focus on treatment. To the dismay of the employee, though, the employee doesn&rsquo;t have any additional leave available under The Family and Medical Leave Act (FMLA), since the full allotment of FMLA leave was recently exhausted while the employee and the employee&rsquo;s spouse were finally bringing home their new adopted baby that they had waited so long for. Is this pulling at your heart strings yet? <br /> <br /> The employer recalls that sometime in 2016, the U.S. Equal Employment Opportunity Commission issued guidance on a leave associated with The Americans with Disabilities Act (ADA)<sup>1</sup> . Ah ha! The employer tells the employee they have just the solution &ndash; take a leave under ADA and the employment and leave situation can be re-evaluated in a few months. The employer tells the employee not to worry about anything except becoming cancer-free; the health plan coverage will continue as long as the employee needs it, even though the last of the employee&rsquo;s paid time off is exhausted and no additional FMLA is available. In other words, the employer, via its health plan, is taking care of its employee, as so many employers try so hard to do. The employee is then signed up for the short-term disability policy which will help replace some income during the leave, and the employee is all set &ndash; there is continuing health plan coverage and some income replacement to boot. All is well. <br /> <br /> Fast forward in time. Three months have passed, and the employee is making miraculous recovery. The employee is not ready to come back to work yet, but things are looking up and the employee is respected to return to work at some point in the near future. With the end of the health plan year approaching, the employer is attempting to get its ducks in a row for renewal season, which includes a stop-loss policy renewal. The cancer treatment claims are continuing to roll in and, as expected, the dollars keep adding up &ndash; but unfortunately, as anticipated, stop-loss is going to become a factor before renewal (ugh).<br /> <br /> Claims are filed with the stop-loss carrier and all the typical supporting documents are provided. During the stop-loss carrier&rsquo;s review, the carrier starts scratching its head. This individual has been on a non-FMLA leave of absence for over three months. The health plan document discusses FMLA and COBRA, but no other types of leave. Why was this employee still on the plan? Why was COBRA not offered when plan coverage seems to have terminated? The stop-loss carrier questions the employer and requests additional documentation to support eligibility; the carrier even generously says the employee handbook is acceptable. As everyone knows, the stop-loss policy is underwritten based on the plan document alone; anything contained within the employee handbook is entirely separate from the plan document and the stop-loss underwriting generally won&rsquo;t take into account anything within the employee handbook. The employer thinks &ldquo;boy, am I lucky!&rdquo; *queue the suspenseful music*<br /> <br /> The employer pulls out the employee handbook and skips to page 42 &ndash; Employer Leave Policies. The employer starts reading, &ldquo;In addition to FMLA, employees that have exhausted paid time off and FMLA may be eligible for an additional extended leave of absence; referred to as non-FMLA leave. This non-FMLA leave is created to comply with the ADA&rsquo;s requirement to provide a leave of absence as a reasonable accommodation and will be offered in addition to FMLA. Thus the non-FMLA leave will not run concurrently with FMLA. Additional information regarding how to request this leave and the additional requirements associated with this leave is further detailed herein:&rdquo;<br /> <br /> The employer&rsquo;s wheels start turning: okay, this ADA leave doesn&rsquo;t run concurrently with FMLA &ndash; great, that helps, but where&rsquo;s the part about continuing health plan coverage? That must be in this handbook somewhere. The employer starts frantically turning pages looking for those magical words &ldquo;employees are entitled the health plan benefits during a non-FM LA leave of absence.&rdquo; But alas, no such wording is contained within the 163-page employee handbook.&nbsp; The employer&rsquo;s internal dialogue starts racing. &ldquo;How can this be? We never meant for our employees to be out sick and not have health coverage. Doesn&rsquo;t the ADA say we have to provide coverage to employees while they&rsquo;re out on leave?&rdquo; So you ask, &ldquo;What now?&rdquo; The bottom line is that there is no stop-loss reimbursement for the cancer claims, and quotes for renewal just added a few extra zeros.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;<br /> <br /> No need to review the gory details in depth &ndash; but one can imagine what happened during the plan and stop-loss renewal. The employer&rsquo;s bank account is looking bleak, as are the proposed stop-loss renewal rates. The employer starts shopping other options despite having been with the same stop-loss carrier for years.&nbsp; All the while, the employer just thinks &ldquo;How did I end up here? All I wanted was to take care of my employees and give them the best benefits possible. Where did I go wrong?&rdquo; &nbsp;<br /> <br /> It&rsquo;s intuitive to think that a leave of absence from employment is coupled with a continuation of health plan coverage, especially if the leave is illness related; to the dismay of many, however, a continuation of coverage (other than COBRA) isn&rsquo;t always coupled with a leave of absence. As shown in the scenario above, many employers struggle to align their health plan documents with their employee handbooks (and other internal policies) which subsequently increases the potential for a gap to arise between all the relevant documents. While most federal and state laws do not require a continuation of coverage, employers can choose to provide the benefit of continued coverage &ndash; but if the employer wants to ensure stop-loss reimbursement, the terms of continuation of coverage need to be clearly spelled out not only in the employee handbook, but also in the health plan document. The health plan document is key to showing proof of continued coverage, especially in a situation where stop-loss is relevant. <br /> <br /> Many employers don&rsquo;t even realize they have gaps between their policies and the health plan documents until it&rsquo;s too late. All it takes is one large medical event - a cancer claim, an ESRD diagnosis, premature twins, a transplant &ndash; to discover that the documents the employers has aren&rsquo;t airtight, and may not even align with the employer&rsquo;s intent. <br /> <br /> In summary, most employers need to do some homework. Go back to the office and take a look at the health plan document and the employee handbook. Do the two documents reference the same types of leave? Do the documents clearly indicate when coverage under the health plan is maintained during a leave? Do the terms of these documents meet the intent of the employer? What does the stop-loss policy say about eligibility determinations? Can the handbook be used to document eligibility in the health plan? What (if any) changes need to be made to minimize or eliminate gaps, to the extent possible? <br /> <br /> Don&rsquo;t let large unexpected claims leave you dead on arrival. Do the leg work now, and figure out what needs to be done to avoid being caught by surprise.<br /> <br /> Kelly E. Dempsey is an attorney with The Phia Group. She is one of The Phia Group&rsquo;s consulting attorneys, specializing in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.<br /> <br /> [1] https://www.eeoc.gov/eeoc/publications/ada-leave.cfm<br /> <br /> <strong>Air Ambulance: Heads in the Clouds</strong><br /> By: Jon A. Jablon, Esq.<br /> <br /> Health plans, third-party administrators, brokers, consultants, and stop-loss carriers are a bit baffled by air ambulance fees. Many are outraged or appalled or disgusted as well &ndash; but it seems that the overwhelmingly common feeling is sheer confusion over how this type of billing is permissible. <br /> <br /> In all other markets &ndash; construction, textiles, grocery, you name it &ndash; the ordinary legal doctrine is that if there is no agreed-upon price for the goods or services, the seller may only charge the reasonable, fair market value of the delivered service or item. Admittedly, in most markets, prices are agreed upon beforehand &ndash; but in the long history of business, there have been enough instances of services rendered without agreed-upon pricing that courts have seen fit to devise controls for just those occasions.<br /> <br /> And yet&hellip;air ambulance charges are frequently between 600 and 800 percent of Medicare rates for the same flight &ndash; and sometimes far, far more. In fact, one recently crossed my desk billed at over 2,600% of Medicare rates. That&rsquo;s right &ndash; a whopping twenty-six times what Medicare would have paid for the same flight.<br /> <br /> The disclaimer is that Medicare rates are not directly relevant to these flights, but instead used as a benchmark to inform what might be the fair market value, since unfortunately there isn&rsquo;t much else to go on. Unlike many other medical providers, though, there seems to be a trend in the air ambulance billing industry where balance-billing is the norm, and many air ambulance providers have the devil-may-care willingness to bill patients which triggers the outrage and disgust that so often has health plans paying upwards of 90% of egregious balances to protect their patients. <br /> <br /> Add to the egregious billing the notion that many flights are not medically necessary or otherwise appropriate to begin with, and it becomes clear that we have a problem on our hands.<br /> <br /> At Northshore International Insurance Services, Inc.&rsquo;s 26th Annual Medical Excess Claims Conference regarding Air Ambulance Claim Cost Containment Strategies, Jeff Frazier &ndash; a partner at Sentinel Air Medical Alliance, a firm specializing in curbing air ambulance costs &ndash; answered quite a few questions, including the following<sup>2</sup> :<br /> <br /> Question: Why is air ambulance ordered for someone who does not really need the service?<br /> <br /> Answer: About 20% of the patients using air ambulance services really need the service. In a lot of cases, patients are not transported to the nearest hospital due to overflight or relationships between the facility and the air ambulance provider.<br /> <br /> Question: How do you determine medical necessity?<br /> <br /> Answer: Review of transport notes or ambulance run reports primarily to determine medical necessity. Sometimes notes from the hospital are also reviewed.<br /> <br /> Question: Why do payors cave?<br /> <br /> Answer: Fear of the provider balance due billing the patient.<br /> <br /> Balance-billing is a major concern of all benefit plans that pay benefits at an amount not tethered to billed charges, which is an increasing trend. If not for balance-billing, it seems likely that all plans would pay objectively reasonable rates rather than percentages of billed charges.<br /> <br /> <strong>&ldquo;Taking Patients for a Ride&rdquo; Article</strong><br /> <br /> A recent (April 6, 2017) Consumer Reports article penned by Donna Rosato &ndash; entitled &ldquo;Air Ambulances: Taking Patients for a Ride<sup>3</sup> &rdquo; &ndash; highlights some real-life scenarios in which air ambulance billing practices have proven to be, in a word, abusive. Aside from citing two separate sources quoting the average air ambulance flight at about $7,000 and about $10,000, the article notes that:<br /> <br /> Rick Sherlock, president and CEO of the Association of Air Medical Services, a trade group, says that many air-ambulance patients are on Medicare or Medicaid, and that those programs pay $200 to $6,000 per transport. So, Sherlock says, air-ambulance operators must collect more from people with private insurance to make up the difference.<br /> <br /> It should be questioned how equitable or ethical it is to jack up prices for one consumer because the provider has chosen to accept less money for another consumer. An air ambulance provider can always refuse to contract with CMS and choose to not accept Medicare or Medicaid &ndash; so to complain about not being paid enough seems a bit petulant.<br /> <br /> <strong>Airline Deregulation Act<br /> </strong><br /> Further challenges are presented by the Airline Deregulation Act of 1978. Through this federal law, states are prohibited from regulating non-hospital affiliated air ambulance providers. That is, this law does not apply to the University of Whatever Health System&rsquo;s own proprietary air ambulance services, since those are considered to be an &ldquo;extension&rdquo; of emergency services as opposed to a separate air ambulance provider &ndash; but the law does apply to FlyingAirTaxiMedicalAmbulance Co., Inc., since it is independent of an emergency room and is its own &ldquo;carrier.&rdquo;<br /> <br /> Through the years there have been proposed changes to the federal Act to account for the disastrous effects it has on air ambulance consumers and health plans, but we&rsquo;re not quite there yet.<br /> <br /> Interestingly, many air ambulance carriers have resorted to quoting the Act when attempting to justify their billing &ndash; or at least when attempting to refute reasonable settlement requests. It seems that the most prevalent argument is against any notion of fair market value; the fact that state law is preempted with respect to air ambulance billing practices is cited as the reason that fair market value is not relevant to the carrier&rsquo;s billing. But, although rooted in state contract law, is it reasonable to suggest that an implied contract for services is &ldquo;state law,&rdquo; sufficient to be preempted or overridden by the federal Airline Deregulation Act?<br /> <br /> In other words, while the federal Act may supersede state laws aimed at regulating air ambulance providers (and others), the concept of fair market value is implicit in the non-contracted nature of air ambulance services. The issue is not one of some state law attempting to regulate air ambulances; fair market value has to do with the open market and general principles of contract rather than some particular state law. <br /> <br /> The Airline Deregulation Act does not set a price or indicate what might be appropriate value. Instead, it dictates that individual states cannot pass laws to regulate the price of these flights. Fair market value is a general principal of contracting rather than some statutory price control, though; air ambulances are free to provide quotes up-front, but in most cases that is either not feasible or just not done. It seems that the general and basic principal of fair market value would still apply when no price is quoted or agreed-upon. The Airline Deregulation Act, after all, was passed to promote a free market economy rather than restrict it. It hardly serves to promote a free market when medical providers can gouge payors without warning.<br /> <br /> One could even contend, somewhat ironically, that demanding surprise payment at an amount far in excess of the fair market value frustrates the very purpose of the same Airline Deregulation Act that these providers rely on to defend their charges.<br /> <br /> <strong>Contract? What Contract?</strong><br /> <br /> Here&rsquo;s where things get even more interesting. Independent air ambulance providers tend to be universally out-of-network. There are a couple of exceptions, but in general, it is near impossible to find an air ambulance provider (unrelated to a hospital) that has contracted with a PPO network to accept discounted fees &ndash; primarily due to the belief that the Act guarantees them their full billed charges no matter what, and that there&rsquo;s no reason to join a network and accept discounted charges.<br /> <br /> Regardless of that belief, another question worthy of consideration is whether the out-of-network flights can truly be considered non-contracted. Contracts are a funny thing and they come in many forms; while there is no contract to pay a certain specified rate or percentage of billed charges &ndash; indeed, a claim that would generally be considered a &ldquo;contracted claim&rdquo; &ndash; consider that the patient (if conscious and competent) almost always signs the provider&rsquo;s &ldquo;assignment of benefits&rdquo; form. On that form, the patient says &ldquo;if my insurance doesn&rsquo;t pay you, in full, 100% of your bill, then I, the patient, agree to be responsible for the remainder.&rdquo;<br /> <br /> For some bizarre reason, courts in this country have indicated that the patient&rsquo;s agreement to pay some unspecified amount supersedes any ordinary market properties. If the patient weren&rsquo;t a patient but a homeowner, and a painter said &ldquo;you will pay me what I bill you for this job&rdquo; and the homeowner agreed, courts have always opined that while the consumer is of course responsible to compensate the painter for its service, the painter is responsible for billing only that which is reasonable &ndash; measured as the fair market value of the services. In the medical industry, though, there are very few (and largely ineffectual) statutory or common law pricing controls. Even the simplistic concept of fair market value, which is perhaps the most basic of all pricing principles, does not apply in ordinary cases. It goes without saying that this needs to be fixed.<br /> <br /> <strong>What Can You Do?</strong><br /> <br /> Whoever you are &ndash; whether a health plan sponsor, third-party administrator, broker, MGU, reinsurer, or anyone else working in the self-funded industry &ndash; air ambulance charges are worrisome. If they don&rsquo;t concern you&hellip;they should. <br /> <br /> Negotiating claims can be an option, as is the case with other out-of-network medical claims, and there are also other, more novel solutions out there in the marketplace. <br /> <br /> Just as programs have developed to assist payors in reducing dialysis billed charges, so are there companies and services that are specifically geared toward controlling air ambulance charges. Specialists in this field can provide assistance from a regulatory and financial standpoint &ndash; and ensuring proper utilization is also crucial to ensuring that payors are not gouged.<br /> <br /> We urge payors to discuss options with a broker or consultant and ask about some of the solutions out there that have helped save health plans countless dollars of unreasonable and unnecessary air ambulance exposure. <br /> <br /> About the Author<br /> <br /> Attorney Jon Jablon joined The Phia Group&rsquo;s legal team in 2013. Since then, he has distinguished himself as an expert in various topics, including stop-loss and PPO networks, focusing on dispute resolution and best practices. In 2016, Jon assumed the role of Director of The Phia Group&rsquo;s Provider Relations department, which focuses on all things having to do with medical providers &ndash; including balance-billing, claims negotiation, PPO and provider disputes, general consulting, and more.<br /> <br /> <br /> [2]&nbsp;http://www.niis.com/2015Conference/Air%20Ambulance%20Claim%20Cost%20Containment%20Strategies.pdf<br /> <br /> [3] http://www.consumerreports.org/medical-transportation/air-ambulances-taking-patients-for-a-ride<br />602Empowering Plans Segment 11 - The Senate Unveils its Repeal & Replace Billhttps://www.phiagroup.com/Media/Posts/PostId/598/the-senate-unveils-its-repeal-replace-billPodcastsThu, 22 Jun 2017 20:29:03 GMTIn this special edition of the Empowering Plans podcast, Sr. Vice President and General Counsel Ron Peck and Attorney Brady Bizarro give their initial thoughts on the Better Care Reconciliation Act. What is in this new bill? What does it mean for the self-funded industry? What is next for healthcare reform?<br /> <br /> <a href="/Portals/phiagroup/June 2017 Webinar/Emergency Episode_01.mp3">Click here to open the podcast!</a>598A Network by any Other Namehttps://www.phiagroup.com/Media/Posts/PostId/597/a-network-by-any-other-nameWebinarsThu, 22 Jun 2017 18:35:38 GMT<p>PPOs, EPOs, HMOs… The days of simple network categories is past.  Today, innovative providers are offering up-front transparent pricing, subscription-based direct primary care (DPC), value based pricing, ACOs, medical tourism, international prescription plans, on-site clinics, telemedicine and direct contracting with “centers of excellence.”<br /> <br /> Thank you for joining The Phia Group’s legal team on Thursday, June 22, as they discussed what a health plan needs to do to ensure the plan document supports the chosen methodology, which contracts and arrangements an employer needs to analyze to avoid conflict, and more.<br /> <br /> <a href="/Portals/phiagroup/June 2017 Webinar/A Network by Any Other Name Video.mp4">Click Here to Download our Full Webinar</a><br /> <a href="/Portals/phiagroup/June 2017 Webinar/A_Network_by_Any_Other_Name_Video.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 597Empowering Plans Segment 10 - Plan Tales: The Good, Bad, and Really Badhttps://www.phiagroup.com/Media/Posts/PostId/595/empowering-plans-segment-10-plan-tales-the-good-bad-and-really-badPodcastsMon, 19 Jun 2017 21:10:35 GMTIn this episode, Adam Russo and Ron Peck interview two key members of The Phia Group&rsquo;s consulting division &ndash; Vice President of Consulting, Attorney Jennifer McCormick, and Product Developer, Kristin Spath. These two have tales to tell, regarding their experiences helping clients with unusual questions, and transforming outlandish ideas into real benefit plan innovations.<br /> <br /> <a href="https://www.youtube.com/watch?v=MjS3G9yu2Rk">Click here to open the podcast!</a>595Empowering Plans Segment 09 - In the Land of the Blindhttps://www.phiagroup.com/Media/Posts/PostId/592/empowering-plans-segment-09-in-the-land-of-the-blindPodcastsMon, 12 Jun 2017 17:22:13 GMTWho will and who won't get (or lose) health insurance coverage under the AHCA? Join The Phia Group's CEO, Adam V. Russo, Sr. VP, Ron E. Peck, and Attorney Brady Bizarro as they discuss the most recent report by the Congressional Budget Office (CBO) on the new Republican health care bill. Despite the debate in Washington, people are still missing the point: affordable health insurance is not affordable health care.<br /> <br /> <a href="https://www.youtube.com/watch?v=befwtzVhjok">Click here to open the Podcast!</a><br /> <br />592Empowering Plans Segment 08 - Healthcares? Alternative Provider Payment Programshttps://www.phiagroup.com/Media/Posts/PostId/588/empowering-plans-segment-08-healthcares-alternative-provider-payment-programsPodcastsMon, 22 May 2017 15:11:49 GMTThe Phia Group&rsquo;s CEO, Adam Russo, and Sr. VP &amp; General Counsel, Ron Peck, discuss movements within the healthcare provider community to change how they charge (and receive payment) for services rendered.&nbsp; For better or worse, change is on the way!<br /> <a href="https://www.youtube.com/watch?v=G5wmAqCQWt0"><br /> Click here to open the Podcast!</a>588Keeping PACE with Appeals, Trends and Fiduciary Responsibilityhttps://www.phiagroup.com/Media/Posts/PostId/587/keeping-pace-with-appeals-trends-and-fiduciary-responsibilitywebinar Mon, 22 May 2017 14:01:57 GMTAs TPAs, consultants, and Plan Sponsors utilizing The Phia Group's Plan Appointed Claim Evaluator service, you are entitled to exclusive educational material. Join The Phia Group's PACE legal team as they provide insight drawn from within the past 2 years of the PACE service.<br /> <br /> During this webinar, you will be provided an insider's view into the latest health plan appeals trends, plan document best practices related to appeals and fiduciary concerns, as well as an update on the current, fiduciary landscape.<br /> <br /> <a href="/Portals/phiagroup/Keeping PACE With Appeals_ Trends and Fiduciary Responsibility .mp4">Download our PACE Webinar!</a>587Decisions, Decisions: Which Plan Types Work Best for Which Groups, and Why?https://www.phiagroup.com/Media/Posts/PostId/585/decisions-decisions-which-plan-types-work-best-for-which-groups-and-whyWebinarsTue, 16 May 2017 21:28:33 GMT<p>Between a traditional PPO plan, a MEC or “skinny” plan, reference-based pricing, narrow network, cafeteria plan, or high-deductible health plan, who can choose? They all have their nuances, and which plan type is best for a given plan sponsor will depend on factors including risk tolerance, geographical location, employee base, and more.<br /> <br /> Thank you for joining The Phia Group’s legal team on Tuesday, May 16, as they discussed the different plan options available to plan sponsors these days – including benefits, dangers, best practices, stop-loss and network considerations, and the future.<br /> <br /> <a href="/Portals/phiagroup/webinars/May2017/Decisions_ Decisions_ Which Plan Types Work Best for Which Groups_ and Why_.mp4">Click Here to Download our Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/May2017/Decisions_Decisions_Which_Plan_Types_Work_Best_for.mp3">Click Here to Download Webinar Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 585Empowering Plans Segment 07 - The American Health Care Acthttps://www.phiagroup.com/Media/Posts/PostId/582/empowering-plans-segment-07-the-american-health-care-actPodcastsTue, 09 May 2017 13:44:32 GMTRepeal and replace, the ACA, the AHCA - what does it all mean? How does it affect us? What&rsquo;s next? Join The Phia Group's CEO, Adam V. Russo, Sr. VP, Ron E. Peck, and Attorney Brady Bizarro as they discuss the American Health Care Act, which passed the House of Representatives on 05/04/2017.<br /> <br /> <a href="https://www.youtube.com/watch?v=EMrWcxfB8NU">Click here to open the Podcast!</a>582The Double-Edged Sword of Discretion: How Even Great Plan Document Language Can Cause Gaps in Coveragehttps://www.phiagroup.com/Media/Posts/PostId/578/the-double-edged-sword-of-discretion-how-even-great-plan-document-language-can-cause-gaps-in-coverageWebinarsThu, 27 Apr 2017 19:54:17 GMT<p>Nearly all Plan Documents have some mention of discretionary authority. The ability to interpret the terms of the plan is necessary to receive deference from the courts, and is needed since not every conceivable scenario can be planned for within the plan document. When it comes to stop-loss, however, open-ended discretion can be a deal-breaker. Particular areas of concern include definitions of Usual and Customary, Medical Necessity, and Experimental/Investigational – and gaps between the Plan Document and the employee handbook are more and more prevalent. When an employer, seeking to exercise blanket discretionary authority, offers to extend coverage to employees on leave, despite the plan document clearly ending coverage well before then, that discretionary authority begins to seem arbitrary and capricious.<br /> <br /> Thank you for joining The Phia Group's legal team on April 27, 2017, as they analyzed some of the pros and cons of discretion, what can be done to avoid these difficult situations, and some changes we have made to our own health plan to fix the same issues for our own organization and users of our plan document template.<br /> <br /> <a href="/Portals/phiagroup/webinars/April 2017/The Double-Edged Sword of Discretion_ How Even Great Plan Document Language Can Cause Gaps in Coverage.mp4">Click Here to Download Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/April 2017/The_Double-Edged_Sword_of_Discretion_How_Even_Grea.mp3">Click Here to Download Audio Only</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 578Empowering Plans Segment 06 - An Employer Call to Actionhttps://www.phiagroup.com/Media/Posts/PostId/575/empowering-plans-segment-06-an-employer-call-to-actionPodcastsTue, 25 Apr 2017 17:04:01 GMTA podcast dedicated to employers. Our goal is to show employers what they can do to improve their health plan and plan performance, without relying on third parties. It&rsquo;s time for employers to get into the game!<br /> <br /> <a href="https://www.youtube.com/watch?v=tz8Tf3ql30s">Click here to open the Podcast!</a>575The Phia Group's 2nd Quarter 2017 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/573/the-phia-groups-2nd-quarter-2017-newsletterNewslettersFri, 21 Apr 2017 20:44:49 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: #FFF; } 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 colspan="2" style="background-color: #4a85d3;"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext" style="text-align: right; background-color: #4a85d3;" valign="bottom"> <p>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 alt="" height="303" src="/Portals/phiagroup/Newsletter%20Q2%202017/mainimage.jpg" width="667" /></td> </tr> <tr> <td colspan="2"><img alt="" height="152" src="/Portals/phiagroup/Newsletter%20Q2%202017/phia_icons.png" width="650" /></td> </tr> <tr> <td style="width: 312px;" valign="top"><a href="https://www.phiagroup.com/LinkClick.aspx?fileticket=GzQu8IJg5GM=&portalid=586" target="_blank"><img alt="" height="216" src="/Portals/phiagroup/Newsletter%20Q2%202017/b1.png" width="325" /></a></td> <td style="width: 323px;" valign="top"><a href="https://www.phiagroup.com/Portals/phiagroup/Flyers/FlagshipFlier_02-07-17.pdf" target="_blank"><img alt="" height="216" src="/Portals/phiagroup/Newsletter%20Q2%202017/b2.png" width="325" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> <tbody> <tr> <td style="width: 51%;" valign="middle"><img alt="" height="341" src="/Portals/phiagroup/Newsletter%20Q2%202017/adam.jpg" width="323" /></td> <td style="width: 49%;" valign="top"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold; color: #000000;"><br /> The Book of Russo:<br /> From the Desk of the CEO</span></p> <p class="bodytext"><span style="color: #000000;">Happy spring to all of you. This is my favorite time of the year as baseball begins, the kids can run outside here in Boston, and I get some sanity by enjoying the weather. At The Phia Group, it's no different. This is the time of year when it's truly heating up from a cost containment and consulting level. Brokers, employers, stop loss carriers and administrators are starting to see outrageous claim charges from the first quarter and reaching out to us for assistance. The bottom line is that we are here to empower you and your plans. I urge you to check out the case study from our unwrapped service, as well as the amazing initiative we have put together from a social media aspect. We decided this year to not only offer industry leading webinars, but also to expand our voice though shorter podcasts and intuitive blog posts.</span></p> </td> </tr> <tr> <td colspan="2" valign="top"><span class="bodytext" style="color: #000000;">We are here to make this industry better for everyone, by doing what we can to lower the overall cost of care. I love this fight, and we here at The Phia Group are passionate about this goal and our overall mission. Thank you for believing in us and reaching out. Happy reading.</span><br />  </td> </tr> </tbody> </table> </td> </tr> <tr> <td class="toc" colspan="2" style="background-color: #eeeeee;" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p class="tocbkgd"><a id="top" name="top"></a><img alt="" height="24" src="/Portals/phiagroup/Newsletter%20Q2%202017/inthisissue.png" width="137" /><br /> <br /> <a class="toc" href="#p1">Phia Group Case Study: Handbook, Schmandbook</a><br /> <a href="#p2">Service Highlight of the Quarter: Phia Unwrapped</a><br /> <a href="#p3">Fiduciary Burden of the Quarter: Strictly Abiding by the Terms of the Plan Document</a><br /> <a href="#p4">New Services Announcement: The Phia Group: Catering to More of Your Needs</a><br /> <a href="#p5">From the Blogosphere</a><br /> <a href="#p6">Webinars</a><br /> <a href="#p7">Podcasts</a><br /> <a href="#p8">The Phia Group’s 2017 Charity</a><br /> <a href="#p9">The Stacks</a><br /> <a href="#p10">Phia’s Speaking Events</a><br /> <a href="#p11">Employee of the Quarter</a><br /> <a href="#p12">Phia News </a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><a id="p1" name="p1"></a><span style="color: #000000;"><br /> Phia Group Case Study: Handbook, Schmandbook</span></p> <p class="bodytext"><span style="color: #000000;">A client of The Phia Group faced a situation in which the group’s Plan Document referenced an extension of coverage for up to 24 months for participants unable to actively work due to disability. To contrast, the employer’s Employee Handbook referenced an extension of coverage for up to 36 months, or longer if deemed appropriate by the employer. The group’s stop-loss policy provided coverage only for the length of time dictated by the plan document (24 months).</span></p> <p class="bodytext"><span style="color: #000000;">The health plan’s broker referred the Plan Document and stop-loss policy to The Phia Group’s consulting team to perform a Gap-Free Analysis. As part of this analysis, it was discovered that the Plan Document’s leave provisions did not align with those in the stop-loss policy. The Phia Group’s team also included a note to ensure that if the Plan Document was changed, the Employee Handbook may need to be changed to align as well. Upon receiving the Gap-Free Analysis, the group’s broker asked The Phia Group to review the Employee Handbook and make whatever changes were necessary for the documents to align; upon review, the additional discrepancy was discovered and remedied.</span></p> <p class="bodytext"><span style="color: #000000;">Three months later, after the Plan Document and Employee Handbook were amended to alleviate the gaps in coverage, a member requested 18 months of leave from the employer. The employer was free to grant the leave based on other terms in the Employee Handbook, but the employee was informed that after twelve months, coverage under the Plan would terminate. As luck would have it, during the fifteenth month of the employee’s leave, she incurred significant medical claims that, if paid by the Plan pursuant to its former language, would have been denied by stop-loss. By addressing gaps in coverage, the Plan successfully avoided a large stop-loss denial.</span></p> <p class="heading1"><span style="color: #000000;"><a id="p2" name="p2"></a><br /> Service Highlight of the Quarter: Phia Unwrapped</span></p> <p class="bodytext"><span style="color: #000000;">In the past, wrap networks provided a great amount of value to health plans. They effectively enlarged the plan’s primary network, somewhat like being able to utilize T-Mobile’s cell phone towers when out of AT&T range. The old theory, however, no longer holds true. Just as primary networks add less and less value as the magnitude of medical bills increase dramatically and arbitrarily, so to have wrap networks become more cumbersome than they are valuable.</span></p> <p class="bodytext"><span style="color: #000000;">Phia Unwrapped is designed as a replacement for non-contracted claims – whether they would normally be subject to a wrap network or treated as out-of-network. Phia Unwrapped is a way of keeping the plan’s primary network as always, but ensuring that all other claims are repriced accurately and responsibly, that patients have an advocate to help them through any potential balance-billing, and that the plan has experienced legal and negotiation support on the back end to secure the best possible outcomes.</span></p> <p class="bodytext"><span style="color: #000000;">In the Plan year 2014-2015, an 1,100 life Employer Group had 32% combined “savings” from their out-of-area wrap PPO program and out-of-network claim “solutions.”  Dissatisfied with these so called solutions and hearing about the strategic merits of reference based pricing (RBP) the employer switched to Phia Unwrapped. This switch allowed the group to pay a reasonable amount on claims while also providing support for members to make sure they were not caught in the crossfire with a provider attempting to collect abusive charges. </span></p> <p class="bodytext"><span style="color: #000000;">The results? In the Plan year 2015-2016, the employer had 74% savings paying 140% of Medicare, totaling an additional $2.8 Million in savings compared to traditional solutions.  Though the employer was initially concerned about “noise” from the members (who to this point only had out of pocket differentials for going out of network), Phia's industry leading balance billing support managed by Attorneys ensured that there was minimal member disruption (2%).  </span></p> <p class="bodytext"><span style="color: #000000;">What does “disruption” look like?<br /> <br /> The group had an out-of-network emergency trauma claim, which was billed at $241,000.  Upon receipt of the out-of-network claim, the pre-setup EDI feed sent the claim to Payer Compass for re-pricing, pursuant to the Phia Unwrapped program. The third-party administrator subsequently received pricing back from Payer Compass; the Plan’s language – which specified payment at 140% of Medicare – allowed a little over $81,000. In accordance with the Phia Unwrapped service, the claims administrator paid the claim at the allowed amount. </span></p> <p class="bodytext"><span style="color: #000000;">Three months later the hospital balance billed the patient, at which point the patient spoke to Payer Compass and The Phia Group, clearly concerned about the balance billing. After a few rounds of back-and-forth with the hospital, the bill was escalated to The Phia Group’s Provider Relations department, which had been authorized to negotiate on the Plan's behalf. After a series of lengthy negotiations, which included email and phone correspondence with the hospital CFO, The Phia Group and the hospital reached an agreement to settle the claims for a total payment of 175% of Medicare, yielding significant savings from billed charges. These savings proved to be much higher than the 20% discount that the Plan would have realized if it still used the wrap network. </span></p> <p class="bodytext"><span style="color: #000000;">In the next billing cycle, The Phia Group reimbursed the difference between what it had originally billed as its fee and what it now billed for the final savings:</span></p> <table border="0" cellpadding="0" cellspacing="0" width="100%"> <tbody> <tr> <td style="width: 45%;"><span class="bodytext" style="color: #000000;">Plan Exposure:                                             <br /> Final Payment:                                             <br /> Phia Intervention Saved:   </span></td> <td style="width: 55%;"><span class="bodytext" style="color: #000000;">$241,000<br /> $101,000<br /> $140,000</span></td> </tr> </tbody> </table> <p class="bodytext"><span style="color: #000000;"><br /> Whatever your out-of-network volume, Phia Unwrapped is the solution you have been waiting for.</span></p> <p class="heading1"><span style="color: #000000;"><a id="p3" name="p3"></a><br /> Fiduciary Burden of the Quarter: Strictly Abiding by the Terms of the Plan Document</span></p> <p class="bodytext"><span style="color: #000000;">ERISA is very clear that the Plan Administrator is required to administer benefits strictly in accordance with the terms of the applicable plan document. Plan Administrators, though, are often faced with difficult situations – situations where paying a claim that might otherwise be excluded under the plan document would avoid considerable headache, appease a member of the C-suite, or more accurately reflect what the drafter of the plan document intended, even if the language does not provide for that outcome.</span></p> <p class="bodytext"><span style="color: #000000;">We at The Phia Group have been presented with many situations in which the plan document says one thing, but the Plan Administrator wants to do another. Our advice is always the same – be careful and mind your fiduciary duties – but at the end of the day, the Plan Administrator is the decision-maker and should do what it feels is appropriate, being mindful that stop-loss will likely not be quite so sympathetic to the Plan Administrator’s deviation from the terms of the plan document.</span></p> <p class="bodytext"><span style="color: #000000;">One such example came in the form of a particular plan working to administer an exclusion for illegal acts. A twelve-year-old plan participant committed an illegal act, according to the plan document, when the child inadvertently drove an ATV on a public road in a jurisdiction that considers it a crime to ride an ATV on that road. In the next county over, this would not have been a crime – and the child reportedly was not aware that he had entered a jurisdiction where his actions were a crime. There was an ATV crash, and claims were incurred. Upon being presented with claims related to the accident, the plan’s TPA read the language of the plan document, analyzed the facts of the case, and came to the conclusion that the claims should be denied. Since these were not claims that were doubtful or disputed, the TPA rendered the determination without the need for any discretion.</span></p> <p class="bodytext"><span style="color: #000000;">Upon discovering the denial, the group was not happy. According to the group, it never intended for its “illegal acts” exclusion to apply to a twelve-year-old on an ATV; this, according to the Plan Administrator, was a simple mistake on the part of the child, who was not aware what he was doing was illegal. The Plan Administrator was eager to overturn the denial to effect what it considered its real intent – which was to punish acts committed by adults, with knowledge of the illegality of their actions.</span></p> <p class="bodytext"><span style="color: #000000;">Is it appropriate to read such an exception into the terms of the plan document? If the plan document says “illegal acts” but the Plan Administrator wants to apply the exclusion to some illegal acts but not others depending on the circumstances, it creates a potential problem in that the Plan Administrator has failed to strictly abide by the terms of the plan document. This means the plan document has been administered inconsistently.</span></p> <p class="bodytext"><span style="color: #000000;">Practically speaking, do people usually complain about claims being paid? Of course not. But legally speaking, is the Plan Administrator permitted to create exceptions to unambiguous language on a case-by-case basis? Not according to ERISA. Violating fiduciary duties is a problem – especially in light of the Department of Labor getting stricter about audits whenever there is even a hint of impropriety. It is not likely that anyone would report this fiduciary violation – but that does not mean it is a good idea to violate the fiduciary duty to begin with. The Phia Group’s attorneys will attest to the notion that a low likelihood of punishment for a fiduciary violation is neither an excuse nor a good reason to commit the violation.</span></p> <p class="bodytext"><span style="color: #000000;">As mentioned above, the stop-loss carrier would likely not be pleased about the Plan Administrator’s determination either. If the Plan Administrator wants the language changed, the Plan Sponsor should effect an amendment – but as far as stop-loss is concerned, the plan document has been underwritten as-is and a claim, such as this one, should be denied by the Plan. As we have all seen first-hand, when a stop-loss carrier receives a claim for reimbursement that should not have been paid by the<br /> Plan in the first place…well…let’s just say it’s not an ideal situation.</span><br />  </p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p4" name="p4"></a><span style="color: #000000;">New Services Announcement: The Phia Group: Catering to More of Your Needs</span></span></p> <p class="bodytext"><a href="https://www.phiagroup.com/LinkClick.aspx?fileticket=GzQu8IJg5GM=&portalid=586" target="_blank">Leave of Absence Review</a><span style="color: #000000;"> – </span><span style="color: #000000;">With The Phia Group’s Leave of Absence Review, employee handbooks, health benefit plan documents, and stop-loss policies align, all while remaining compliant with applicable law.</span> <a href="https://www.phiagroup.com/LinkClick.aspx?fileticket=GzQu8IJg5GM=&portalid=586" target="_blank">Click here to learn more!</a></p> <p class="bodytext"><a href="https://www.phiagroup.com/Portals/phiagroup/Flyers/FlagshipFlier_02-07-17.pdf" target="_blank">Flagship Plan Document</a><span style="color: #000000;"> – </span><span style="color: #000000;">With The Phia Group’s Flagship Plan Document, clients can enjoy speedy & efficient production of best-in-class plan documents, with minimal time or monetary investment.</span> <a href="https://www.phiagroup.com/Portals/phiagroup/Flyers/FlagshipFlier_02-07-17.pdf" target="_blank">Click here to learn more!</a></p> <p class="bodytext"><span style="color: #000000;">If you would like to speak with one of our specialists regarding the new services we offer, please feel free to contact us at</span> <a href="mailto:info@phiagroup.com">info@phiagroup.com</a> <span style="color: #000000;">so we can schedule a call. </span></p> <p class="bodytext"><a href="#top">Back to top ^</a><br />  </p> <hr class="horiz" /> <p class="heading1"><a id="p5" name="p5"></a><span style="color: #000000;">From the Blogosphere</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/556/aca-to-ahca-a-look-back-on-the-past-7-years.aspx" target="_blank">ACA to AHCA… A Look Back on the Past 7 Years.</a> <span style="color: #000000;">Seven years in the making.</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/558/health-insurance-is-not-health-care.aspx" target="_blank">Health Insurance is NOT Health Care.</a> <span style="color: #000000;">Sit back, relax and enjoy Ron Peck’s metaphors.</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/564/us-airways-v-mccutchen-where-are-they-now.aspx" target="_blank">U.S. Airways v. McCutchen – Where Are They Now?</a> <span style="color: #000000;">It seems like it was just yesterday.</span></p> <p class="bodytext"><span style="color: #000000;">•</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/480//the-guilty-shall-remain-nameless-yet-i-shall-shame-them-again.aspx" target="_blank">The Guilty Shall Remain Nameless - Yet I Shall Shame Them… Again.</a> <span style="color: #000000;">Quote: “Yes… Is there someone else here I can talk to?”</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p6" name="p6"></a><span style="color: #000000;">Webinars</span></span></p> <p class="bodytext"><span style="color: #000000;"><strong>The Double-Edged Sword of Discretion: How Even Great Plan Document Language Can Cause Gaps in Coverage</strong></span></p> <p class="bodytext"><span style="color: #000000;">On April 27, 2017, The Phia Group will present “The Double-Edged Sword of Discretion: How Even Great Plan Document Language Can Cause Gaps in Coverage.”</span></p> <p class="bodytext" style="font-size: 18px; text-align: center; color: #003399;"><a href="https://attendee.gotowebinar.com/register/3676823339912899841" target="_blank">Click HERE to Register!</a></p> <p class="bodytext"><span style="color: #000000;">On March 23, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/560/medical-bill-blues-pre-payment-contracting-and-negotiation-pricing-alternatives-and-post-payment-recovery-of-overpayments.aspx" target="_blank">“Medical Bill Blues: Pre-Payment Contracting and Negotiation, Pricing Alternatives, and Post-Payment Recovery of Overpayments,”</a><span style="color: #000000;"> where we analyzed the various ups and downs we associate with "provider relations.”</span></p> <p class="bodytext"><span style="color: #000000;">On February 15, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/401/top-miscues-employers-make-when-it-comes-to-their-health-plans-and-what-we-all-can-do-to-become-health-plan-heroes.aspx" target="_blank">“Top Miscues Employers Make When It Comes To Their Health Plans ... And What We All Can Do To Become Health Plan Heroes.”</a></p> <p class="bodytext"><span style="color: #000000;">On January 19, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/396/back-to-the-self-funding-future-which-echoes-of-2016-will-continue-to-impact-self-funding-in-2017.aspx" target="_blank">“Back to The Self-Funding Future – Which Echoes of 2016 Will Continue to Impact Self-Funding in 2017,”</a> <span style="color: #000000;">where our legal team talks about how the past decade has ushered in both outrage and opportunity for self-funded plans.</span></p> <p class="bodytext"><span style="color: #000000;">On January 4, 2017, The Phia Group presented a brief webinar to describe some</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/394/changes-to-the-phia-groups-reporting-portal.aspx" target="_blank">changes recently made to our reporting portal.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p7" name="p7"></a><span style="color: #000000;">Podcasts</span></span></p> <p class="bodytext"><span style="color: #000000;">On April 4, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/566/empowering-plans-segment-05-the-ahca-failed-where-to-next.aspx" target="_blank">“The AHCA Failed: Where To Next,”</a> <span style="color: #000000;">where our legal team discusses the recent, stunning failure of the GOP’s American Health Care Act.</span></p> <p class="bodytext"><span style="color: #000000;">On March 13, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/554/empowering-plans-segment-04-attack-of-the-killer-savings.aspx" target="_blank">“Attack of the Killer Savings,”</a> <span style="color: #000000;">where we identify facilities that provide the best outcomes for the least cost.</span></p> <p class="bodytext"><span style="color: #000000;">On February 28, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/402/empowering-plans-segment-03-the-journey-continues.aspx" target="_blank">“The Journey Continues,”</a> <span style="color: #000000;">where Adam Russo & Ron Peck discuss what makes our health benefit plan unique. </span><br /> <br /> <span style="color: #000000;">On February 13, 2017, The Phia Group presented</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/400/empowering-plans-segment-02-the-next-episode.aspx" target="_blank">“The Next Episode,”</a> <span style="color: #000000;">where we talked about what makes our health plan a source of savings.</span></p> <p class="bodytext"><span style="color: #000000;">On January 30, 2017, The Phia Group presented our very first podcast,</span> <a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/399/empowering-plans-episode-01-the-maiden-voyage.aspx" target="_blank">“The Maiden Voyage.”</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p8" name="p8"></a><span style="color: #000000;">The Phia Group’s 2017 Charity</span></span></p> <p class="bodytext"><span style="color: #000000;">The Phia Group's 2017 charity is the Boys & Girls Club of Brockton. </span><br /> <br /> <img alt="" height="73" src="/Portals/phiagroup/Newsletter%20Q2%202017/bandgclub.png" width="253" /></p> <p class="bodytext"><span style="color: #000000;">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. </span></p> <p class="bodytext"><span style="color: #000000;">The Boys & Girls Club of Brockton (BGCB) 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. </span></p> <p class="bodytext"><span style="color: #000000;">Since their founding, more than 20,000 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.</span></p> <p class="bodytext"><strong><span style="color: #000000;">Monthly Donations From Phia</span><br /> <br /> <img alt="" height="199" src="/Portals/phiagroup/Newsletter%20Q2%202017/donations.jpg" width="313" /></strong></p> <p class="bodytext"><span style="color: #000000;">For more information or to get involved, visit</span> <a href="http://www.bgcbrockton.org" target="_blank">www.bgcbrockton.org</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p9" name="p9"></a><span style="color: #000000;">The Stacks</span></span></p> <p class="bodytext" style="font-weight: bold;"><span style="color: #000000;">Self-Funded Health Plans May Have a New Ally in the Fight Against Specialty Drug Prices<br /> By: Brady Bizarro, Esq.</span></p> <p><span class="bodytext"><span style="color: #000000;"><br /> Throughout the bitter and seemingly endless presidential election cycle, Donald Trump and Hillary Clinton vehemently disagreed on almost every issue, especially those involving health policy. Yet, there was at least one health policy issue on which both candidates agreed: prescription drugs are too expensive. For self-funded health plans, this is old news. The industry continues to face increasing costs overall, and prescription drugs make up a significant portion of those costs. Specialty drugs are particularly culpable. Specialty drugs accounted for 32 percent of all drug expenditures in 2014 despite making up less than one percent of all written prescriptions, according to research conducted by Express Scripts.</span></span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/570/the-stacks-2nd-quarter-2017.aspx" target="_blank">Click here to read the rest of this article.</a></p> <p><span class="bodytext"><br /> <span style="font-weight: bold; color: #000000;">Appealing to Reason<br /> By: Jon A. Jablon, Esq.</span></span></p> <p class="bodytext"><span style="color: #000000;">The language is exceedingly common within benefit plans. We’ve all seen it; in order to appeal a denial, a medical provider must be specifically appointed by the patient as the patient’s “authorized representative.” Only members may appeal their own claims, unless they appoint someone to do so. Some third-party administrators and plan administrators even have a form that a member must fill out. These are long-held maxims by many – but are they truly compliant?</span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/570/the-stacks-2nd-quarter-2017.aspx" target="_blank">Click here to read the rest of this article. </a></p> <p class="bodytext" style="font-weight: bold;"><span style="color: #000000;">Held Captive by Appeals<br /> By: Tim Callender, Esq.</span></p> <p><span class="bodytext"><span style="color: #000000;">Prior to the passage of the Affordable Care Act, self-funding was already healthy and growing. Since the passage of the Affordable Care Act (and predominantly due to the ironic increase in healthcare insurance costs through the fully-insured, carrier model) we have seen self-funding grow even more. Although this growth has been significant, there are some employer groups – primarily small and mid-sized groups – that have struggled to find a sustainable path into self-funding nonetheless. </span></span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/570/the-stacks-2nd-quarter-2017.aspx" target="_blank">Click here to read the rest of this article.</a></p> <p class="bodytext" style="font-weight: bold;"><span style="color: #000000;">As Employer-Sponsored Plans Multiply, Self-Funding Remains an Attractive Option<br /> By: Brady Bizarro</span></p> <p class="bodytext"><span style="color: #000000;">As the new year begins, we can reflect on annual reports and surveys recently released by federal agencies and non-profit organizations which measure public and private healthcare spending and reveal trends in national health policy. One of the most prominent reports is the National Health Expenditure Accounts report, which was released in December by the Centers for Medicare and Medicaid Services. Some of CMS's findings forecast tough times ahead for employer-sponsored health insurance. Now, more than ever, employers will need to develop innovative approaches to continue offering affordable coverage to their employees.</span></p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/TabId/23892/PostId/570/the-stacks-2nd-quarter-2017.aspx" target="_blank">Click here to read the rest of this article.</a></p> <p> </p> <p class="bodytext"><span style="color: #000000;">To stay up to date on other industry news,</span> <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">please visit our blog.</a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="heading1"><a id="p10" name="p10"></a><span style="color: #000000;">Phia’s Speaking Events</span></p> <p><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Adam Russo’s 2017 Speaking Engagements:</span><br /> <span class="bodytext">• 2/22/17 – TABA Spring Conference – Austin, TX<br /> “The Good, The Bad, and the Naughty – Ethics: Simple Mistakes vs. Breach”<br /> • 3/16/17 - IMA National Independent Agency Consortium – Bonita Springs, FL<br /> “Not Your Grandmother’s Self-Funding: Best Practices for a Changing Industry”<br /> • 3/21/17 – Advantage Benefits RBP Seminar – Grand Rapids, MI<br /> “The Best Gets Better - Getting the Most Out of Your Self-Funded Plan”</span><br /> <br /> <span class="boldtext">Adam Russo’s Upcoming Speaking Engagements in 2017:</span><span class="bodytext"><br /> • 4/24/17 - Berkley Captive Symposium – Grand Cayman Islands<br /> “The Best Gets Better - Getting the Most Out of Your Self-Funded Plan”<br /> • 5/4/17 – Benefest – Westborough, MA<br /> "Multiple Personalities - The Biggest Issues Impacting Plans & Employers, and Instances Where They are Their Own Worst Enemy"</span><br /> <br /> <span class="boldtext">Ron Peck’s 2017 Speaking Engagements:</span><span class="bodytext"><br /> • 4/3/2017 – Eastern Claims Conference (ECC) – Boston, MA<br /> “The Good, The Bad, and The Ugly: Understanding Reference Based Pricing in the Special Risk Market”</span></span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Tim Callender’s 2017 Speaking Engagements:</span><br /> • 2/2/17 – Alaska Association of Health Underwriters – Anchorage, AK<br /> “Innovation and Cost-Containment In the Self-Funded Space”<br /> • 2/27/17 – LBG Advisors: Benefits Symposium – Anaheim, CA<br /> “Innovation and Cost-Containment In the Self-Funded Space”</span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Tim Callender’s Upcoming Speaking Engagements in 2017</span><br /> • 5/22/17 - Group Underwriters Association of America Annual Conference - Denver, CO<br /> “The Future of Health Plans”<br /> • 7/17/17 - Health Care Administrator’s Association TPA Summit - St. Louis, MO<br /> “Conference Emcee”<br /> <br /> <span class="boldtext">Jen McCormick’s 2017 Speaking Engagements:</span><br /> • 3/29/17 – SIIA Executive Forum – Tucson, AZ<br /> “Department of Labor Audits”<br /> <br /> <span class="boldtext">Brady Bizarro’s 2017 Speaking Engagements:</span><br /> • 1/22/17 – Texas Association of Benefit Administrators (TABA) – Austin, TX<br /> “Healthcare Policy under the Trump Administration”</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a><span style="color: #000000;">Get to Know Our Employee of the Quarter:<br /> Erik Graber</span></span></p> <p class="bodytext"><span style="color: #000000;">Congratulations to Erik Graber, the Phia Group’s Q1 2017 Employee of the Quarter!</span></p> <p class="bodytext"><span style="color: #000000;">“Erik embodies everything Phia is about from our mission statement to our vision to our culture.  Throughout Q1, Erik has been tenacious in his pursuit of teaching and training new team members; giving them the tools essential to succeed in their roles.  The life of an IT Director is not a glamorous one and Erik works assiduously, oftentimes nights and weekends – sacrificing precious family time – to meeting and exceeding his goals and deadlines to ensure our company runs seamlessly.  If there is an issue you can rest assured Erik will promptly handle the matter – possibly with a bit of sass and sarcasm!  Erik is truly an asset to The Phia Group, and we’re fortunate to have him!” </span><br /> <br /> <img alt="" height="253" src="/Portals/phiagroup/Newsletter%20Q2%202017/erikg.jpg" width="266" /><br />  </p> <p class="bodytext"><span style="color: #000000;">Congratulations Erik and thank you for your many current and future contributions.</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="p12" name="p12"></a><span style="color: #000000;">Phia News</span></span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Promotions at Phia:</span><br /> • Keith McMahon was promoted from CI to CRS III<br /> • Lauren Vermette was promoted from legal assistant role to CI<br /> • Cara Carll was promoted to Team Leader of the MedPay & Work Comp. Tier<br /> • Kerri Sherman was promoted to Team Leader of BI Tier & Case Investigation<br /> • James Newell was promoted to Team Leader of Claim & Case Support<br /> • Angela Grande was promoted to CRS III<br /> • Katie Delaney was promoted to Team Leader of the Quality Analysts.<br /> • Jude McNeil was promoted to Team Leader of the Call Center in Customer Service<br /> • Lisamarie DeCristoforo was promoted to Team Leader of Case Evaluation in Customer Service</span></p> <p class="bodytext"><span class="boldtext" style="color: #000000;">New Hires This Quarter: </span><span style="color: #000000;"><br /> The Phia Group has added 5 new employees to its staff this quarter. They include:<br /> • Matthew Painten was hired into our Marketing department<br /> • Jeff Hanna was hired into our Accounting department<br /> • Randal Moody was hired into our IT department<br /> • Krista Maschinot was hired into our Phia Group Consulting department<br /> • Victoria Pace was hired into our Phia Group Consulting department</span></p> <p class="bodytext"><span style="color: #000000;"><span class="boldtext" style="color: #000000;">Open Positions at Phia</span><br /> • Case investigator<br /> • Attorney I<br /> • ETL Specialist<br /> • Data Architect<br /> • IT Technologist<br /> • Product Analyst</span></p> <p class="bodytext"><a href="https://workforcenow.adp.com/jobs/apply/posting.html?client=Phiagroup&ccId=19000101_000001&type=MP&lang=en_US" target="_blank">Click here for more information or to apply today!</a></p> <p class="bodytext"><span class="boldtext" style="color: #000000;">Additions to the Phamily:</span><span style="color: #000000;"><br /> • Tara Trojano gave birth to a baby girl, Emily Rose, on 02/09/17<br /> • Liz Welcome gave birth to a baby boy, Quinton Jay Robert Pereira, on 02/01/17</span><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext" style="text-align: justify; margin-left: 160px;"> <img alt="" height="346" src="/Portals/phiagroup/Newsletter%20Q2%202017/footerlogo.png" width="387" /></p> </td> </tr> <tr> <td colspan="2" style="background-color: #4a85d3;"> <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> 573The Stacks – 2nd Quarter 2017https://www.phiagroup.com/Media/Posts/PostId/570/the-stacks-2nd-quarter-2017NewslettersFri, 14 Apr 2017 19:01:33 GMT<strong>Self-Funded Health Plans May Have a New Ally in the Fight Against Specialty Drug Prices</strong><br /> By Brady Bizarro, Esq.<br /> <br /> Throughout the bitter and seemingly endless presidential election cycle, Donald Trump and Hillary Clinton vehemently disagreed on almost every issue, especially those involving health policy. Yet, there was at least one health policy issue on which both candidates agreed: prescription drugs are too expensive. For self-funded health plans, this is old news. The industry continues to face increasing costs overall, and prescription drugs make up a significant portion of those costs. Specialty drugs are particularly culpable. Specialty drugs accounted for 32 percent of all drug expenditures in 2014 despite making up less than one percent of all written prescriptions, according to research conducted by Express Scripts.<br /> <br /> Self-funded health plans employ a variety of cost-containment strategies in an effort to ameliorate the fiscal burden of prescription drugs. These include increased cost-sharing (through copayments, coinsurance, and deductibles) and utilizing manufacturer copay cards and tiered benefit programs. Now, the self-funded industry may be given new tools by the President-elect to fight the pharmaceutical companies. <br /> <br /> Chief among President-elect Trump&rsquo;s health policy priorities is his campaign promise to &ldquo;repeal and replace&rdquo; the Affordable Care Act. In addition, he has announced at least two priorities which depart from conventional conservative thinking and have important implications for the future of self-funding: requiring price transparency from all healthcare providers and permitting consumers to import drugs from overseas. <br /> <br /> As part of Trump&rsquo;s plan for &ldquo;Healthcare Reform to Make America Great Again,&rdquo; the President-elect proposed that Congress must:<br /> <br /> Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.<br /> <br /> It is hard to overestimate the savings a self-funded health plan can realize if permitted to import drugs from overseas. One of the main reasons why prices for brand-name drugs are typically lower in most developed countries than in the U.S. is because of increased negotiating power. In the U.S., the government has forfeited its negotiating power. Medicare, the largest single purchaser of prescription drugs in the U.S., is prohibited by law from negotiating prices with pharmaceutical companies. By contrast, in the United Kingdom, brand-name drug prices are generally much lower because the government and the industry negotiate agreements which contain set spending caps and require drug companies to reimburse the government any amount which exceeds the cap. While some of these agreements do contain opt-out provisions for the reimbursement requirement, most pharmaceutical companies agree to these contracts as-is in order to gain access to a much larger market. <br /> <br /> Also consider the case of Canada, which is often touted as a prime example of a source of low-cost prescription drugs. The Canadian government negotiates with pharmaceutical companies on behalf of the public. As a result, brand-name and even generic drugs are less expensive in Canada than they are in the United States. In 2004, the median prescription drug prices in Canada were nearly 79 percent lower than those in the U.S., according to the Patent Medicine Prices Review Board Annual Report. The 2013 report revealed that Canadian consumers still paid less than half of what U.S. consumers paid for patented-drug products. If the President-elect succeeds in pushing through legislation which ends the ban on foreign drug imports, U.S. consumers could realize similar savings.<br /> <br /> This would not be the first time that a politician has attempted to lift the ban on importing foreign drugs. The Safe and Affordable Drugs from Canada Act of 2015 was sponsored by Senator John McCain (R-AZ) and had bi-partisan support, including from Senator Bernie Sanders (D-VT). The bill remains stalled in the Senate Committee on Health, Education, Labor, and Pensions. There was also an attempt to permit importation in 2009 while the Affordable Care Act was being pushed by Democrats, but that effort also failed. Despite past failed attempts, there are many reasons to think that the importation of prescription drugs from overseas may actually become legal (at least in some form) under a Trump Administration. <br /> <br /> First, public support for change and increased price transparency is at an all-time high, especially in light of recent, high-profile price-gouging controversies. In August 2015, Turing Pharmaceuticals acquired the exclusive rights to distribute Daraprim, a drug used to treat AIDS-related symptoms. A month later, the company raised the price of Daraprim from $13.50 per pill to $750 per pill overnight, an increase of over 5,500 percent (before 2010, the drug cost $1 per pill). A joint study by the Infectious Disease Society of America and the HIV Medicine Association found that the increase in price would result in an average bill of $634,500 per year for most patients. In response to the public outcry, the CEO of Turing Pharmaceuticals defended his company&rsquo;s actions, citing the need to modernize the drug and create new alternatives with fewer side effects. A year later, the price of the drug is $375 in the U.S., and between $1 and $2 per pill internationally.<br /> <br /> Turing Pharmaceuticals is not the only company to drastically increase the price of its brand-name drugs and face near-universal criticism. Mylan, a global generic and specialty pharmaceuticals company, faced an even bigger political firestorm in the summer of 2016 when it raised the price of a two-pack supply of its popular EpiPen to $608 (the same two-pack EpiPen is available in the United Kingdom for $69). The EpiPen, which sold for $100 as recently as 2009, is an epinephrine auto injector device used to control allergic reactions to food and environmental allergens. What made this case more contentious was a media report revealing that over the past eight years, while the price of EpiPens increased 461 percent, the salary of Mylan&rsquo;s CEO rose 671 percent, up to $18.9 million a year.<br /> <br /> Although many experts agree that these examples are egregious, it is important to note that there are enormous costs associated with pharmaceutical research and development. Furthermore, there is a very real need to encourage drug development as a matter of good public health and public policy. This is why the U.S. government provides regulatory protections to assist pharmaceutical firms in the development of life-saving drugs. Nonetheless, recent polling confirms that Americans are fed up with the price of brand-name drugs. Nearly eight in ten Americans agree that drugs are too expensive, and almost 86 percent agree that pharmaceutical companies should be required to reveal how drug prices are set, according to a survey released by the Kaiser Family Foundation in September 2016. <br /> <br /> In addition to the public outcry over specific pricing controversies, the Food and Drug Administration (FDA) has sent mixed signals regarding the agency&rsquo;s willingness to enforce the ban on foreign drug imports. The FDA&rsquo;s website explains that the agency has a policy &ldquo;that it typically does not object to personal imports of drugs that FDA has not approved under certain circumstances . . .&rdquo; Those circumstances include when less than a three-month supply is imported, and when the consumer importing the drug verifies in writing that it is for her own use and provides contact information for the doctor providing her treatment.<br /> <br /> Perhaps most importantly, President-elect Trump will enjoy the benefits of a Republican-controlled House and Senate. While in recent weeks he has shown signs of scaling back some of his campaign promises, this particular health policy initiative enjoys bi-partisan support. As such, there may be no better opportunity to push through legislation lifting the ban on safe, dependable imported drugs.<br /> <br /> <strong>Appealing to Reason</strong><br /> By Jon A. Jablon, Esq.<br /> <br /> The language is exceedingly common within benefit plans. We&rsquo;ve all seen it; in order to appeal a denial, a medical provider must be specifically appointed by the patient as the patient&rsquo;s &ldquo;authorized representative.&rdquo; Only members may appeal their own claims, unless they appoint someone to do so. Some third-party administrators and plan administrators even have a form that a member must fill out. These are long-held maxims by many &ndash; but are they truly compliant?<br /> <br /> In what it has deemed a frequently asked question, the Department of Labor, in its Benefit Claims Procedure Regulation FAQs , has asked itself &ldquo;Does an assignment of benefits by a claimant to a health care provider constitute the designation of an authorized representative?&rdquo; The Department of Labor simply, and helpfully, led its answer with the word &ldquo;no.&rdquo; To elaborate on this &ldquo;no,&rdquo; the DOL wrote that &ldquo;Typically, assignments are not a grant of authority to act on a claimant's behalf in pursuing and appealing a benefit determination under a plan.&rdquo;<br /> <br /> But how much does that truly clarify? Without some context, it is fairly unhelpful &ndash; and in context, it is revealed that this guidance from the DOL is somewhat inaccurate.<br /> <br /> An authorized representative is one who is authorized to act as the representative of another &ndash; a description that could scarcely be any clearer. In our sense, an authorized representative is generally used in the context of the right to appeal. To illustrate the utility of this concept, consider three scenarios; in all three, a plan member has received services from a non-contracted medical provider, and in all three the Plan&rsquo;s available benefits are not quite enough to cover the provider&rsquo;s full billed charges. Appeals will occur &ndash; but the difference in the scenarios hinges on exactly who is appealing, and on whose behalf. <br /> <br /> In scenario number one, the health plan systemically prohibits all assignments of benefits, and pays benefits directly to the member. The member endorses the Plan&rsquo;s payment to the provider to compensate the provider for its services &ndash; but the provider is dissatisfied with the payment amount. In this scenario number one, the provider may not appeal to the health plan unless the provider appeals on the patient&rsquo;s behalf, since the provider itself was due benefits from the patient, rather than from the health plan, since there was no assignment of benefits &ndash; and in such case the provider would need to be appointed by the member as the member&rsquo;s authorized representative, since the provider has no independent right to benefits from the health plan in this scenario. In other words, the provider would need to appeal on the member&rsquo;s behalf, and would therefore need to be the member&rsquo;s authorized representative to do so.<br /> <br /> In scenario number two, there is again no assignment of benefits, but the provider decides to balance-bill the member instead of getting involved in the appeals process. The member, rather than the provider, appeals directly to the Plan. Members, of course, are always claimants and are always entitled to appeal to the health plan if the member feels that a greater amount of benefits should be paid. In this scenario two, there is no need for the member to appoint the provider as the member&rsquo;s authorized representative, since the member needs no representative if she appeals on her own behalf.<br /> <br /> Now, consider scenario number three, where there is a valid assignment of benefits from the member to the provider (as is almost universally the case in self-funded health care). Through the assignment of benefits, the provider is invited to submit its claims directly to the health plan, and receives only partial payment of its billed charges in return. In this scenario three, the provider desires to appeal the denial. The provider submits an appeal to the health plan &ndash; in accordance with all of the plan&rsquo;s written and established procedures &ndash; and the third-party administrator answers the provider with a letter stating that only members may appeal, unless the member fills out a specific form to authorize the provider to appeal on the member&rsquo;s behalf. How compliant is that, though? Might the health plan be at risk of noncompliance if it denies providers the right to appeal their own claims? <br /> <br /> An authorized representative, as described above, is one who is authorized to be the representative of another. In a case such as this, a medical provider might be authorized to act as the representative of the member, therefore becoming the member&rsquo;s personal representative. Consider, however, federal regulations that afford all claimants the right to appeal; claimant is a term of art that explicitly includes participants and beneficiaries . A beneficiary is defined as &ldquo;a person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit thereunder.&rdquo;<br /> <br /> Forget the legalese; the important thing is to note that medical providers, if benefits are assigned to them, are beneficiaries, as that term is defined by the regulations &ndash; and beneficiaries become claimants when they submit claims to the health plan. If you remember, all claimants are empowered to submit claims to the health plan, appeal a denial of those claims, and even ultimately sue for redress under ERISA. (As one court put it, &ldquo;there is now a broad consensus that when a patient assigns payment of insurance benefits to a healthcare provider, that provider gains standing to sue for that payment under ERISA &sect; 502(a). &rdquo;)<br /> <br /> The same regulation that defines &ldquo;claimant&rdquo; also provides that:<br /> <br /> Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination. <br /> <br /> According to these regulations, not only are claimants afforded the right to file claims, but they are also guaranteed the right to appeal, by imposing this responsibility upon the health plan to afford claimants the right to appeal. The relevant regulations unambiguously explain that a claimant may appeal an adverse benefit determination. Moreover, the text of ERISA itself provides that &ldquo;A civil action may be brought&hellip;by a participant or beneficiary&hellip;to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan. &rdquo; To simplify, again, claimants can sue for benefits. Since medical providers are claimants if they are assigned plan benefits, then providers can appeal and ultimately sue if necessary.<br /> <br /> As another court wrote, somewhat more bluntly, &ldquo;the assignment is only as good as payment if the provider can enforce it. &rdquo; This is a matter of public policy, and seems fairly intuitive; if a provider has the right to submit a claim, and the health plan has the right to tender a denial of that claim, practically speaking, why should the provider not also have the right to appeal the denial of its claim? According to courts and the regulations, the provider does in fact have this right.<br /> <br /> We now know that medical providers who have been assigned benefits can submit claims, appeal denials of those claims, and sue for redress pursuant to ERIA. It should be noted, however, that although the law on the topic may be established, not everyone is on the same page, as is so often the case in our industry. <br /> <br /> The DOL&rsquo;s answer to its own question (&ldquo;Does an assignment of benefits by a claimant to a health care provider constitute the designation of an authorized representative?&rdquo;) continues by specifying that &ldquo;An assignment of benefits by a claimant is generally limited to assignment of the claimant's right to receive a benefit payment under the terms of the plan.&rdquo;<br /> <br /> But how can that be the case? Claimants have the right to appeal, and claimants include anyone &ldquo;designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit thereunder.&rdquo; The regulations say one thing, but the DOL&rsquo;s FAQ seems to say the opposite.<br /> <br /> The DOL&rsquo;s answer to its own question yields an absurd conclusion: that a provider that has accepted an assignment of benefits and submitted claims to a health plan is not a claimant. According to applicable law, however, either the provider accepts assignment of benefits and submits claims, and therefore earns the right to appeal and sue &ndash; or the provider does none of those things. These rights are not discrete; they are a package deal, inseparable from one another. Each right &ndash; the right to submit claims, the right to appeal a denial, and the right to sue under ERISA &ndash; has &ldquo;not for individual sale&rdquo; marked on its label.<br /> <br /> The confusion doesn&rsquo;t stop there, though. Coming back to the Department of Labor&rsquo;s answer to its own frequently asked question, the Department has stated that &ldquo;[t]ypically, assignments are not a grant of authority to act on a claimant's behalf in pursuing and appealing a benefit determination under a plan.&rdquo; This is a correct statement, although very misleading in context. It is true that an assignment of benefits does not grant a provider authority to act on a claimant&rsquo;s behalf &ndash; because a provider who has received an assignment of benefits is a claimant unto itself, and is not acting on anyone else&rsquo;s behalf. The provider therefore needs no authority to act on anyone&rsquo;s behalf.<br /> <br /> Where do we go from here? There is conflicting guidance; FAQs are suggestive rather than binding, but most take them as gospel nonetheless, since they are explicitly designed to be written in plain English rather than the legalese of the regulations.<br /> <br /> The rules surrounding who has what rights and under what circumstances are undoubtedly confusing at times; guidance provided by our regulators is sometimes confusing, vague, and &ndash; at times &ndash; even contradictory. This is one of those times, and affording all relevant rights to medical providers is an important topic now more than ever in the face of incoming bouts of regulatory scrutiny of the self-funded industry and the fiduciaries who act within this space.<br /> <br /> As health plans struggle to contain costs, health plan administrators, third-party administrators, and brokers should be careful not to handicap themselves by employing the same thinking as prior decades simply because that&rsquo;s what has always been done. Performing an in-depth review of claims and appeal processes &ndash; and the rest of the health plan to boot &ndash; is the best way of staying ahead of the curve and ensuring compliance and viability.<br /> <br /> <strong>Held Captive by Appeals</strong><br /> By: Tim Callender, Esq.<br /> <br /> Prior to the passage of the Affordable Care Act, self-funding was already healthy and growing.&nbsp; Since the passage of the Affordable Care Act (and predominantly due to the ironic increase in healthcare insurance costs through the fully-insured, carrier model) we have seen self-funding grow even more.<br /> <br /> Although this growth has been significant, there are some employer groups &ndash; primarily small and mid-sized groups &ndash; that have struggled to find a sustainable path into self-funding nonetheless.&nbsp; For purposes of this article I will refer to these employers as &ldquo;Small-Mids.&rdquo;&nbsp; Obviously, opinions differ as to what a &ldquo;small&rdquo; or &ldquo;mid-sized&rdquo; employer group is, but for today&rsquo;s discussion, we are looking at employer groups ranging from 50 employees up to approximately 200 employees. &nbsp;<br /> <br /> One of the primary barriers to entry for Small-Mids is the financial risk inherent to the self-funded model.&nbsp; Even with a stop-loss policy in place (assuming the employer is domiciled in a state that has not regulated stop-loss to the point of making it prohibitive to gain a policy for a small to mid-sized employer), many Small-Mids do not have the cash reserves necessary to make it through a high health spend year before stop-loss reimbursement might kick in. There are programs in the market such as &ldquo;level-funding&rdquo; whereby an employer&rsquo;s risk is effectively capped at a certain figure in exchange for a set monthly expense, but such programs are still in their infancy and not very widely-used.<br /> <br /> &nbsp;In the traditional market, however, figure in a handful of dialysis claims, one or two air ambulance claims, and one plan member on a growth hormone prescription, and the Small-Mid is running for the hills.&nbsp; Lest we forget that Small-Mids are often terrified of financial ruin on many fronts to begin with, let alone bearing the risk of high claims exposure.&nbsp; For them, it is unquestionably easier to sign up for that prototypical fully-insured option and trade financial risk for predictable premiums. The problem, though, is that predictable premiums are generally high premiums.<br /> <br /> Another barrier to entry for the Small-Mids is the appeals experience.&nbsp; &ldquo;What do you mean, &lsquo;appeals experience,&rsquo; Tim?&rdquo; you might ask.&nbsp; In short, as those of us working in the self-funded health plan space know, a health claim&rsquo;s denial triggers appeals rights.&nbsp; These appeals may be pursued by the plan member, a plan beneficiary, or even the medical provider through an assignment of benefits or appeals authorization.&nbsp; The typical claims and appeals cycle tends to look something like this:<br /> <br /> (1)&nbsp;&nbsp; &nbsp;A claim for health benefits is submitted to the plan-sponsor&rsquo;s third-party administrator by the Claimant (the Claimant might be the plan member, a plan beneficiary, or a medical provider); <br /> (2)&nbsp;&nbsp; &nbsp;The claim is adjudicated, by the TPA, pursuant to the terms of the governing plan document, as created and adopted by the plan-sponsor; <br /> (3)&nbsp;&nbsp; &nbsp;The claim is denied pursuant to the terms of the plan document; <br /> (4)&nbsp;&nbsp; &nbsp;The Claimant files a first-level appeal.<br /> (5)&nbsp;&nbsp; &nbsp;The first-level appeal is handled by the TPA.&nbsp; Sometimes input from the plan-sponsor is solicited, sometimes not.&nbsp; Every TPA / plan-sponsor relationship is different.<br /> (6)&nbsp;&nbsp; &nbsp;The denial of benefits is upheld by the TPA / plan-sponsor at the conclusion of the first-level appeal process.<br /> (7)&nbsp;&nbsp; &nbsp;The Claimant files a second-level appeal. &nbsp;<br /> (8)&nbsp;&nbsp; &nbsp;The TPA will handle the second-level appeal in one of two ways: (i) it will review the second-level appeal, provide a recommendation to the plan-sponsor regarding the determination, and ask the plan-sponsor to make a final determination based on the TPA&rsquo;s recommendation; or (ii) the TPA will submit the second-level appeal to the plan-sponsor, in its entirety, for the plan-sponsor to review and determine, on its own, whether the denial should be upheld or overturned.<br /> It is step (8) where the wheels typically come off for an existing self-funded plan and it is step (8) that is a significant barrier for Small-Mids to get past when they analyze and consider self-funding.&nbsp; Imagine a Small-Mid that is privately held and made up of hard-working, blue-collar employees and blue-collar leaders who have risen to positions such as Vice President of H.R., or Chief Operations Officer.&nbsp; Suddenly, it is these leaders who are faced with a second-level appeal based on the medical necessity of cortisone injections for the treatment of migraines; suddenly it is these leaders who are faced with a second-level appeal based on the interpretation of a complex plan exclusion, such as the &ldquo;hazardous activities exclusion&rdquo; or the &ldquo;illegal acts exclusion.&rdquo;&nbsp; We have all heard these stories and we are all familiar with the fallout that might occur when a Small-Mid is faced with this daunting task. &nbsp;<br /> <br /> Additionally, how many stories exist of the closely held Small-Mid&rsquo;s leadership team suddenly faced with a second-level appeal that directly concerns their highest performing sales person?&nbsp; Or, more generally, consider the heartache involved for any Small-Mid&rsquo;s leadership team when they must decide an appeal on a health claim for a well-known and well-loved employee, regardless of his or her title! Many Small-Mids have close-knit employee populations, many of whom have been coworkers and friends for years.<br /> &nbsp;How many times have we heard, &ldquo;we make motorcycle clutches and just wanted to provide our employees with good health benefits!&nbsp; We never signed up to make these types of decisions!&rdquo;&nbsp; Another group leaves self-funding and then the horror stories trickle downstream, preventing other Small-Mids from moving toward self-funding.&nbsp; Or, if the Small-Mid stays in the self-funded space, there is a very real chance that they unknowingly breach their fiduciary duty as a plan-sponsor, time and again, when they throw their hands in the air and pay claims that should not be paid pursuant to the governing plan document, simply because of the emotion, heartache, and the difficulty of handling complex appeals. <br /> <br /> Solutions to the problems discussed above do exist, and these solutions are exploding across the industry and across the country.&nbsp; The captive model is one such solution, primarily focused as a remedy to the Small-Mid&rsquo;s concern over self-funding and financial devastation.&nbsp; Captive risk-sharing is not a new idea &ndash; yet it is not as common in the self-funded health space as we all might think.&nbsp; Time and again, my colleagues and I are surprised as we travel and speak on self-funding topics, all around the country, to learn that many employers, not to mention their brokers, have either never heard of captive risk sharing or have simply never invested the time to learn much beyond the basics. &nbsp;<br /> <br /> The proof is in the pudding. The numbers show that properly-run captive programs, filled with Small-Mids, are breaking down doors and bringing Small-Mids into self-funding through the assurance of responsible, managed risk-sharing.&nbsp; Whether heterogeneous (made up of groups spanning multiple industries) or homogeneous (groups within the same industry) in makeup, a captive provides a common goal amongst its members to keep costs down and prop one another up through the safety net of a pool of funds that many might view as a &ldquo;rainy day fund.&rdquo; &nbsp;<br /> <br /> Regarding the second barrier to entry for Small-Mids, directly handling health claim appeals, there are solutions covering that problem as well.&nbsp; Third-party, second-level appeals outsourcing is becoming more prominent in the self-funded industry.&nbsp; Historically, the only option that might exist for a plan sponsor was to hope it landed with a TPA that might be willing to handle second-level appeals, usually for a fee.&nbsp; But, most TPAs steer away from this administrative add-on for two reasons.&nbsp; (1) it drastically blurs the line between who is acting as a fiduciary for the plan and (2) it can create a potential conflict of interest and call objectivity into question when the same entity has adjudicated the initial claim, handled the first appeal, and then went on to handle the second appeal. &nbsp;<br /> <br /> Figure in a solution that can handle the appeals concerns discussed above and we are looking at the pinnacle method to eliminate the two most prominent barriers to self-funding faced by Small-Mids: financial concerns over claims exposure, and managing appeals. &nbsp;<br /> <br /> <strong>As Employer-Sponsored Plans Multiply, Self-Funding Remains an Attractive Option</strong><br /> By Brady Bizarro, Esq.<br /> <br /> As the new year begins, we can reflect on annual reports and surveys recently released by federal agencies and non-profit organizations which measure public and private healthcare spending and reveal trends in national health policy. One of the most prominent reports is the National Health Expenditure Accounts report, which was released in December by the Centers for Medicare and Medicaid Services. Some of CMS's findings forecast tough times ahead for employer-sponsored health insurance. Now, more than ever, employers will need to develop innovative approaches to continue offering affordable coverage to their employees.<br /> <br /> Healthcare expenditures grew more than two percent faster than the overall economy in 2015. Spending was up overall by nearly six percent in 2015, up to $3.2 trillion, or $9,990 a person. Private health insurance spending increased by seven percent, with annual premiums for employer-sponsored family plans already topping $18,000 this year (up three percent from last year). Prescription drug spending, high-cost patients, and an increased use of services were cited as the primary cost drivers. <br /> <br /> To the surprise of many health policy experts, many of whom had warned of a mass exodus from employer-sponsored plans to the exchanges, the CMS data also shows that enrollment in employer-sponsored plans rose slightly in 2015. As a result, an increasing number of small and mid-sized employers in particular will face the burden of soaring healthcare costs in 2017.<br /> <br /> Self-funding an employee health plan remains one of the most effective cost-containment strategies for employers with a relatively healthy workforce and a willingness to customize a plan. From 2013 to 2015, the number of mid-sized firms that "self-insure" jumped nearly 20 percent, according to the Employee Benefit Research Institute. Among small companies, that share is now up seven percent. As the cost of maintaining fully-funded plans continues to rise, in large part spurred by the Affordable Care Act's coverage mandates, we can expect these numbers to rise.<br /> <br /> Self-funding provides employers with flexibility and the opportunity for employee engagement when designing their health plans. Employers can avoid many state-based coverage mandates and administrative costs because of federal preemption of state health insurance regulations. They can work with third-party vendors to analyze claims data and implement unique risk controls such as wellness programs, smoking cessation initiatives, and tiered prescription drug benefits.<br /> <br /> A more recent development in the self-funded industry has been the increased use of employer incentive programs. These programs reward employees with cash and other incentives if they create savings for the health plan by voluntarily obtaining care from lower-cost healthcare providers. Many resources exist that enable employees to determine what various providers of different medical services commonly charge for certain services, and what to expect in terms of the quality of their outcomes. For example, third-party organizations routinely provide objective analyses of medical billing by claim type and by facility, while others measure how many mistakes are made by providers. These resources provide quality metrics, a comparison of prices, and even letter grades based on factors such as quality outcomes and lack of provider error. In its Review of State Reports (2008-2015), Freedman Healthcare confirms that "high prices do not directly correlate with high quality of care -- in other words, the highest paid providers do not necessarily provide the highest quality of care." For some procedures, the price discrepancy can be substantial. For example, one employer reported a price difference of $18,000 for a gastric sleeve procedure between two facilities in Louisiana.<br /> <br /> While these programs can help alleviate the financial burden, cost will not be the only concern for employer-sponsored care this year. Under a new administration, employers will also face legislative and regulatory uncertainty. President-elect Trump has vowed not only to repeal and replace the Affordable Care Act, but to reduce regulations overall at the federal level. This would be a welcome development for employers, but it remains to be seen which provisions of the Affordable Care Act will be left in place. For example, if the Trump Administration moves to repeal the employer mandate, employers would no longer be required to offer health insurance to their full-time employees. Also, employers would no longer need to report coverage to the IRS or determine the value and affordability of their plans. <br /> <br /> Despite the uncertainty, Trump has promised to keep in place two of the most popular ACA provisions; the ban on denying coverage to individuals with pre-existing conditions and the extension of dependent coverage up until age 26. Health policy experts have warned that these two components of the ACA are only viable if accompanied by coverage mandates, which would diversify insurance risk pools. Whether or not the employer mandate is preserved, employers seeking affordable coverage options for their employees will continue to benefit from the flexibility of self-insuring.<br /> <br /> <br /> <br /> <br />570Empowering Plans Segment 05 - The AHCA Failed: Where To Next?https://www.phiagroup.com/Media/Posts/PostId/566/empowering-plans-segment-05-the-ahca-failed-where-to-nextPodcastsTue, 04 Apr 2017 20:53:42 GMTJoin The Phia Group's CEO, Adam V. Russo, Sr. VP, Ron E. Peck, and Attorney Brady Bizarro as they discuss the recent, stunning failure of the GOP's American Health Care Act, the most recent news and predictions on the effort to repeal and replace the ACA, and what this all means for the self-funded industry.<br /> <a href="https://www.youtube.com/watch?v=F4eD7YoxxVc&amp;t=5s"><br /> </a><a href="https://www.youtube.com/watch?v=F4eD7YoxxVc&amp;t=5s">Click here to open the Podcast!</a>566The Phia Group, LLC is pleased to announce the addition of “Leave of Absence” reviews. https://www.phiagroup.com/Media/Posts/PostId/562/the-phia-group-llc-is-pleased-to-announce-the-addition-of-leave-of-absence-reviewsPress ReleasesMon, 27 Mar 2017 19:18:56 GMT<span style="font-size: 18px;"><em><strong>Braintree, MA</strong></em><strong> &ndash; The Phia Group, LLC is pleased to announce the addition of &ldquo;Leave of Absence&rdquo; reviews.</strong></span> &nbsp;<br /> <br /> <span style="font-size: 18px;">Recognizing that employee handbooks are rarely compliant with applicable law, and promise employees extended health plan coverage contrary to health plan documents whose terms require termination of coverage, The Phia Group is pleased to provide a Leave of Absence review service.&nbsp; The Phia Group&rsquo;s team of plan document experts and attorneys will analyze the applicable plan document side-by-side with the employer&rsquo;s handbook and stop-loss policy, to ensure there are no gaps in coverage and that all are in compliance with applicable law. &nbsp;<br /> <br /> &ldquo;Too often we see employees &ndash; and their employer &ndash; caught unawares by limits existent in their own plan document.&rdquo; remarked The Phia Group&rsquo;s Vice President of Consulting, Jennifer McCormick, Esq., &ldquo;Employers enact generous policies regarding leaves of absence, reflected in their handbooks, but totally forget to update their health plans accordingly.&rdquo; <br /> <br /> For more information regarding The Phia Group&rsquo;s Leave of Absence Review, or to learn about any of The Phia Group&rsquo;s other services, please contact Tim Callender by email at&nbsp;<a class="ApplyClass" href="mailto:tcallender@phiagroup.com?subject=Leave of Absence Inquiry ">tcallender@phiagroup.com</a> or by phone at 781-535-5631.<br /> <br /> <strong>About The Phia Group:</strong><br /> <br /> The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.&nbsp; By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.<br /> <br /> </span><br />562Medical Bill Blues: Pre-Payment Contracting and Negotiation, Pricing Alternatives, and Post-Payment Recovery of Overpaymentshttps://www.phiagroup.com/Media/Posts/PostId/560/medical-bill-blues-pre-payment-contracting-and-negotiation-pricing-alternatives-and-post-payment-recovery-of-overpaymentsWebinarsThu, 23 Mar 2017 18:46:24 GMT<p><br /> It’s common knowledge that not every network contract adds real value, nor can medical providers always be relied upon to bill responsibly. As the fiduciary duty to be prudent with plan assets becomes increasingly relevant, it's important that self-funded health plans, and those who service them, not fall behind.<br /> <br /> Thank you for joining The Phia Group's legal team on March 23, 2017 as they analyzed the various ups and downs we associate with "provider relations," including overpayments, claim negotiations, reference-based pricing, balance billing and more - and discussed some best practices for working within each of these domains.<br /> <br /> <a href="https://www.phiagroup.com/LinkClick.aspx?fileticket=xVJd3TcgSrM%3d&tabid=23892&portalid=586&mid=38035" target="_blank">Click Here to Download Full Webinar</a><br /> <a href="https://www.phiagroup.com/LinkClick.aspx?fileticket=NulyzvzSqLo%3d&tabid=23892&portalid=586&mid=38035" target="_blank">Click Here to Download Audio</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 560Empowering Plans Segment 04 - Attack of the Killer Savingshttps://www.phiagroup.com/Media/Posts/PostId/554/empowering-plans-segment-04-attack-of-the-killer-savingsPodcastsMon, 13 Mar 2017 14:33:23 GMTJoin The Phia Group's CEO, Adam V. Russo, and Sr. VP, Ron E. Peck, as they describe how The Phia Group identifies facilities that provide the best outcomes for the least cost, and encourage plan participants to visit those facilities.<br /> <br /> <a href="http://www.youtube.com/watch?v=9q8X7smb0AE">Click here to open the Podcast!</a><br /> <br /> <iframe src="http://www.youtube.com/watch?v=9q8X7smb0AE" height="315" frameborder="0" width="560"></iframe>554Empowering Plans Segment 03 - The Journey Continueshttps://www.phiagroup.com/Media/Posts/PostId/402/empowering-plans-segment-03-the-journey-continuesPodcastsTue, 28 Feb 2017 15:54:42 GMTOnce again The Phia Group&rsquo;s CEO, Adam V. Russo, and Sr. VP, Ron E. Peck, delve into what makes their own company&rsquo;s health benefit plan unique, and share tips employers (and those that service them) can use to improve their own plan&rsquo;s performance.<br /> <a href="http://www.phiagroup.com/LinkClick.aspx?link=https%3a%2f%2fwww.youtube.com%2fwatch%3fv%3dBQIIHus0ycw&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Click here to open the Podcast!</a><br /> <br /> <iframe src="https://www.youtube.com/watch?v=BQIIHus0ycw" height="315" frameborder="0" width="560"></iframe>402Top Miscues Employers Make When It Comes To Their Health Plans ... And What We All Can Do To Become Health Plan Heroeshttps://www.phiagroup.com/Media/Posts/PostId/401/top-miscues-employers-make-when-it-comes-to-their-health-plans-and-what-we-all-can-do-to-become-health-plan-heroesWebinarsWed, 15 Feb 2017 19:47:16 GMT<p>Employers who self-fund their health plan act as a traditional employer, a plan sponsor, and a plan administrator. Juggling this many roles, conflicts and contradictions are bound to happen. For instance, an  employee handbook’s handling of disability leave may conflict with the health plan document as it relates to employment and plan coverage.<br /> <br /> Thanks for joining The Phia Group’s legal team on February 15, 2017, as they discussed top miscues employers make when it comes to their health  plans, and what we all can do to become health plan heroes; rescuing employers who have blurred the lines, and will without our help soon be stuck between a rock and a hard place.<br /> <br /> <a href="/Portals/phiagroup/webinars/feb2017/ThePhiaGroup_s February Webinar - Top Miscues Employers Make.mp4" target="_blank">Click Here to Download Full Webinar</a><br /> <a href="/Portals/phiagroup/webinars/feb2017/ThePhiaGroup_s February Webinar - Top Miscues Employers Make.mp3">Click Here to Download Audio</a><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 401Empowering Plans Segment 02 - The Next Episodehttps://www.phiagroup.com/Media/Posts/PostId/400/empowering-plans-segment-02-the-next-episodePodcastsMon, 13 Feb 2017 03:18:24 GMTIn this second installment of The Phia Group's official podcast, our hosts begin sharing what makes their own health plan a source of savings for the employer and benefits employees love.<br /> <a href="http://www.phiagroup.com/LinkClick.aspx?link=https%3a%2f%2fwww.youtube.com%2fwatch%3fv%3d1rio5omeoDg&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Click here to open the Podcast!<br /> </a> <iframe src="https://www.youtube.com/watch?v=1rio5omeoDg" height="315" frameborder="0" width="560"></iframe>400Empowering Plans Segment 01 - The Maiden Voyagehttps://www.phiagroup.com/Media/Posts/PostId/399/empowering-plans-episode-01-the-maiden-voyagePodcastsTue, 31 Jan 2017 13:20:00 GMTWelcome to the maiden voyage of "Empowering Plans," a new Podcast by The Phia Group where our hosts will review the purpose of this new series of Podcasts, reveal what the next few episodes will be about, and open the forum to our partners for comments and ideas.<br /> <br /> <iframe src="https://www.youtube.com/embed/xzaZqBhSrIY" width="560" height="315" frameborder="0"></iframe>399Back to The Self-Funding Future – Which Echoes of 2016 Will Continue to Impact Self-Funding in 2017https://www.phiagroup.com/Media/Posts/PostId/396/back-to-the-self-funding-future-which-echoes-of-2016-will-continue-to-impact-self-funding-in-2017WebinarsThu, 19 Jan 2017 18:44:06 GMT<p>The past decade has ushered in both outrage and opportunity for self-funded plans, and 2016 was no different. The characteristics of self-funded plans continued to alter in concert with new laws and regulations. While these bureaucratic efforts often hindered our ability to self-fund, for those daring enough to change with the times, we saw increased growth and prosperity. We will no doubt see these issues and opportunities continue to evolve in 2017, and only those that prepare will thrive.<br /> <br /> Thank you for joining The Phia Group’s team of attorneys on January 19, 2016 as they reviewed the most troublesome and costly issues of 2016 and opportunities that were born from strife - and examined how they will impact self-funding in 2017 while offering some solutions for the new year.<br /> <br /> <a href="/Portals/phiagroup/webinars/Jan2017/The Phia Group - Back to the Self-Funding Future - 1-19-17.mp4">Click here to download the video.</a><br /> <a href="/Portals/phiagroup/webinars/Jan2017/The Phia Group - Back to the Self-Funding Future - 1-19-17.mp3">Click here to download the audio.</a></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to <a href="mailto:mpainten@phiagroup.com" style="color:#0563c1; text-decoration:underline">mpainten@phiagroup.com</a>. </span></span></span></p> 396The Phia Group's 1st Quarter 2017 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/395/the-phia-groups-1st-quarter-2017-newsletterNewslettersTue, 17 Jan 2017 16:07:52 GMT<object type="application/pdf" data="http://www.phiagroup.com/Portals/phiagroup/newsletters/ThePhiaGroup - 2017 Q1 Newsletter.pdf" width="100%" height="800px"></object> <strong><br /> <br /> <span style="font-size: 18px;">Alternatively, you can download the file <a href="http://www.phiagroup.com/Portals/phiagroup/newsletters/ThePhiaGroup - 2017 Q1 Newsletter.pdf">here</a>.</span><br /> </strong>395The Stacks - 4th quarter 2016https://www.phiagroup.com/Media/Posts/PostId/393/the-stacks-4th-quarter-2016Misc,Newsletters,PublicationsTue, 03 Jan 2017 20:35:12 GMT<strong>Section 1557: Removing the Gender Divide in Employer Medical Plans<br /> By Jennifer M. McCormick, Esq.</strong><br /> <br /> The fourth quarter is exciting. Not only do we have the holidays to look forward to, but we have so many opportunities and ideas to contemplate for the upcoming plan year. Generally, over the course of the year we see regulations take effect and guidance clarified, and even learn some new cost containment techniques. Unfortunately, this does not always mean that we know exactly what must be revised in our health plan documents for the upcoming plan year in order to ensure we fully implement these compliance updates and cost savings. To complicate matters, we&rsquo;re on the edge of our seats to see whether (and how) the recent presidential election could further disrupt the Affordable Care Act (ACA). <br /> <br /> This is particularly true for some employer groups who are questioning what (if anything) they must modify in their health plan to comply with the ACA non-discrimination rule. In order to alleviate any heartburn this specific aspect of ACA may cause for the upcoming renewal season, let&rsquo;s try and break down what Section 1557 really means for plan sponsors.<br /> <br /> <em>What Is Section 1557?</em><br /> <br /> Section 1557 prohibits discrimination in certain health programs and activities on the basis of race, color, national origin, sex, age, or disability. It&rsquo;s not news that discrimination against an individual on the basis of race, color, national origin or disability is prohibited &ndash; but &ndash; Section 1557&rsquo;s expansion of these protected classes to now include discrimination on the basis of sex, is. As with other new regulations, the issued guidance leaves us with a lack of clarity and many unanswered questions; however, despite confusion and uncertainty, employers are still required to review and potentially revise internal processes and documents. <br /> <br /> This article focuses on the new classification of &ldquo;sex&rdquo; and the new corresponding considerations for plan sponsors. For instance, if Section 1557 is applicable to an employer&rsquo;s health plan, that plan cannot discriminate based on gender identity, meaning it cannot deny coverage based on an individual&rsquo;s sex or gender identity (i.e. an individual&rsquo;s internal sense of gender, which may be male, female, neither or a combination). <br /> <br /> Prior to making any Section 1557 related updates, however, it is important to understand what is required, and of whom. For example: (1) who must comply with Section 1557; (2) what does Section 1557 exactly require; (3) are there exceptions; and (4) what must change?<br /> <br /> <em>Who Must Comply?</em><br /> <br /> When more closely examined, the scope of Section 1557 is not particularly vast as it is only applicable to particular covered entities. For the purpose of this rule, a covered entity is an entity that operates a health program or activity, any part of which receives Federal financial assistance. Specifically, covered entities include all health programs and activities, any part of which receive federal assistance from HHS, health programs and activities administered by HHS (including the Federal Marketplace), and health programs and activities administered by entities under Title I of the ACA (including State Marketplaces).<br /> This generally means that an entity that receives a grant, loan, or subsidy or has another arrangement whether the federal government provides funds, services of federal personnel or property (real or personal) is subject to the Section 1557.<br /> <br /> Entities likely subject to Section 1557 include those involved in the administration of health care. For example, health insurance issuers, hospitals, health clinics, physicians&rsquo; practices, pharmacies, nursing homes, dialysis facilities, community health centers, providers that accept Medicare, and issuers on the Marketplace are generally subject to Section 1557.<br /> <br /> Once applicability of Section 1557 is confirmed, the entity must next make compliance related changes. Ensuring compliance is difficult, particularly since the text of Section 1557 describes what must not be done, instead of what must be done. <br /> <br /> <em>What&rsquo;s Required?</em><br /> <br /> According to the rule, an entity subject to Section 1557 must not: (1) deny, cancel, limit or refuse to issue health coverage based on sex; (2) deny or limit a claim; (3) impose additional cost sharing; or (4) employ discriminatory marketing or benefit design. Specifically, this means a health plan must not deny or limit treatment for any health care that is ordinarily or exclusively available to individuals of one gender based on the fact that the person seeking services identifies as belonging to another or different gender. <br /> <br /> While effective as of July 18, 2016, if Section 1557 requires changes to a health plan, the rule does not become effective for the health plan until the first day of the first plan year beginning on or after January 1, 2017. <br /> <br /> Changes to a health plan will be necessary if the plan design denies coverage based on gender identity, denies treatment or access to facilities for sex-specific ailments, categorically excludes services related to gender transition or excludes transition related treatment as experimental or cosmetic. As a result, health plan documents must be carefully reviewed and any relevant exclusionary language timely removed.<br /> <br /> Additionally, entities subject to Section 1557 must comply with certain notice and tagline requirements. Unlike the health plan changes, these notice requirements took effect 90 days after the July 18, 2016 effective date.<br /> <br /> One of the requirements is that notice be placed in significant publications and significant communications targeted to beneficiaries, enrollees, applicants, and members of the public. While the term &lsquo;significant publications and significant communications&rsquo; has not been explicitly defined, the agencies suggested they will interpret this term broadly and it will not be limited to those publications or communications intended for a broad audience, but could also include those directed at individuals. As a result, it will be important for employers to review their communications to ensure compliance with the notice requirements.<br /> <br /> Section 1557 outlines what must not be done with respect to benefits and requires that notices be included in certain materials, and hints at potential exceptions to these requirements.<br /> <br /> <em>Are There Any Exceptions?</em><br /> <br /> This rule does not include an exception, unlike other ACA requirements which allow for certain exemptions and accommodations (i.e. the contraceptive piece of the preventive care requirement). <br /> <br /> The rule, however, does state that certain protections already exist and Section 1557 would not displace regulations issued under the ACA related to preventive health services. Further, HHS did note that application of any requirement under Section 1557 which would violate applicable federal statutory protections for religious freedom and conscience is not required. Cases in multiple jurisdictions are currently underway and we expect to see additional guidance on this issue as a result of the litigation.<br /> <br /> Additionally, a third party administrator (TPA) subject to Section 1557 does not render a plan for which it administers benefits automatically subject to Section 1557 (and vice versa). A TPA will only be liable for Section 1557 non-compliance if their own actions are discriminatory. <br /> <br /> As it relates to the notice requirement, the preamble to Section 1557 did note that entities subject to the rule may exhaust their current supplies of significant publications and communications prior to incorporating the required notice.<br /> <br /> <em>What Must Change?</em><br /> <br /> Guidance implies that Section 1557 will be interpreted broadly so entities must first decide if they are subject to the rule.<br /> <br /> If subject to the rule, the health plan should be reviewed for compliance. Note that the rule does not explicitly require coverage of any particular service (either surgical or non-surgical) to treat gender dysphoria, gender identity disorder, or any individual that is transitioning genders, exclusions or coverage limitations related to sex, gender dsyphoria or sexual orientation must be removed. However, if a plan has an exclusion for sex change surgery for individuals diagnosed with gender dysphoria, it should be removed or modified. <br /> <br /> Further, the rule does not require a plan to cover health care that is based on gender when the care is not deemed to be medically necessary (e.g. prostate exam for a woman that identifies as a transgender male). Additionally, a plan may use reasonable medical management to apply neutral, non-discriminatory standards (as long as it resulted from &ldquo;a neutral rule or principle&rdquo; when adopted and the reason for its coverage decision was not a pretext for discrimination). <br /> <br /> If not subject to Section 1557, the health plan is not required to make benefit changes. The entity, however, should evaluate their risk tolerance as there is still the potential for the U.S. Equal Employment Opportunity Commission (EEOC) to investigate complaints of discrimination by the employer. Cases regarding plan exclusions of sex reassignment surgery are currently pending in the courts. Further, this should be a significant consideration after a federal court ruled on November 7, 2016 to deny a motion to dismiss a sex discrimination case that the EEOC had filed. Specifically, the EEOC&rsquo;s motion explained that sexual orientation discrimination was a form of prohibited sex discrimination. <br /> <br /> Even if an entity has a high tolerance for risk (or is not concerned about potential employment discrimination), consider other reasons for complying with Section 1557, including the impact on potential claims. According to a June 2016 study from the Williams Institute, there are an estimated 1.4 million adults who identify as transgender in the United States, or 0.6 % of the population. Many entities are opting to cover these benefits and coverage could be seen as a competitive advantage or good public relations.<br /> <br /> <em>Summary</em><br /> <br /> Since the final rules were issued, insurers and other industry entities are taking a position on how to address Section 1557. Insurers are directly subject to 1557 and fully insured plans taking a conservative approach are being modified to include surgical and non-surgical treatment for gender dysphoria.<br /> <br /> Employers subject to Section 1557, and those not subject but who wish to avoid EEOC scrutiny, should remove any exclusions from health plans which could be viewed as categorical exclusions of transgender services. The decision to cover or exclude transgender benefits, however, ultimately depends on the risk adversity of the employer. As a result, every employer and plan sponsor must review their situation on a case by case basis for Section 1557 applicability and modify relevant materials accordingly.<br /> <br /> Of course all of this could become irrelevant if the ACA is repealed or replaced, so I guess we&rsquo;ll have to wait and see&hellip;<br /> <br /> <hr /> <strong><br /> How to Avoid Common Pitfalls When Managing a Self-Funded Health Plan<br /> By Brady C. Bizarro, Esq.</strong><br /> <br /> Since the passage of the Affordable Care Act in 2010, employers have become increasingly aware of the potential financial benefits that come with adopting a self-funded health plan. A primary benefit of self-funding is that under the Employee Retirement Income Security Act, self-funded plans are shielded from the reach of state insurance regulations. States are unable to regulate these self-funded ERISA plans as they would fully-insured health plans.<br /> <br /> As a result, employers are empowered to use innovative plan language to craft an affordable, flexible plan. Additionally, employers benefit from uniform coverage and cost continuity because a single plan can cover many employees in multiple states.<br /> <br /> Despite the real advantages of self-funding, many employers still seek out tools they can use to transfer actual or perceived risk away from their plans. That's where incentives and disincentives come into play -- but there are potential pitfalls to be aware of.<br /> <br /> Federal law expressly prohibits discrimination against plan participants based on sex, disability, health factors, and other criteria. For example, offering incentives to enroll in Medicare is not permitted according to the Medicare Secondary Payer Act. This is part of the basic structure of the act and, as might be expected, the regulatory bodies charged with enforcement take a very broad view of what actions might constitute such an incentive. While it may be intuitive for a plan to suggest that its participants can, for a monetary incentive, terminate coverage under the plan and instead become covered under Medicare, this runs afoul of the act.<br /> <br /> According to the Department of Labor, an employer can't give a cash reimbursement for the purchase of an individual market policy. If it does so, the payment arrangement is part of a &ldquo;plan, fund, or other arrangement established or maintained for the purpose of providing medical care to employees, without regard to whether the employer treats the money as pre-tax or post-tax to the employee.&rdquo; Therefore, the arrangement is a group health plan under ERISA. Under the ACA, such arrangements can't be integrated with individual market policies. To be compliant with the ACA, a premium reimbursement plan (or HRA) must be integrated with a compliant group health plan.<br /> <br /> Offering a choice between cash and health benefits is generally allowable, but the compensation can't be designated specifically for the payment of individual premiums. Any attempt to condition these payments on proof the employee enrolled in exchange coverage would therefore be noncompliant with the ACA.<br /> <br /> An offer of cash in lieu of benefits would also be deemed discriminatory if made only to high risk or ill employees. Such an offer must be extended to all employees. It's also worth noting that if the employer offers affordable coverage which meets the minimum value requirements, employees would not be eligible for subsidies on the exchange -- and exchange coverage would therefore likely be less affordable or attractive to an employee than the employer&rsquo;s group plan.<br /> <br /> Modifying copays and deductibles is another way an employer can incentivize employee behavior. The Department of Labor indicates that a plan may waive or lower a copayment for the cost of certain services in order to encourage participants to seek a certain type of care -- such as well-baby visits or regular physicals. This can benefit the group by ensuring employees and their families are healthy. Similar to copayments, plans may waive or lower deductibles for certain services at the employer's discretion. It should be noted that a HSA-qualified high-deductible health plan is can't retain its HSA qualification if the plan pays first-dollar for services other than preventive care -- so HDHPs can't utilize deductible waivers as an incentive in most cases.<br /> <br /> Just as providing incentives to employees may lower the cost of self-funding, so can disincentives.<br /> <br /> The simplest type of disincentive is raising deductibles and even lowering the percentage of covered services. By doing this, the plan sends the message to participants that remaining enrolled in the plan may not be the best financial choice. At the very least, a raise in price may cause participants to explore other options. <br /> <br /> However, employers should note that raising deductibles could adversely impact the plan in the form of driving even healthy lives to the exchanges. In other words, recklessly including high deductibles in a plan could drive away the very lives the plan needs to thrive, as well as those it wanted to disincentivize in the first place.<br /> <br /> An alternative option to consider would be for the plan to have no deductible up to a certain point, at which point the deductible becomes applicable -- and the deductible is the highest permitted by applicable law. By doing so, the plan can ensure that the healthy lives it wants to keep on the plan are satisfied with the care offered because they won't have a deductible for their care. <br /> <br /> A &ldquo;skinny plan&rdquo; is a type of plan that has been developed in the wake of the ACA. As the ACA imposes many requirements on self-funded plans, the skinny plan attempts to comply perfectly with the requirements of the ACA, and cover the bare minimum allowed by law. A skinny plan is a sort of bare-bones model -- it's generally considered not suitable to employees who have underlying conditions, who may need specialty care. The ACA doesn't require that the plan cover specialty care, so skinny plans don't cover a lot of services that many employees need on a regular basis. <br /> <br /> The ACA requires that all large employers offer healthcare to their employees -- but there's no requirement that the employees enroll on the employer&rsquo;s plan. If the employer offers a skinny plan, and many employees elect to not enroll due to its lack of coverage of services they may need, then the employer has still complied with the ACA. <br /> <br /> One potential pitfall of offering a skinny plan may be relevant to employers with smaller employee bases; if not enough employees enroll, maintaining a self-funded plan may prove unfeasible. For this reason, offering a skinny plan is likely only a good option for larger employers.<br /> <br /> Pursuing healthcare cost containment strategies is increasingly important for employers who wish to offer affordable health insurance to employees, especially after the passage of the ACA. Self-funded plans can benefit from creative plan design -- and managing risk with incentives and disincentives can provide even greater savings. Provided that employers can stay compliant with anti-discrimination regulations, self-funded health plans will continue to be uniquely flexible and offer real savings to both employers and employees alike.<br /> <br /> <hr /> <br /> <strong>Confessions of a Self-Insured Employer<br /> By Adam V. Russo, Esq.</strong><br /> <br /> As an employer and founder of a business, I will never forget my first experience purchasing health insurance for my employees at The Phia Group. It was 2002 and I was so excited that the company I co-founded in my mother&rsquo;s basement with my best friend from college was successful enough to actually need health care coverage because we finally had employees. Excitement turned to frustration, and that experience with the health insurance market opened my eyes and sparked within me a new level of passion for revolutionary change; to change how health insurance should look and feel.<br /> <br /> How could purchasing health coverage be so different than every other thing that we purchased for the office? I'm not talking about pens, desks, or paper; I&rsquo;m talking about other employee benefit options such as life insurance, 401k plans, and our firm&rsquo;s errors and omissions coverage. In every other purchase we made, there was transparency, there was true competition, and there was actual and meaningful discussion. When it came to buying health insurance there was...well, nothing. <br /> <br /> The insurance broker walked into my office and after exchanging pleasantries she showed me three options for health insurance. The first option was with a certain insurance company that the broker clearly wanted us to use. There were color brochures for this carrier with great family photos; broad smiles and even bigger fonts. The other proposals didn't come with the fancy colorful brochures (or even brochures at all for that matter). It was clear that the broker wasn't being transparent and had her own agenda to pursue. The broker was getting great commissions from this one particular carrier and that was it. I asked basic questions that in any other industry would be easy and obvious to answer or research. She just smiled.<br /> <br /> I was told what the premiums would be and how there were basically two options available to my employees. They could have a $20 or $50 copayment coupled with a few deductible options. So (basically), the &ldquo;actual&rdquo; consumers of the health services (a.k.a. the employees), would believe that the cost of the services are either $20 or $50 - in their minds this is the total bill. There was no skin in the game for my employees. <br /> <br /> There was nothing that my employees could do to lower the overall cost of the plan. If every single one of my employees was in perfect health and never even saw a doctor, my plan's rates would be guaranteed to increase over 10% a year. So what is the incentive? For me to be creative? For my employees to care? There was nothing we or anyone else could do about the cost. We were helpless and that's how it must feel for every employer or insured group that pays insurance premiums to a fully insured carrier or exchange marketplace policy. <br /> <br /> Like you, I figured that maybe this was just my experience and that this one broker was an anomaly, but I have since realized that this is the norm. The broker who actually offers expertise, consults with their clients and focuses on data and plan design is the anomaly. For most of us, we are at the whim of the carriers. <br /> <br /> There is no shopping for rates unless you want to strip down or increase the contributions of your employees. <br /> <br /> Imagine buying a car and being told every year that you will pay more for the same car (that you hardly used), or you can strip it down in an effort to maintain the payment level and keep the same monthly rates. Next year you will only have a 10% increase if you agree to remove the leather interior! That is exactly what happens with healthcare. The reason &ldquo;why&rdquo; is because nobody expects or demands anything different. The options available via the exchanges, for many, are even worse. Many people only have one option - like in the old Soviet Union where the select few who could afford it had the choice of buying a Russian Lada in black or white; the rest get what they&rsquo;re given.<br /> <br /> Think about this for a second. People spend more time choosing the big screen for their living room than they do where and how they get their health care. New parents spend more time researching the day care center for their children than the hospital or pediatrician that treat the same children. CFOs across the country spend so much of their time trying to find ways to increase profit and reduce expenses yet rarely think about health care costs. They look at the revenue stream and the expense lines to see what they can do to cut costs and increase profitability. Most CFOs just assume that their health insurance will go up, and compare it to the cost (penalty) of offering nothing; that the expenditures are essentially a fixed cost that grows each year. There is hardly any discussion relating to how to lower it since these individuals feel powerless to do anything about it. <br /> <br /> As someone who risked it all and started my own business, there was no way I was going to adopt this approach with my health care spend. This was the moment I realized that I needed control over my healthcare dollars and looked at self-funding my employee benefit plan for the first time, almost a decade ago, and we have never looked back. The beauty of self-funding is that you can lay your own path. You are in total control of your health plan and you can design the features to meet the needs of your employee population. <br /> <br /> The reality is this &ndash; a health plan design for a tire manufacturer should not be the same as for a chain of yoga studios. Unfortunately in today&rsquo;s fully insured market &ndash; where a carrier sells you a cookie cutter policy, it is. By having access to the claims data, a self-funded employer can actually see how and where your employees are spending the plan's health care dollars. Using the data analytics readily available only to a self-funded plan, you can then design a plan that meets your needs.<br /> <br /> <em>Incentivizing Our Employees through Unique Plan Design</em><br /> <br /> Medical service providers are businesses. They service customers who pick what to buy, but don&rsquo;t pay the fee directly. A kid at a baseball game with dad&rsquo;s credit card will buy more hot dogs, regardless of the price, and the vendor knows it. When the price isn&rsquo;t something the consumer considers, the supplier has no reason to cap it. <br /> <br /> If your employees do not care about the cost of health care, then costs will never decrease. Step one then, is to care. With fully funded insurance, savings belong to the insurance carrier. I understand not caring about that! But with self-funding, most employees (wrongfully) feel that if a self-funded plan saves money then the money just goes into the CEO&rsquo;s pocket. This is not true, as every dollar recouped or not spent goes back into the general assets of the plan, which is a combination of employee and employer contributions. To combat this incorrect perception, we have educated our employees about who pays for the plan (they do), and incentivized our employees to actually care about the cost of the care they get &ndash; not just their co-pays, deductibles and out-of-pockets.<br /> <br /> It all starts with your health insurance employee plan document. When you open The Phia Group plan document, the first thing you see is a section titled &ldquo;cost containment incentives.&rdquo; It truly is an actual page in the document that tells employees how they can make money and put cash in their pocket by looking at the whole bill and not just their co-pay. The first time an employee gets money in exchange for creating plan savings, word spreads like wildfire throughout the organization. People talk about it at the water cooler; and whether it&rsquo;s $100 in savings or $30,000, every bit counts and adds up.<br /> <br /> As mentioned, our plan document features numerous provisions enabling participants to enjoy substantial savings and benefits when they take proactive measures to contain overall plan expenditures. We address the various instances where responsible, cost-containment behavior is incentivized. <br /> <br /> For instance, we created a claim audit review program designed to reward employees for identifying erroneous charges on bills recoverable by the plan. Simply put, if the patient identifies something questionable in their &ldquo;bill&rdquo; (actually, the explanation of benefits or &ldquo;EOB&rdquo; since participants rarely see the provider bill itself), and the plan doesn&rsquo;t have to pay it or is able to recoup the payment, the patient gets 25% of the savings in their pocket, regardless of the amount. Trust me; we only pay for services that actually occurred and are valid! One employee received a check for over $10,000 for identifying $40,000 in claims we didn&rsquo;t have to pay. This is promoted across our entire organization.<br /> <br /> This next one has likely saved us many thousands in potential claim costs. Participants who preemptively consult with our human resources department regarding non-emergency &ldquo;to-be-scheduled&rdquo; medical procedures, to discuss options available to the participant, can receive a financial reward. We had a recent situation where one of our employees needed a medically necessary surgery. The employee&rsquo;s surgeon could have performed the operation at two different facilities. The employee met with our HR team and after reviewing the claims data available to us we realized that the higher quality facility would have a total cost of $7,000 to perform the operation, while the other facility, using the same surgeon, would cost $40,000. We saved $33,000 and our employee received 25% of this amount in a check payable to them! That&rsquo;s called having skin in the game. <br /> <br /> At any other self-funded plan, employees would just go to the place that may be closer to their home, or maybe they know a friend who works at the hospital, or they pick one over the other for any other reason ... perhaps they choose a location with better parking because at the end of the day, they have the same co-pay and deductible regardless of where they go. They have no idea that one facility will cost the plan tens of thousands of additional dollars for the same exact procedure. However, at our company they do know and they do care ... and that&rsquo;s a real difference maker.<br /> <br /> We have another provision stating that there is no co-pay for the use of urgent care facilities in lieu of a hospital&rsquo;s emergency room. Think about how much time and money this saves the patient and the large bill that doesn&rsquo;t exist for the plan. We took it a step further by stating that the co-pay (normally applicable to diagnostic services if performed at a hospital) is waived if the service is sought at any self-standing non-hospital facility. What this provision has done is change the behavior of our employees. When they need testing done, they ask if it can be done at a non-hospital facility. In addition, in order to encourage the use of generic medication whenever possible, we waived any co-pay.<br /> <br /> The cultural change affects every aspect of our health plan and the reduction of overall plan spending. Under our current network, you can purchase a nebulizer after the network discount for a total plan cost of $200. If you go to Amazon.com, you can purchase that same nebulizer for $118 with free two day shipping on Amazon Prime. It&rsquo;s a savings of $82 and the employee receives a check for 25% of that amount. While it&rsquo;s a small amount compared to the overall plan expense, it&rsquo;s a huge change in our employees&rsquo; behavior. They look for ways to reduce the cost, whether it&rsquo;s big or small, because that $20.50 is added to their paycheck. <br /> <br /> <em>The Future is Now</em><br /> <br /> Instead of telling their employer plan sponsor clients to pay more in premium, deductibles, out of pockets and co-pays, brokers should be telling their clients and employees the real reason behind the high cost of health insurance &ndash; the unjustifiable facility charges. Facilities are taking advantage of the fact that most employees only care about their out of pocket, co-pays and deductibles &ndash; not the entire bill. This is in essence the best thing about networks and the worst thing about networks. There is no patient noise because they don&rsquo;t care. If they only have to pay $20, the fact that it costs the employer $20,000 or $200,000 doesn&rsquo;t matter. So how do we get the employees to care? Easy. Self-fund your health plan, teach the participants how it&rsquo;s funded, instill an appreciation for the fact that the medical bills are being paid with their money, and give them cash &ndash; incentivize savings. <br /> <br /> At the day of the day, what really matters to employers? Do they care what the network is, what the logo looks like, what the overall discount is, how many free tickets to the ballgame they receive or how fancy the website looks? I would argue no. As an employer myself, I feel that I have the right to answer this question with some level of authority. I want my employees to be happy. I want my employees to feel secure and that security includes a respectable pay check for a hard week&rsquo;s work and health insurance coverage that will be there for them and their loved ones when they need it most. <br /> <br /> The only way to ensure there is reliable health coverage for my employees in the future is to innovate and get everyone to care. When an insurance carrier collects premium, takes all the risk associated with paying medical bills, and none of us know (or have a reason to know) what things cost, we don&rsquo;t care. If we don&rsquo;t care, we don&rsquo;t innovate. The simplest ways to innovate right now and get the most bang for our buck is to put ourselves and our employees in a position of financial risk and reward, tied to healthcare spending, focus less on discounts off of arbitrary prices and focus more on what is actually being charged.<br /> <br /> We can revolutionize health care and insurance in this country. Self-funding is the first step towards offering the innovation, technology, plan design, and customization tied to having skin in the game, and that is what this country needs. <br /> <br /> <hr /> <br /> <strong>What You Don't Know Can Hurt You: Be Prepared For the Unintended Consequences of Effective Cost Containment <br /> By Christopher M. Aguiar, Esq.</strong><br /> <br /> The cost of healthcare in the United States is out of control, and virtually everyone operating in the world of healthcare should know the root of the problem. As stated by Gerard Anderson, a healthcare economist at the Johns Hopkins School of Public Health, &lsquo;the prices are too @#$% high.'[i] A sweeping statement that encapsulates the healthcare conundrum in five simple words. Many in the industry are giving it their all to try to combat those prices, and in no area is that more prevalent than in the world of self-insurance, where a new cost containment idea appears to service daily. But to launch those ideas without a full understanding of all the elements of a self-funded benefit plans and all the issues that may arise can put plans and their advisors in the line of fire. Whether it is through ineffective implementation of a cost containment strategy (make sure your plan language is strong before you start repricing those medical claims), misunderstanding the many relationships a plan enters into (consider your stop loss and network obligations before you try to implement any cost containment initiative), or not evaluating the situational prudence of a particular strategy, administrators must avoid going into any cost containment venture blindly. <br /> <br /> Why would any plan or administrator rush into a decision with such broad implications on its benefit plan? Quite simply, the pressure is on. Increasingly, courts are holding plans and advisors responsible for their duties as plan fiduciaries and careful oversight and dissemination of plan assets is under a microscope Unless you have been living under a rock, you know how aggressively health costs are rising, but just in case, consider the following statistics:<br /> <br /> 1. Healthcare inflation has outpaced inflation of the consumer price index every year dating back to at least 2005. [ii]<br /> 2. In 2015, Healthcare inflation outpaced the consumer price index by 900%. [iii]<br /> Those statistics do not even specifically reference some of the shortfalls of the highly touted savior of healthcare, the Affordable Care Act (the ACA). <br /> 3. According to the Henry J. Kaiser Family Foundation, between 2014 and 2015, Benchmark Silver Premiums were either flat or increased up to more than 10% in the majority of the country. [iv] <br /> 4. The number of exchange participating insurers is down approximately 25% from 2013 to 2016 with major players such as Aetna, United Health Care, and Humana all pulling themselves from the marketplace. [v]<br /> <br /> Due to the continued increase in costs, benefit plans and their advisors continue to develop viable ways to provide robust benefits. When faced with challenges, business owners rely on their entrepreneurial spirit and seek innovative answers; many are looking to self-insurance as their alternative. <br /> <br /> An excellent example of some innovative approaches for which those who seek alternatives often underestimate the downstream consequences is a reference based pricing approach to claims payment. Perhaps the most innovative and often discussed strategies, reference based pricing is still utilized by a small percentage of plans because its implementation is complicated and can be difficult and volatile. There are different types of reference based pricing plans that can help minimize the disturbance while maximizing their impact on savings. Some plans choose to go with a very aggressive approach, severing all arrangements with networks and instead paying all claims as if they are out of network by setting pricing parameters based on several data references derived from publicly available sources such as Medicare or hospitals' cost data. On the surface, an approach like this can be sold quickly by savvy sales professionals because they can tout hundreds of points in savings, virtually overnight. Unfortunately, there are some very important details that must be considered before proceeding: 1) no pricing model will be successful unless you have airtight plan language; 2) unless you work with a stop loss insurer that understands the complexities of a reference based pricing model and who will support the efforts, any reference base pricing approach will likely fail; and most importantly, 3) any aggressive repricing model will experience backlash as hospitals use the best resource they have against the benefit plans, the patients. The stark reality and the unrest it causes often leads to the demise of such innovative endeavors. As so many self-funded professionals will tell you, and especially with the new batch of organizations looking to self-fund in a post-ACA world, once burnt, a self-funded employer flees to the world of the fully insured, never to take on the risk of self-funding again, regardless of how lucrative the rewards might be.<br /> <br /> Amongst all of the innovative approaches discussed in the self-insured marketplace, all of which could have a separate article concerning the potential consequences of an ineffective implementation or execution of the model, many of the consequences and considerations discussed above are relatively contained within the confines of the model itself. But what about these models' impacts on other, oft overlooked, perhaps more downstream cost containment tools? Bear in mind that many of the cost containment mechanisms that are sought after and publicized today are designed to control costs before the claims are actually paid, whereas more traditional cost containment strategies (e.g. subrogation) are focused on recovering funds that are already spent. So every cost containment model designed at reducing the amount spent will necessarily have an impact on the execution of an effective third party recovery program.<br /> <br /> Consider this example: ABC, Inc. sponsors a self-insured employee benefit plan. It utilizes a referenced based pricing model with no network obligations; instead, it has established very effective plan language that provides for payment of 200% of some reference price. John Smith is a beneficiary of the benefit plan and suffers injuries in an automobile accident. The benefit plan receives $200,000.00 in medical bills. Mr. Smith brings a third party claim and obtains the full insurance limits available to him, $50,000.00. Of that $50,000.00, he owes his attorney a 33% contingency fee, leaving him with a net settlement of $33,333.37. Assume that 200% of the reference price as established by the terms of the plan totals $100,000.00. Because the plan established its program effectively, the plan's payment is entirely defensible. On the surface, the provider received a fair payment derived from publicly available data which covers the costs incurred in providing the services as well as an additional amount to ensure profitability. So, what is the problem? Recall that the provider's initial bill for its services was for $200,000.00. When Mr. Smith went to the hospital, he signed a document wherein (the hospital will argue) he agreed to pay any balance remaining once his insurance pays for the services. As a result, the provider in this case now puts a lien on Mr. Smith's settlement for $100,000.00, i.e. the difference between the $200,000.00 charge and the $100,000.00 paid by the plan. Of course, Mr. Smith also has an obligation to reimburse the Plan the full amount of his settlement. <br /> <br /> Balance billing, the practice by which the provider seeks the remainder of a bill from a patient after the insurance payment, is an unintended consequence of a reference based pricing strategy and can negatively impact the plan&rsquo;s rights in a third party recovery case. It occurs because the only way to prevent a provider from seeking full payment from a patient is to enter into a contract wherein the provider agrees not to bill the patient upon receipt of payment from the plan, subject to other conditions. Without this agreement, in almost every situation, the provider is free to request payment from Mr. Smith. As this hypothetical example is designed to illustrate, the provider&rsquo;s ability to bill Mr. Smith for the remainder of the bill causes complications in the plan's ability to recover the third party funds from Mr. Smith&rsquo;s settlement. Note that even if Mr. Smith wanted to issue reimbursement to the Plan, he now has a rather large elephant in the room &ndash; a $100,000.00 provider lien. In this scenario, the best a plan can likely hope for is that the provider agrees to some split between the parties of the remaining $33,333.37 rather than insist on full payment. Otherwise, the only way to successfully recover money for the plan is with a lawsuit challenging the enforceability of the agreement Mr. Smith signed when he arrived at the hospital. In many jurisdictions, the plan participant's lawyer will simply deposit the money with the courts and file an interpleader, i.e. an action which forces all interest holders to appear before the court and prove their claim to the money.<br /> <br /> As many who have engaged in any dispute with a hospital over a perceived debt can attest, providers will make their claim with exhaustive persistence often refusing to concede the actual value of their services or the questionable legality of their contract with patients guaranteeing payment. In order to obtain a recovery, the plan or its administrator may need to engage legal counsel and incur additional expenses thereby calling into question the prudence of such a pursuit; once those costs are factored in, and in light of the limited funds available, it may no longer make financial sense to pursue the recovery. Some advisors will stress the plan&rsquo;s duty to seek every recovery dollar as required by the terms of the plan and its fiduciary duty under ERISA. While this is unquestionably a very important obligation of the plan, many plan advisors will forget the second, perhaps more important duty of a benefit plan administrator, to exercise prudence in its administration of plan assets. <br /> <br /> In the end, it is imperative for plans and administrators to understand the complexities and consequences of every decision and benefits strategy they choose to utilize. There is a bevy of innovative tools and cost containment mechanisms that can be used to help benefit plans maximize savings. These include but are not limited to the reference based pricing strategies discussed above as well as some of the more hybrid approaches customized to give benefit plans the best of both worlds (strong plan language controlling out of network charges and some form of network for a feel as seamless as their fully-insured counterparts), self-insured plans can be tailored to fit the needs of the plan. As more benefit plans become more aggressive and experts come up with new strategies, it is important that those who establish benefit plans understand the full range of issues that may arise from their decisions. Utilizing experts that understand the self-insurance industry is an absolute necessity. Whether an administrator, a plan document drafting partner, a repricing agent, or a subrogation expert, understanding the self-insured marketplace improves the experience for the benefit plan, and puts it in the best position to succeed, and ultimately, remain self-insured. <br /> ________________________________________<br /> [i] http://www.citizen-times.com/story/opinion/contributors/2014/02/17/lets-face-it-todays-gigantic-hospitals-are-ripping-us-off/5493643/<br /> <br /> [ii] http://www.forbes.com/sites/mikepatton/2015/06/29/u-s-health-care-costs-rise-faster-than-inflation/#5a035ef16ad2<br /> <br /> [iii] http://www.forbes.com/sites/mikepatton/2015/06/29/u-s-health-care-costs-rise-faster-than-inflation/#5a035ef16ad2<br /> <br /> [iv] http://kff.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-affordable-care-acts-health-insurance-marketplaces/<br /> <br /> [v] Edmund F. Haislmaier: Senior Research Fellow, Center for Health Policy Studies, http://www.heritage.org/research/reports/2016/03/insurer-aca-exchange-participation-declines-in-2016<br /> <br /> <hr />393The Phia Group Appoints Tim Callender, Esq. as Vice President of Sales & Marketinghttps://www.phiagroup.com/Media/Posts/PostId/392/the-phia-group-appoints-tim-callender-esq-as-vice-president-of-sales-marketingPress ReleasesTue, 03 Jan 2017 17:47:09 GMT<span style="font-size: 18px;"><strong>The Phia Group Appoints Tim Callender, Esq. as Vice President of Sales &amp; Marketing</strong><br /> <br /> <em>Braintree, MA</em> &ndash; The Phia Group, LLC is pleased to announce the appointment of Attorney Tim Callender to the role of Vice President of Sales &amp; Marketing.<br /> <br /> The Phia Group benefits from its reputation as a forward thinking advocate for the employer based and self-funded health plan industry. In this newly established role, Tim will provide customer guidance, brand development, and lead The Phia Group in its offerings to the industry. Sales Executive, Garrick Hunt, will continue to serve in his vital role and benefit from Tim&rsquo;s leadership and industry expertise.<br /> <br /> Tim brings with him over 10 years of legal and business experience, ranging from private legal practice, to various industry association board memberships and his time as general counsel for a large TPA.<br /> <br /> Commenting on his new role, Tim stated, &ldquo;This new role is a natural progression and a perfect fit. I&rsquo;m very fortunate that my career has allowed me to learn the ropes of the self-funded industry first from the TPA perspective and then grow that knowledge from within The Phia Group&rsquo;s industry-wide footprint. With my legal background, I know that I am uniquely positioned to understand the nuances and legal difficulties presented to those within our industry and then work to apply solutions best suited to fit those needs.&rdquo;<br /> <br /> The Phia Group&rsquo;s CEO, Adam V. Russo, remarked, &ldquo;Tim is an attorney who has walked in the shoes of our clients, and spent the majority of his career defending them. As the VP of Sales and Marketing, Tim will once again be called upon to improve the standing of our industry &ndash; by sharing opportunities to work with The Phia Group and benefit from our efforts, products, services, and ideas. His legal acumen, ability to communicate in any forum, and overall leadership qualities make him a perfect fit for this new role.&rdquo;<br /> <br /> <strong>For more information regarding Tim&rsquo;s new role and The Phia Group&rsquo;s many services, please contact Attorney Callender by email at <a href="mailto:tcallender@phiagroup.com" class="ApplyClass">tcallender@phiagroup.com</a> or by phone at 781-535-5631.</strong><br /> <br /> <em>About Timothy Callender, Esq.</em><br /> <br /> Tim was raised in the pinnacle business environment &ndash; a successful, family-run cattle operation in central Idaho. Tim began practicing law in Boise in the early 2000s before transitioning to the role of in-house legal counsel for a third party administrator where he learned the ins and outs of the TPA world and the self-funded industry as a whole. Tim has spoken on a variety of industry topics at respected venues such as the Society of Professional Benefit Administrators (&ldquo;SPBA&rdquo;) and the Health Care Administrator&rsquo;s Association (&ldquo;HCAA&rdquo;). Tim currently sits on the Board of Directors for the HCAA as well. In the past year, Tim has held a leadership role within The Phia Group, directly related to Phia&rsquo;s Plan Appointed Claim Evaluator (&ldquo;PACE&rdquo;) service as well as Phia&rsquo;s Independent Consultation and Evaluation (&ldquo;ICE&rdquo;) service. Tim works out of The Phia Group&rsquo;s Boise, Idaho office.<br /> </span>392List of Self-Funded Industry Acronymshttps://www.phiagroup.com/Media/Posts/PostId/390/list-of-self-funded-industry-acronymsMiscThu, 15 Dec 2016 15:09:01 GMT<p style="text-align: left;"><span style="font-size: 18px;">By popular demand, The Phia Group has published a list of common or helpful <strong>industry acronyms</strong>. This list has historically been used this as a <strong>training tool</strong> for The Phia Group's own employees, but it is being provided here in the hopes that it is found informative.<br /> <br /> <a target="_blank" href="/Portals/phiagroup/Publications/AcronymList/The Phia Group - List of Industry Acronyms.pdf"><strong><em>Click here for the list.</em></strong></a><br /> <br /> <strong>The Phia Group thanks you for sharing its common goal of reducing health care costs and helping the self-funded industry grow.</strong><br /> </span></p>3902017 Phia Forecasthttps://www.phiagroup.com/Media/Posts/PostId/389/2017-phia-forecastWebinarsTue, 13 Dec 2016 20:55:09 GMT<span style="font-size: 16px;">2016 has been another huge year for self-funding, and a year of significant change for healthcare in general &ndash; and with the results of the recent presidential election, 2017 is slated to be an exciting year as well. 2016 has played host to all sorts of new federal regulations, state laws, market trends, and cost-containment options, and we expect 2017 to be even more unpredictable&hellip;but still great for self-funding.<br /> <br /> Thank you for joining The Phia Group&rsquo;s legal team on December 13, 2016, for the 2017 Phia Forecast.<br /> <br /> <a target="_blank" href="/Portals/phiagroup/webinars/Dec2017/ThePhiaGroup - 2017 Phia Forecast - 12-13-16.pdf">Click here to download slides.</a><br /> <a href="/Portals/phiagroup/webinars/Dec2017/ThePhiaGroup - 2017 Phia Forecast - 12-13-16.mp4">Click here to download video.</a><br /> <a href="/Portals/phiagroup/webinars/Dec2017/ThePhiaGroup - 2017 Phia Forecast - 12-13-16.mp3">Click here to download audio.</a></span>389Independent Consultation & Evaluationhttps://www.phiagroup.com/Media/Posts/PostId/388/independent-consultation-evaluationPress ReleasesTue, 22 Nov 2016 13:43:17 GMT<span style="font-size: 18px;"><strong>The Phia Group, LLC Officially Announces the Release of its New &ldquo;Independent Consultation &amp; Evaluation&rdquo; (ICE) Service</strong><br /> <br /> Braintree, MA &ndash; The Phia Group has for more than a decade been a source of document review, claim analysis, and regulatory compliance consultation for the health benefits industry. Today, statutory changes are occurring with greater frequency, and the industry needs objective analysis and expert consultation now more than ever before. <br /> <br /> Unfortunately, hourly billing (the method by which most legal consultants charge clients) tends to be difficult to budget, predict, and afford. Rather than force clients to choose between dealing with open ended invoices and addressing difficult situations without assistance, The Phia Group now offers a consultation service featuring a per-employee per-month subscription fee.<br /> <br /> &ldquo;From business development and third party contract review to the application of ambiguous plan exclusions in unusual circumstances, you need legal consultation. To address regulatory compliance concerns, claim processing queries, and to collaborate on difficult administrative tasks, having an experienced team of attorneys and industry experts on call is a must have,&rdquo; remarked The Phia Group&rsquo;s CEO, Adam V. Russo, &ldquo;The Phia Group understands, however, that the cost can be prohibitive &ndash; until now.&rdquo;<br /> <br /> The Phia Group&rsquo;s Senior Vice President and General Counsel, Ron E. Peck, remarked, &ldquo;We believe that we are all ethically obligated to seek out objective, professional feedback in response to difficult situations. When the cost of such aid increases as the time spent on the matter extends, those who bill by the hour are rewarded for delays, and clients are punished for seeking out thorough review. The Phia Group opposes that inherent conflict of interest.&rdquo;<br /> <br /> With an ICE subscription fee, clients can preemptively budget for and share the cost of this invaluable resource &ndash; allowing The Phia Group and their clients to focus on what is really important &ndash; results.<br /> <br /> For more information regarding ICE and The Phia Group&rsquo;s many other services, please contact The Phia Group&rsquo;s Sales Executive, Garrick Hunt, by email at <strong><a class="ApplyClass" href="mailto:ghunt@phiagroup.com?subject=Independent Consultation &amp; Evaluation Service">ghunt@phiagroup.com</a></strong> or by phone at <strong>781-535-5644</strong>.<br /> <br /> </span>388The First 100 Days: President-elect Donald Trump, Healthcare, and Self-Fundinghttps://www.phiagroup.com/Media/Posts/PostId/387/the-first-100-days-president-elect-donald-trump-healthcare-and-self-fundingWebinarsMon, 21 Nov 2016 20:54:28 GMT<span style="font-size: 16px;">The election is behind us, and no matter who you supported, it was one of the most divisive in recent history. Regarding the contentious topic of healthcare, President-elect Donald Trump has promised to repeal the Affordable Care Act and replace it with a better, more efficient system. The future of our industry is sure to change.<br /> <br /> Thank you for joining The Phia Group as we shared our predictions in a special-edition webinar. It&rsquo;s going to be an interesting year&hellip;<br /> <br /> <a target="_blank" href="/Portals/phiagroup/webinars/Nov2016/The Phia Group - November Webinar - First 100 Days.pdf">Click here to download the slides.</a><br /> <a href="/Portals/phiagroup/webinars/Nov2016/The Phia Group - November Webinar - First 100 Days.mp4">Click here to download the video.</a><br /> <a href="/Portals/phiagroup/webinars/Nov2016/The Phia Group - November Webinar - First 100 Days.mp3">Click here to download the audio.</a></span>387The Good, The Bad, and The Ugly – Ethics: Simple Mistakes vs. Breachhttps://www.phiagroup.com/Media/Posts/PostId/386/the-good-the-bad-and-the-ugly-ethics-simple-mistakes-vs-breachWebinarsTue, 15 Nov 2016 19:31:30 GMT<span style="font-size: 16px;">As the Department of Labor hones in on what is ethical (or unethical) and what constitutes fiduciary liability, plan administrators, third party administrators, brokers, and various advisors who service self-funded plans must make a renewed effort to ensure that their actions are in compliance with current legal and ethical standards. All self-funded entities must take steps to avoid actions that may be deemed unethical or in violation of their considerable responsibilities - and even when exercising good faith, it is still possible to act unethically.<br /> <br /> &ldquo;Every day, millions of dollars are responsibly handled by HCAA members on behalf of self-funded health plans. Unfortunately, we all know of cases where our fellow administrators have made errors or acted unethically,&rdquo; said HCAA&rsquo;s CEO, Carol Berry. &ldquo;The Phia Group&rsquo;s attorneys are experts in the fields of ethics and fiduciary liability, and we thought it timely to partner with them in presenting an informational webinar to our industry.&rdquo;<br /> <br /> Thank you for joining The Phia Group&rsquo;s CEO, Adam V. Russo, Esq., and Sr. Vice President and General Counsel, Ron E. Peck, Esq. on November 15, 2016. In this presentation, they delved into the intricacies of the law surrounding self-funded ethics and examine recent case law involving entities that have toed the line of unethical behavior, sometimes finding themselves on the wrong side of this quagmire.<br /> <strong><br /> <a href="/Portals/phiagroup/webinars/HCAA Ethics - Nov2016/The Good_ the Bad_ and the Naughty – Ethics_ Simple Mistakes vs. Breach.pdf" target="_blank">Click here to download slides.</a><br /> <a href="/Portals/phiagroup/webinars/HCAA Ethics - Nov2016/The Good_ the Bad_ and the Naughty – Ethics_ Simple Mistakes vs. Breach.mp4">Click here to download video.</a><br /> <a href="/Portals/phiagroup/webinars/HCAA Ethics - Nov2016/The Good_ the Bad_ and the Naughty – Ethics_ Simple Mistakes vs. Breach.mp3">Click here to download audio.</a></strong><br /> </span>386How Low Can You Go? Managing Specialty Drugs, Reducing Overall Pharmacy Spend, and Unraveling the Mystery Behind PBMshttps://www.phiagroup.com/Media/Posts/PostId/385/how-low-can-you-go-managing-specialty-drugs-reducing-overall-pharmacy-spend-and-unraveling-the-mystery-behind-pbmsWebinarsThu, 27 Oct 2016 20:14:18 GMTPharmacy Benefit Managers, or PBMs, are an important factor in the cost and value of self-funding - yet many TPAs, brokers, and plan sponsors feel it is impractical to even look into changing the status quo. Self-funded plans and those who service them, however, should be constantly on the lookout for effective alternatives to their current procedures - especially in this aggressive economic and legal climate.<br /> <br /> Thank you for joining The Phia Group's legal team on October 27, 2016 as they analyzed some of the processes and agreement terms offered by PBMs, to help you make the decision regarding whether or not your current PBM is the best choice for you, your employees, and your clients.<br /> <br /> <a href="/Portals/phiagroup/webinars/Oct2016/The Phia Group - How Low Can You Go - 10-27-16.pdf" target="_blank">Click here to download the slides.</a><br /> <a href="/Portals/phiagroup/webinars/Oct2016/The Phia Group - How Low Can You Go - 10-27-16.mp3">Click here to download the audio.</a><br /> <a href="/Portals/phiagroup/webinars/Oct2016/The Phia Group - How Low Can You Go - 10-27-16.mp4">Click here to download the video.</a>385Independent Consultation & Evaluation: ICE, ICE, Baby!https://www.phiagroup.com/Media/Posts/PostId/384/independent-consultation-evaluation-ice-ice-babyWebinarsThu, 22 Sep 2016 20:16:17 GMTOur industry is plagued by issues related to compliance, contracts, and cost-containment &ndash; and a myriad of other legal issues as well. Engaging an expert for a second set of eyes is a chore in itself, requiring approval from management or an individual group as well as a cost-benefit analysis of the expert&rsquo;s fees &ndash; sometimes resulting in the decision not to consult a neutral third-party at all.<br /> <br /> The Phia Group has been providing consulting services since its inception seventeen years ago. We have seen thousands of problems that could have been mitigated or avoided entirely by consulting an expert. As a result, we have created the ICE service &ndash; short for Independent Consultation and Evaluation.<br /> <br /> Thank you for joining The Phia Group&rsquo;s legal team on September 22, 2016 at 1:00pm (EST) as they discussed some of the problems facing the self-funded industry today, provided examples of situations where being proactive rather than reactive would have been beneficial, and presented the value that ICE can hold for TPAs and health plans.<br /> <br /> <a target="_blank" href="/Portals/phiagroup/webinars/Sept2016/ThePhiaGroup - ICE ICE Baby - 9-22-16.pdf">Click here to download the slides.</a><br /> <a href="/Portals/phiagroup/webinars/Sept2016/ThePhiaGroup - ICE ICE Baby - 9-22-16.mp3">Click here to download the audio.</a><br /> <a href="/Portals/phiagroup/webinars/Sept2016/ThePhiaGroup - ICE ICE Baby - 9-22-16.mp4">Click here to download the video.</a><br />384Unwrapping Your Wrapshttps://www.phiagroup.com/Media/Posts/PostId/383/unwrapping-your-wrapsWebinarsWed, 24 Aug 2016 01:41:12 GMTWrap networks provide plans with discounts off billed charges for claims that don&rsquo;t fall within the plan&rsquo;s primary network. But do these wraps really add value? With skyrocketing provider charges and static discounts off of those charges, the modern-day wrap network doesn&rsquo;t seem to provide much help when it comes to claims costs.<br /> <br /> Thank you for joining The Phia Group&rsquo;s legal team on August 23rd, as we analyzed provisions of wrap network agreements, with a focus on what plans can or can&rsquo;t do to cut costs. We proposed some innovative ways for your plans to save additional money above and beyond wrap networks, generating unprecedented value for your plans.<br /> <br /> <a target="_blank" href="/Portals/phiagroup/webinars/Aug2016/ThePhiaGroup - Unwrapping Your Wraps - 8-23-16.pdf">Click here to download the slides.</a><br /> <a target="_blank" href="/Portals/phiagroup/webinars/Aug2016/ThePhiaGroup - Unwrapping Your Wraps - 8-23-16.mp4">Click here to download the video.</a><br /> <a href="/Portals/phiagroup/webinars/Aug2016/ThePhiaGroup - Unwrapping Your Wraps - 8-23-16.mp3">Click here to download the audio.</a><br />383The Phia Group's Response to the DOL Final Rulehttps://www.phiagroup.com/Media/Posts/PostId/382/the-phia-groups-response-to-the-dol-final-rulePublicationsWed, 17 Aug 2016 13:56:04 GMT<object data="http://www.phiagroup.com/Portals/phiagroup/Publications/2016/PHIA-DOL.pdf" height="800px" type="application/pdf" width="100%"></object> <p><b>Alternatively, you can download the file <a href="https://www.phiagroup.com/Portals/phiagroup/Publications/2016/PHIA-DOL.pdf">here</a>.</b></p> 382Back to Basics: Plan Documents 101 (Part 2)https://www.phiagroup.com/Media/Posts/PostId/381/back-to-basics-plan-documents-101-part-2WebinarsWed, 13 Jul 2016 14:37:17 GMTWhen we think of hot topics in the self-funded industry, plan document drafting is hardly the first thing that come to mind. Instead, issues such as fiduciary duties, reference-based pricing, transgender coverage, employee incentives, and provider abuse are on the tip of everybody's tongues. All these topics, however, share a common feature: they're all reflected, in some way or another, within the plan document. Without compliant and effective plan document language, a plan can't offer robust benefit programs while containing costs.<br /> &nbsp;<br /> Thank you for joining The Phia Group's legal team (including Jen McCormick) on Wednesday, July 13th, 2016, at 1:00pm (EST), as we presented Part 2 of our "Back to Basics: Plan Documents 101" presentation. We discussed some more of the best and worst practices for plan drafting, to help you make the most of every page of your plan document.<br /> <br /> <a target="_blank" href="/LinkClick.aspx?fileticket=cbsLfKJ3yG8%3d&amp;portalid=586">Click here to download slides.</a><br /> <a href="/Portals/phiagroup/webinars/Jul2016/ThePhiaGroup - Back to Basics - Plan Language 101 - Part 2.mp4">Click here to download video.</a><br /> <a href="/Portals/phiagroup/webinars/Jul2016/ThePhiaGroup - Back to Basics - Plan Language 101 - Part 2.mp3">Click here to download audio.</a>381Back to Basics: Plan Language 101https://www.phiagroup.com/Media/Posts/PostId/378/back-to-basics-plan-language-101WebinarsWed, 15 Jun 2016 18:51:56 GMTMost situations that involve self-funded benefit plans revolve around language within the plan document. Whether deciding if a service is experimental, or figuring out whether a dependent is actually covered, or deciding whether a leave of absence will extend coverage, the plan document controls in just about all situations. For that reason, it's all the more disastrous when poor plan language handicaps plans and TPAs. Like we always say, your rights are only as good as your language.<br /> <br /> Back by popular demand, The Phia Group's very own Jen McCormick was the star of this webinar, since nobody knows plan documents like Jen.<br /> <br /> Thank you for joining The Phia Group's legal team - and Jen McCormick - for an hour on Wednesday, June 15th, 2016, at 1:00pm (EST), as we went "back to basics" and discussed some best and worst practices for plan drafting, to help make sure your plans don't lose their rights by failing to claim them in the first place.<br /> <strong><br /> <a target="_blank" href="/Portals/phiagroup/webinars/June2016/The Phia Group_s June 2016 Webinar - Back to Basics - Plan Language 101.pdf">Download the Slides</a><br /> <a target="_blank" href="/Portals/phiagroup/webinars/June2016/The Phia Group_s June 2016 Webinar - Back to Basics - Plan Language 101.mp3">Download the Audio</a><br /> <a target="_blank" href="/Portals/phiagroup/webinars/June2016/The Phia Group_s June 2016 Webinar - Back to Basics - Plan Language 101.avi">Download the Video</a></strong>378The Tangled Web of Contractshttps://www.phiagroup.com/Media/Posts/PostId/377/the-tangled-web-of-contractsWebinarsThu, 12 May 2016 19:25:22 GMTThe self-funded industry is made up of a complex system of contracts, and navigation across them is anything but simple. Network contracts supersede plan documents; Administrative Services Agreements &ldquo;add&rdquo; plan provisions, stop-loss policies embrace carve-outs but networks prohibit them, employee handbooks promise benefits not provided by the SPD&hellip;and those are just a few examples of areas of confusion. <br /> <br /> Thank you for joining The Phia Group on May 12th, 2016 as its legal team gave a crash course in contracts. Cost-containment can be impacted by the contracts you sign, and there are often exceptions and restrictions buried deep down, or potential issues not considered beforehand. In this webinar, The Phia Group explained some of the contracting pitfalls experienced on a daily basis within the self-funded industry.<br /> <br /> <a target="_blank" href="http://www.phiagroup.com/LinkClick.aspx?fileticket=uHJ8bTVX0AM%3d&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Download the video</a><br /> <a href="http://www.phiagroup.com/LinkClick.aspx?fileticket=qogyacYk3Lg%3d&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Download the audio</a><br /> <a href="http://www.phiagroup.com/LinkClick.aspx?fileticket=NM-xQI06eAo%3d&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Download the slides</a><br /> <br /> <br />377Unraveling FAQ Part 31https://www.phiagroup.com/Media/Posts/PostId/376/unraveling-faq-part-31WebinarsWed, 04 May 2016 16:21:52 GMTReference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now; in its latest FAQ, published just last week (FAQs about Affordable Care Act Implementation, Part 31), the regulators reiterate concerns regarding network adequacy and how it relates to - and regulates - reference-based pricing arrangements. <br /> <br /> Thanks for joining us as The Phia Group's legal team and special guest Tim Martin of Payer Compass helped unravel the mystery of the DOL's latest FAQ - and what it means for you and your plans.<br /> <br /> <a target="_blank" href="http://www.phiagroup.com/LinkClick.aspx?fileticket=8Nk71sZu_YM%3d&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Download the video</a><br /> <a target="_blank" href="http://www.phiagroup.com/LinkClick.aspx?fileticket=x3eauaBqrFg%3d&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Download the audio</a><br /> <a target="_blank" href="http://www.phiagroup.com/LinkClick.aspx?fileticket=3-aytnEh3ZM%3d&amp;tabid=23892&amp;portalid=586&amp;mid=38035">Download the slides</a><br /> <br />376A Changing Industry: Navigating the current (Events)https://www.phiagroup.com/Media/Posts/PostId/375/a-changing-industry-navigating-the-current-eventsWebinarsFri, 15 Apr 2016 00:34:09 GMTThe self-funded industry changes rapidly and without notice. In recent memory, the biggest culprit has been the ACA - and in its aftermath, there have been numerous regulatory guidelines and court cases that have helped interpret the ACA's provisions. Still, though, there are many other changes occurring at any given time. Examples include assignments of benefits, discrimination, preemption, bankruptcy, subrogation, stop-loss, and more. <br /> <br /> Thank you for joining The Phia Group's legal team as they described recent goings-on within the legal and regulatory framework in which we all operate. Being aware of changes within the industry can be important to take the necessary action as well as to be able to predict and prepare for what might be on the horizon.<br /> <br /> <a href="/LinkClick.aspx?fileticket=13hRML87y1w%3d&amp;portalid=586" target="_blank">Download the video</a><br /> <a href="/LinkClick.aspx?fileticket=C-DkYvzLgMw%3d&amp;portalid=586" target="_blank">Download the audio</a><br /> <a href="/LinkClick.aspx?fileticket=sGU1zVM4zhw%3d&amp;portalid=586" target="_blank">Download the slides</a><br />375The Replacementshttps://www.phiagroup.com/Media/Posts/PostId/374/the-replacementsWebinarsFri, 08 Apr 2016 19:24:48 GMTAs the self-funded industry evolves, benefit plans are forced to evolve with it or get left in the dust. Employees need quality coverage &ndash; but providing robust yet affordable programs has proven difficult for many self-funders. This conundrum can be addressed by changing inefficient or archaic processes; in response to contractual handcuffs limiting your ability to target cost drivers, too many health plans and TPAs overreact, thinking that the solution is to trash their plan entirely, and to try something new and untested &ndash; trading security for savings. <br /> <br /> When it comes to benefits, don&rsquo;t remove, don&rsquo;t reduce... replace! Avoid the extreme sides of the spectrum, achieve balance, and ensure your own viability with &ldquo;The Replacements.&rdquo; Thank you for joining The Phia Group on Tuesday, February 16th, as we identified the trouble spots found in all benefit plans, and helped develop strategies to carve them out and replace faulty portions with new alternatives &ndash; without harming the rest of the plan!<br /> <br /> Download Video Here<br /> <a href="/Portals/phiagroup/portals/phiagroup/webinars/The Phia Group_s Feb 2016 Webinar - The Replacements - 2-16-16.mp3" target="_blank" title="Click to listen to audio">Download Audio Here</a><br /> <a href="/Portals/phiagroup/portals/phiagroup/webinars/February Webinar.pptx" target="_blank">Download Slides Here</a><br />374Saving Stop-Loss - Protecting a Key Self-Funding Ingredient in a Hostile Worldhttps://www.phiagroup.com/Media/Posts/PostId/317/saving-stop-loss-protecting-a-key-self-funding-ingredient-in-a-hostile-worldWebinarsTue, 19 Jan 2016 22:49:03 GMT<div class="entry"> <p>Stop-loss is vital to the self-funded marketplace, and for good reason &ndash; because catastrophic claims can bankrupt an employer in the blink of an eye. Not all is well in the land of stop-loss, however, as forces &ndash; both internal and external &ndash; conspire against stop-loss carriers. Regulators, fearing the impact self-funded adverse selection may have on PPACA exchanges seek to eliminate self-funding by striking at stop-loss. Meanwhile, many will attest that some stop-loss carriers have taken a more heavy handed approach to cost containment. There are different types of carriers and MGUs in the marketplace, with varying attitudes toward discretion, plan language, bill auditors, caps on payable amounts, and many other aspects of a reinsurance arrangement that can be the difference between being able to comfortably self-fund a health plan and being forced into the fully-insured market.</p> <p>Thank you for joining The Phia Group&rsquo;s legal team on Tuesday, January 19, 2016, as they provided first-hand insight into the self-funded market&rsquo;s reliance on stop-loss and threats to that industry, including what TPAs and brokers should look for &ndash; and look out for &ndash; when advising health plan sponsors regarding stop-loss options.</p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Jan2016/The Phia Group's Jan 2016 Webinar - Saving Stop-Loss - 1-19-16.mp4">Download Video Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Jan2016/The Phia Group's Jan 2016 Webinar - Saving Stop-Loss - 1-19-16.pdf">Download Slides Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Jan2016/The Phia Group's Jan 2016 Webinar - Saving Stop-Loss - 1-19-16.mp3">Download Audio Here</a></p> </div>317Issue of the Year: Reference-Based Pricing and Balance-Billinghttps://www.phiagroup.com/Media/Posts/PostId/316/issue-of-the-year-reference-based-pricing-and-balance-billingWebinarsMon, 28 Dec 2015 22:47:58 GMT<div class="entry"> <p>In 2015 the self-funded industry evolved like never before. Innovative ideas spread like wildfire, as TPAs, stop-loss carriers, employers and brokers all over the country implemented new techniques to contain costs and secure the best results. Yet, the path to savings hasn&rsquo;t been an easy one to travel.</p> <p>All along, The Phia Group has worked with you to resolve thousands of issues &ndash; and by far, the most misunderstood, repeated, passion-inspiring issue has been reference-based pricing, balance billing, and the role of a fiduciary when handling such an arrangement.</p> <p>Thank you for joining The Phia Group&rsquo;s legal team on December 15th as they discussed reference-based pricing and balance-billing from the ground up and debunked common myths associated with it. This webinar will ended the year with a comprehensive primer on reference-based pricing and balance-billing, the rights of all parties involved, and what you can do to be proactive and successfully administer a reference-based pricing program.</p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Dec2015/The Phia Group's December Webinar - RBP and Balance Billing - 12-15-15.mp4">Download Video Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Dec2015/The Phia Group's December Webinar - RBP and Balance Billing - 12-15-15.pdf">Download Slides Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Dec2015/The Phia Group's December Webinar - RBP and Balance Billing - 12-15-15.mp3">Download Audio Here</a></p> </div>316Less Takes More - The Phia Group Addresses the Summary of Benefits & Coverage Requirementhttps://www.phiagroup.com/Media/Posts/PostId/353/less-takes-more-the-phia-group-addresses-the-summary-of-benefits-coverage-requirementPress ReleasesWed, 23 Dec 2015 06:26:00 GMT<div class="entry"> <p>Benjamin Franklin, Blaise Pascal, and Mark Twain are all credited with having said, &ldquo;I would have written a shorter letter, if I&rsquo;d had the time.&rdquo; Unfortunately, efforts to simplify complex matters often constitute the greatest challenge. This fact of life is certainly proven by the Affordable Care Act and its requirement that health plans provide consumers with a concise document detailing, in plain language, information about plan benefits and coverage. This summary of benefits and coverage document ( or &ldquo;SBC&rdquo;) is meant to help consumers better understand the coverage available to them, and allow them to easily compare options by summarizing key features such as the covered benefits, cost-sharing provisions, coverage limitations and exceptions.</p> <p><a href="/portals/phiagroup/images/December-18.pdf">Read More</a></p> </div>353Keeping PACE With The Trendshttps://www.phiagroup.com/Media/Posts/PostId/315/keeping-pace-with-the-trendsWebinarsMon, 07 Dec 2015 22:46:40 GMT<div class="entry"> <p>The self-funding industry is experiencing great opportunity and growth. In the past two years, millions of lives have transitioned away from the fully-insured health plan model in favor of the self-insured model &ndash; and despite the rise of exchanges, many employers are steering away from them for various reasons. These encouraging facts are tempered by the increased burdens facing both new and existing employer sponsors, third party administrators, industry brokers, and even stop-loss carriers and MGUs. </p> <p>Fiduciary responsibilities have grown, liability shifting is now a common theme in a standard RFI, and lawsuits over claims and appeals decisions are becoming more prevalent. </p> <p>Thanks for joining The Phia Group&rsquo;s legal team on November 30th as we explored the numbers behind our industry&rsquo;s growth and provided real-world discussion on the topic, while we explored real solutions to the issues presented.</p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Nov2015/The%20Phia%20Group_A%20Changing%20Industry%20-%20Keeping%20PACE%20with%20the%20Trends.mp4" target="_blank">Download Webinar (Slides with Audio) Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Nov2015/The%20Phia%20Group_A%20Changing%20Industry%20-%20Keeping%20PACE%20with%20the%20Trends.pdf">Download Slides Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Nov2015/The%20Phia%20Group_A%20Changing%20Industry%20-%20Keeping%20PACE%20with%20the%20Trends.mp3">Download Audio Here</a></p> </div>315The Phia Group, LLC Comments on Recent Industry Developmentshttps://www.phiagroup.com/Media/Posts/PostId/352/the-phia-group-llc-comments-on-recent-industry-developmentsPress ReleasesSat, 24 Oct 2015 05:24:38 GMT<div class="entry"> <p>These last few weeks have brought with them a whirlwind of controversy and concern. The Phia Group, LLC is pleased to announce that it will be addressing three of the hottest topics during its monthly webinar. If you have not yet signed up for our FREE webinar, to be held on Thursday, October 30th, 2014, from 1:00 &ndash; 2:00 PM EST, then you will most certainly be missing out!</p> <p style="text-align: left;"><a href="/portals/phiagroup/images/October-22.pdf">Read More</a></p> <p>&nbsp;</p> </div>352Plan Appointed Claim Evaluator (PACE)https://www.phiagroup.com/Media/Posts/PostId/344/plan-appointed-claim-evaluator-paceNewslettersSat, 17 Oct 2015 04:40:56 GMT<strong>Making determinations on medical claim appeals is a frightening prospect.</strong> The process can involve complex factual, legal, and medical issues, and can distract a plan administrator from its ordinary business functions, posing a significant resource drain. The PACE service is designed to let the plan administrator shift the fiduciary duty away, onto the PACE, for final-level, internal claim appeals.<br /> <br /> <div class="row"> <div class="col-sm-4"> <div class="panel panel-primary"> <div class="panel-heading">Questions &amp; Answers</div> <div class="panel-body"> <center> <a href="/portals/phiagroup/images/PACEdocs/TPAQA.pdf" class="btn btn-primary">Download Q &amp; A</a> </center> </div> </div> </div> <div class="col-sm-4"> <div class="panel panel-primary"> <div class="panel-heading">PACE Flyer</div> <div class="panel-body"> <center> <a href="/portals/phiagroup/images/PACEdocs/TPAMarketingFlyer.pdf" class="btn btn-primary">Download Flyer</a> </center> </div> </div> </div> <div class="col-sm-4"> <div class="panel panel-primary"> <div class="panel-heading">Guide To Implementation</div> <div class="panel-body"> <center> <a href="/portals/phiagroup/images/PACEdocs/ImpFlowchart.pdf" class="btn btn-primary">Download Imp. Flowchart</a> </center> </div> </div> </div> </div> <div class="row"> <div class="col-sm-6"> <div class="panel panel-primary"> <div class="panel-heading">Guide To Appeals</div> <div class="panel-body"> <center> <a href="/portals/phiagroup/images/PACEdocs/AppealsFlowchart.pdf" class="btn btn-primary">Download Appeals Flowchart</a> </center> </div> </div> </div> <div class="col-sm-6"> <div class="panel panel-primary"> <div class="panel-heading">PACE Webinar Slides</div> <div class="panel-body"> <center> <a href="/portals/phiagroup/images/PACEdocs/GroupWebinar.pdf" class="btn btn-primary">Download Slides</a> </center> </div> </div> </div> </div> <p>In the classic TPA arrangement, the TPA does not assume fiduciary duties, instead relying on the plan administrator for guidance on claims and appeals that require discretion. Many TPAs are still living in the past &ndash; an era where Plan Sponsors embraced fiduciary duties &ndash; but now, &nbsp;plans and their brokers exist in a new paradigm, in which a TPA not offering a fiduciary option stands at a substantial disadvantage. As such, business opportunities are lost.</p> <p>With this in mind, The Phia Group has developed PACE.&nbsp; With a PACE, plan sponsors and TPAs assign the riskiest fiduciary duty (that is, the power to make payment decisions in response to final appeals), to The Phia Group.&nbsp; This authority carries with it the most risk, because it is this final payment directive that will be scrutinized upon external review.</p> <p>Self-funding veterans and novices alike will benefit from PACE. Groups that are moving from fully-insured or ASO arrangements can use PACE as a valuable tool to aid in the transition; these groups have never before had to be the fiduciary of their plans &ndash; and with the PACE, that daunting responsibility can be delegated to a neutral and capable third party.</p> <p><strong>The PACE not only enables the TPA to obtain new business not previously available to it, but also encourages client &ldquo;stickiness&rdquo; and also creates a new profit center for the TPA in the form of an administrative fee paid directly by The Phia Group to the TPA, in exchange for the TPA&rsquo;s facilitation of the PACE service. In other words, PACE adds unprecedented value to the TPA from both a business and a revenue perspective.</strong></p> <p>In addition to having a third party expert analyze all appealed claims before they reach an external review, the PACE also ensures that legally mandated independent review organizations (IROs) are in place, and the PACE handles facilitation of external appeals with these IROs.&nbsp;Regardless of whether the PACE upholds or reverses a denial, the PACE&rsquo;s service continues to apply.&nbsp; From handling external appeals of denied claims to negotiating amounts payable for claims deemed to be covered by the benefit plan, the PACE works to ensure the correct and optimal outcome every time.&nbsp;This includes coordinating efforts with stop-loss, plan sponsors, brokers, and TPAs whenever these partners do not align.</p> <p>As we know, any entity exercising control over a benefit plan or its assets may be deemed to be a fiduciary; third party administrators, brokers, and any other entity making decisions on behalf of these benefit plans may be dealing with liability for which it simply isn&rsquo;t prepared. PACE is a way for the employer to be able to focus less on the complexities of its health plan, fiduciary duties, and stop-loss concerns, and more on what matters &ndash; its business.</p> <p>PACE is also a way for the TPA to rest easy knowing that it is not unwittingly assuming fiduciary duties on final appeals.</p> <p>For years, self-funded plan sponsors and TPAs have asked how they can avoid the risks inherent in self-funding, while still enjoying the benefits of that plan structure.&nbsp; According to our CEO, Adam Russo, &ldquo;With a PACE in place, we&rsquo;re taking a giant step in the right direction. It&rsquo;s a game changer.&rdquo;</p>344A Call To Action!https://www.phiagroup.com/Media/Posts/PostId/314/a-call-to-actionWebinarsThu, 15 Oct 2015 21:45:14 GMT<div class="entry"> <p>All too often, we find ourselves comfortably observing change from a distance, allowing others to dictate our destinies. Today, various litigious matters are being presented to courts of law, regulators are issuing new rules, law makers are drafting statutes, and insurance commissioners are releasing bulletins that impact how we operate. Elsewhere, stop loss carriers, TPAs, plan sponsors, networks, and other entities that should be working in concert are instead working against each other.</p> <p>Thanks for joining The Phia Group&rsquo;s legal team on October 14th as we discussed many such ongoing instances, and shared with you opportunities to take an active role in the preservation of our industry.</p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Oct2015/The%20Phia%20Group's%20October%20Webinar%20-%20A%20Call%20to%20Action.mp4" target="_blank">Download Webinar (Slides with Audio) Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Oct2015/The%20Phia%20Group's%20October%20Webinar%20-%20A%20Call%20to%20Action.pdf">Download Slides Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Oct2015/The%20Phia%20Group's%20October%20Webinar%20-%20A%20Call%20to%20Action.mp3">Download Audio Here</a></p> </div>314The Phia Group, LLC Announces the Release of its New "Phia Document Management" (PDM) Softwarehttps://www.phiagroup.com/Media/Posts/PostId/351/the-phia-group-llc-announces-the-release-of-its-new-phia-document-management-pdm-softwarePress ReleasesSat, 03 Oct 2015 05:23:28 GMT<div class="entry"> <p>October 1, 2014; Braintree, MA &mdash; A first of its kind plan document drafting solution, Phia Document Management (PDM) was created to satisfy the needs of the entire health plan industry. PDM allows for instant population of an online template featuring The Phia Group&rsquo;s critically acclaimed plan language, while still ensuring customization to meet each client&rsquo;s unique needs.</p> <p style="text-align: left;"><a href="/portals/phiagroup/images/PDM-BLAST1.pdf" target="_blank">Read More</a></p> <p>&nbsp;</p> </div>351The Phia Group, LLC Announces Exclusive U.S. Relationship with Jason Davishttps://www.phiagroup.com/Media/Posts/PostId/350/the-phia-group-llc-announces-exclusive-us-relationship-with-jason-davisPress ReleasesSat, 05 Sep 2015 05:22:21 GMT<div class="entry"> <p>September 2, 2014; Braintree, MA &mdash; The Phia Group LLC, one of the health benefit industry&rsquo;s leading cost-containment service providers, announces that we have agreed to a U.S. exclusive consulting agreement with Jason C. Davis. Mr. Davis will assist The Phia Group with sales and product development.</p> <p><a href="/portals/phiagroup/images/The-Phia-Group_Jason-Davis-Website-Announcement.pdf" target="_blank">Read More</a></p> </div>350Inc. Magazine Unveils Its Annual Exclusive List of America's Fastest-Growing Private Companies - The Inc. 500|5000https://www.phiagroup.com/Media/Posts/PostId/349/inc-magazine-unveils-its-annual-exclusive-list-of-americas-fastest-growing-private-companies-the-inc-5005000Press ReleasesThu, 27 Aug 2015 05:20:56 GMT<div class="entry"> <p style="text-align: left;">New York, August 22, 2013 &mdash; <em>Inc. </em>magazine today ranked The Phia Group on its annual Inc. 500|5000; an exclusive ranking of the nation&rsquo;s fastest-growing private companies.&nbsp; The list represents the most comprehensive look at the most important segement of the economy&mdash;America&rsquo;s independent entrepreneurs.&nbsp; The Phia Group joins LivingSocial, Edible Arrangements, CDW and Lifelock, among other prominent brands featured on this year&rsquo;s list.</p> <p style="text-align: left;"><a href="/portals/phiagroup/images/Press_Release_Final.pdf" target="_blank">Click Here</a></p> <p>&nbsp;</p> </div>349"Phia Case Studies" - When Silence is Loud and Assumptions Mean Disasterhttps://www.phiagroup.com/Media/Posts/PostId/313/phia-case-studies-when-silence-is-loud-and-assumptions-mean-disasterWebinarsTue, 04 Aug 2015 21:43:53 GMT<div class="entry"> <p>We&rsquo;ve got the stories that will enable us all to learn from others&rsquo; mistakes, and see that &ldquo;what we have here&hellip;is a failure to communicate.&rdquo;</p> <p>As employers look to self-fund with increasing frequency, expectations that brokers, vendors, and third party administrators will take on more binding authority are trending as well. Cases where an entity is held liable for failing to uphold a responsibility it didn&rsquo;t intend to adopt are consequently on the rise as well. These recent cases impact how you are (or at least should be) handling claims.</p> <p>Are you living up to expectations? Gaps in coverage and a lack of clarity expose you all to punishment and regulation.</p> <p>Thanks for joining The Phia Group&rsquo;s legal team on September 17th, at 1:00 PM EST, as they analyzed recent cases featuring communication breakdowns, regulation popping up in its wake, and best practices to make sure you know your role and do your job.</p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Phia%20Case%20Studies%20-%20When%20Silence%20is%20Loud%20and%20Assumptions%20Mean%20Disaster%20(9-17-15).mp4">Download Webinar Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Phia%20Case%20Studies%20-%20When%20Silence%20is%20Loud%20and%20Assumptions%20Mean%20Disaster%20(9-17-15).pdf">Download Slides Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Phia%20Case%20Studies%20-%20When%20Silence%20is%20Loud%20and%20Assumptions%20Mean%20Disaster%20(9-17-15).mp3">Download Audio Here</a></p> </div>3132nd Quarter Newsletter 2015https://www.phiagroup.com/Media/Posts/PostId/343/2nd-quarter-newsletter-2015NewslettersFri, 17 Jul 2015 04:29:38 GMT<div class="entry"> <p>&nbsp;The past few months have brought so much intrigue to our industry.&nbsp; Everywhere you looked, something or someone was affecting health care and the insurance industry as a whole.&nbsp; We saw the Supreme Court make a few monumental decisions that will affect how plans are written in the future and the viability of the ACA.&nbsp; We saw interesting court cases placing more potential fiduciary risks upon brokers and administrators.&nbsp; We watched and reacted as more states attempted to limit the ability for smaller employers to self fund their benefits through the use of stop loss coverage and last, but certainly not least, we have seen a monumental increase in the DOL audits to our clients and the industry at large.&nbsp; If there ever was a time that The Phia Group&rsquo;s services were needed, this is it!</p> <p>There is no question that health claims costs continue to skyrocket and the use of so called wrap discounts on many of these claims isn&rsquo;t helping to reduce the burden.&nbsp; If you are looking for some innovative options to stand out from the pack, please contact me as there are so many great ways to truly make a powerful impact on behalf of your employer plans.&nbsp; We can save you and your plans significant claim dollars, you just need to strategize and identify your major pain points.</p> <p>The next quarter will continue to be eventful so while you enjoy your summer weather, please be sure to let us know if you need some assistance &ndash; we are here for you.&nbsp; Happy reading</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1121672331409.html">Click Here </a> to read more!</p> </div>343"Stories From The Front Lines" - Real Wins, Losses, & Difference Makershttps://www.phiagroup.com/Media/Posts/PostId/312/stories-from-the-front-lines-real-wins-losses-difference-makersWebinarsWed, 20 May 2015 21:41:28 GMT<div class="entry"> <p>Join The Phia Group on Wednesday, May 20th, from 1 to 2 PM EST, as its attorneys discuss their experiences providing plan administrators with guidance as it relates to difficult claim processing decisions, conflict resolution, and bill negotiation&hellip; as well as dissect the small factual differences between otherwise similar scenarios that made all the difference. </p> <p>These are our Stories from the Front Lines.</p> <p><a href="https://www.phiagroup.com/images/May-Webinar-5-20-15.pdf">View Slides Here! </a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/The%20Phia%20Group%27s%20Webinar%20-%20Stories%20from%20the%20Front%20Line.wmv">Download Webinar! </a></p> </div>312"Survival of the Fittest" - Best Practices to Perfect a Modern TPAhttps://www.phiagroup.com/Media/Posts/PostId/311/survival-of-the-fittest-best-practices-to-perfect-a-modern-tpaWebinarsThu, 23 Apr 2015 21:40:07 GMT<div class="entry"> <p>Join The Phia Group on April 23, from 1 to 2 PM EST, as they discuss best practices and new methodologies TPAs are considering, in their quest to remain relevant in a modern healthcare arena. Covered topics will include innovative services, products, and processes being used today, and developed for tomorrow. The Phia Group will identify both the issues and solutions that seem to be spreading, and how proactive administrators are addressing both.</p> <p>Join The Phia Group&rsquo;s legal team as they discuss the best practices for TPA&rsquo;s and how this can help you!</p> <p><a href="https://www.phiagroup.com/images/April-Webinar-2015.pdf">View PDF here! </a></p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/Survival of the Fittest_Best Practices TPA.wmv ">Download Webinar here! </a></p> </div>311"To Be Or Not To Be"... A Fiduciary - Do You Even Have A Choice?https://www.phiagroup.com/Media/Posts/PostId/310/to-be-or-not-to-be-a-fiduciary-do-you-even-have-a-choiceWebinarsWed, 25 Mar 2015 21:39:03 GMT<div class="entry"> <p>Being a fiduciary is serious business. Determining whether you are one can also be very complicated. Case law increasingly establishes that being a fiduciary has more to do with the action one takes, than the contract one signs. Entities working on behalf of self-funded benefit plans may be unknowingly taking on fiduciary status. Are you a fiduciary? What are the advantages and disadvantages of taking on that burden? What can you do to protect yourself? </p> <p><a href="https://www.phiagroup.com/images/March-2015-Webinar_-Fiduciary_Final.pdf">View PDF here!</a></p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/2015Or%20Not%20To%20Be.wmv">Download Webinar</a></p> </div>310Pushback & Counter-Attackhttps://www.phiagroup.com/Media/Posts/PostId/309/pushback-counter-attackWebinarsThu, 12 Feb 2015 22:37:50 GMT<div class="entry"> <p>Pushback &amp; Counter-Attack &ndash; How attorneys, providers, and the government are combating your efforts to contain costs&hellip; and what you should be doing about it!!!!</p> <p>ERISA has been a target of scrutiny since its passage. Rights to subrogation, coordination of benefits, audit claims and enforce plan provisions &ndash; though pillars of cost containment &ndash; are constantly attacked. Attempts to prudently manage plan assets, though required by federal law, are met with pushback at every level. Now, with the passage of PPACA, old and new methods to maximize plan benefits and minimize costs are challenged. Join The Phia Group&rsquo;s team of attorneys on Thursday, February 12th at 1PM as they discuss the hurdles we face, both old and new; and what we can do to not only survive, but thrive in the face of such adversity.</p> <p><a href="https://www.phiagroup.com/images/February-2015-Webinar_Final.pdf">View PDF here!</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/2015-02-12%20Pushback%20_%20Counter-Attack.wmv">View Webinar</a></p> </div>309IMPLANT WARS!https://www.phiagroup.com/Media/Posts/PostId/308/implant-warsWebinarsWed, 14 Jan 2015 22:36:30 GMT<div class="entry"> <p>IMPLANT WARS: How monitoring provider self-referrals, &amp; negotiating based on actual costs can result in major plan savings!</p> <p>Those who fail to identify ways to separate themselves from the pack through new, innovative cost containment processes will be left behind. Yet, even the most diligent administrator feels powerless in the face of excessive costs, finding it nearly impossible to negotiate claims with providers, or apply reasonable and appropriate pricing. Thriving requires tackling you plans&rsquo; biggest cost drivers; but how can you carve out, monitor, and negotiate &ldquo;the big claims?&rdquo; Kick-off the new year by joining The Phia Group&rsquo;s CEO, Adam V. Russo and his legal team, as they discuss this important topic and introduce you to their newest offering; Implant Cost Pro! This is a webinar not to be missed.</p> <p><a href="https://www.phiagroup.com/images/January-2015-Webinar_Final.pdf">View PDF Here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/IMPLANT%20WARS.wmv">Download Webinar Here</a></p> </div>3084th Quarter Newsletter 2014https://www.phiagroup.com/Media/Posts/PostId/342/4th-quarter-newsletter-2014NewslettersWed, 14 Jan 2015 05:27:28 GMT<div class="entry"> <p>I&rsquo;d like to start by thanking all of you that have chosen The Phia Group as your trusted partner. I know very well that other options are available to you, and we are inspired and thankful everyday that you place your trust in us. I have always, and will continue to promise, that our team of recovery specialists, plan drafters, paralegals, lawyers, and support staff will do everything in our power to maximize the benefits while lowering the cost of your health benefit programs!</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1119511899547.html" target="_blank">Read More</a></p> </div>342"In Reference To The FAQ"... The DOL FAQ Dissected - Part Deux!https://www.phiagroup.com/Media/Posts/PostId/307/in-reference-to-the-faq-the-dol-faq-dissected-part-deuxWebinarsThu, 20 Nov 2014 22:35:18 GMT<div class="entry"> <p>On October 10, 2014, the Department of Labor, in conjunction with other regulatory agencies, released its &ldquo;FAQ XXI.&rdquo; In response, during its October Webinar, The Phia Group tore through the FAQ, sharing its concerns regarding the FAQ&rsquo;s questionable verbiage and provisions. The support shown for The Phia Group&rsquo;s October Webinar, &ldquo;Creeping Around Pitfalls on the Way to Scary Savings! &ndash; How to Avoid Horror When Implementing Cost Containment Schemes!&rdquo; was overwhelming! Not only did we enjoy an incredible turnout, but our attendees responded by providing some thought provoking insight to consider. Many of our industry&rsquo;s greatest minds have since joined The Phia Group in assessing the FAQ&rsquo;s meaning, impact, and steps we need to take to continue down the path of Reference Based Pricing. In November, we will share these ideas and conclusions with you.</p> <p>Join The Phia Group&rsquo;s CEO, Adam V. Russo; Sr. VP &amp; General Counsel, Ron E. Peck; and other members of the legal team as we continue to dissect the FAQ, its key provisions, and how it impacts &ldquo;RBP Plans .</p> <p><a href="https://www.phiagroup.com/images/November-2014-Webinar.pdf">View PDF here</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/In_Reference_t0_the_FAQ_Part.wmv">View Webinar</a></p> </div>307Phia Group Consulting Addresses Regulatory Compliancehttps://www.phiagroup.com/Media/Posts/PostId/348/phia-group-consulting-addresses-regulatory-compliancePress ReleasesMon, 17 Nov 2014 06:19:02 GMT<div class="entry"> <p>Braintree, MA &ndash; For years, The Phia Group&rsquo;s team of consultants have been dealing with various regulatory inquiries. In response to the impending influx of regulation bound to follow the recent election and rollout of PPACA&rsquo;s most complex provisions, The Phia Group announced this week the official formation of its Regulatory Compliance team.</p> <p><a href="https://www.phiagroup.com/images/Regulatory_PressRelease1.pdf" target="_blank">Click here</a></p> </div>348Creeping Around Pitfalls on the Way to Scary Savings? - How to Avoid Horror When Implementing Cost Containment Schemeshttps://www.phiagroup.com/Media/Posts/PostId/306/creeping-around-pitfalls-on-the-way-to-scary-savings-how-to-avoid-horror-when-implementing-cost-containment-schemesWebinarsThu, 30 Oct 2014 21:33:57 GMT<div class="entry"> <p>DON&rsquo;T MISS OUT! Whether you&rsquo;re embarking on a new cost containment adventure in-house, or with the help of a vendor, most programs are not simple &ldquo;plug and play&rdquo; affairs. Those who head into the dark unprepared will undoubtedly find themselves spooked by what hides around the corner. </p> <p>Are regulatory nightmares keeping you up at night? Just last week the federal government announced some gory changes to their regulations, sure to have a scary impact on reference based pricing. Nervous the path you&rsquo;re headed down will lead to certain doom? Many are questioning how far they can go with dialysis carve-outs, without running afoul of the Medicare Secondary Payer Act. Are the tricks piling up, but no treats are in sight? The HHS has announced a scheme to crush skinny plans. If that isn&rsquo;t enough to scare you straight, someone had better check for a heartbeat!</p> <p>Now is not the time to explore the regulatory wilderness alone! If you are looking to create some sweet savings, join The Phia Group&rsquo;s own CEO, Adam Russo, Sr. VP &amp; General Counsel, Ron Peck, and other members of the legal team, as they review the hottest topics and biggest news to impact our industry in the recent weeks.<br /> Don&rsquo;t be left &ldquo;holding the bag;&rdquo; add this free webinar to your calendar; October 30 at 1 PM and fear no more! </p> <p><a href="https://www.phiagroup.com/images/October-2014-Webinar_Creeping-Around-Pitfalls-on-the-Way-to-Scary-Savings_10_30_2014-1.pdf">Click here for PDF version!</a></p> <p><a href="http://www.phiagroup.com/portals/phiagroup/webinars/Creeping_Around%20Pitfalls_Way_Scary%20Savings%20implementing%20cost%20containment%20schemes%21.wmv">Click here to view webinar</a></p> </div>306Sun Life Financial Announced SunElite, a New Stop-Loss Value-Added Servicehttps://www.phiagroup.com/Media/Posts/PostId/347/sun-life-financial-announced-sunelite-a-new-stop-loss-value-added-servicePress ReleasesSun, 19 Oct 2014 05:18:04 GMT<div class="entry"> <p><a href="http://www.businesswire.com/news/home/20121018006030/en/Sun-Life-Financial-Announces-SunEliteSM-Stop-Loss-Value-Added" target="_blank">Click here</a></p> </div>3473rd Quarter Newsletter 2014https://www.phiagroup.com/Media/Posts/PostId/341/3rd-quarter-newsletter-2014NewslettersWed, 08 Oct 2014 04:26:44 GMT<div class="entry"> <p>Well, the fall is definitely upon us! Over in Boston, leaves are falling, changing to majestic landscapes, and the nights are getting cold; but The Phia Group is just heating up. We have so much information to share with you this newsletter from new service offerings to case law to regulatory changes. One of the things I wanted to share with you is the amazing conference I had the privilege to speak at this past weekend in Oklahoma City; the First Free Market Medical (FMMA) Association conference. It is rare that I am overwhelmed with new information, but this forum did the trick. The goal of the Free Market Medical Association is to bring together physicians, surgeons, providers, facilities, and support businesses to provide necessary resources to promote a successful industry. Its focus is to defend the practice of free market medicine without the intervention of government or other third parties. </p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1118576319415.html" target="_blank">Read More</a></p> </div>341Plans For The Futurehttps://www.phiagroup.com/Media/Posts/PostId/305/plans-for-the-futureWebinarsWed, 24 Sep 2014 21:32:46 GMT<div class="entry"> <p>As new products, procedures and methodologies are adopted by health benefit plans, each change in claims processing must be preceded by a change made to the applicable plan document. Nothing &ndash; from reference based pricing to MEC/Skinny Plans &ndash; can be implemented unless and until the plan document is adjusted accordingly. </p> <p>The Phia Group has developed the industry&rsquo;s first and only plan document drafting program that combines the convenience of online software with the personal attention to detail expected from The Phia Group&rsquo;s team of plan drafting specialists. </p> <p>Join The Phia Group&rsquo;s CEO, Adam V. Russo, Esq., as he and Senior Vice President and General Counsel (Ron E. Peck, Esq.), Vice President of Consulting (Jennifer McCormick, Esq.), and a team of expert plan drafting specialists discuss the Phia Document Management system, innovative plan design, and why it is especially relevant in light of changes we predict all plan documents will be required to undergo in the coming years.</p> <p><a href="https://www.phiagroup.com/images/September-2014-Webinar_Plans-For-The-Future_9_24_14.pdf">View Webinar</a></p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/2014-09-24%2013.02%20Plans%20for%20the%20Future.wmv">Download Audio</a></p> </div>3052nd Quarter Newsletter 2014https://www.phiagroup.com/Media/Posts/PostId/340/2nd-quarter-newsletter-2014NewslettersThu, 24 Jul 2014 04:25:35 GMT<div class="entry"> <p>What a spring we have had here at The Phia Group. From travelling across the country speaking at various venues, hosting our own Phia Forum a few weeks ago, to our new service offerings; we have been extremely busy here at the home office. Now that the summer is here, you would expect that things would slow down but that&rsquo;s not the case at all. As the temperature rises, so does our work load, as the number of issues facing the self insured industry continues to grow. Who said that health insurance is boring!?!?!?</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1117778678027.html" target="_blank">Read More</a></p> <p>&nbsp;</p> </div>340"Dude, Where's My Subro?" - Integrating Subrogation - Sought by Employers & Loved by Administratorshttps://www.phiagroup.com/Media/Posts/PostId/304/dude-wheres-my-subro-integrating-subrogation-sought-by-employers-loved-by-administratorsWebinarsThu, 15 May 2014 21:24:01 GMT<div class="entry"> <p>As plan sponsors and administrators examine their benefit plans in light of recent legal upheaval, now is our chance to implement important cost containment mechanisms. While only some changes are &ldquo;mandatory,&rdquo; while the &ldquo;hood is open,&rdquo; why not look around and make some other improvements? First and foremost, but often forgotten, is coordination of benefits, third party liability and subrogation. &rdquo;Subro&rdquo; is one item that must be set forth in writing, and flow cohesively between the plan, stop-loss, network, and administrative service agreement. How recovery efforts are handled, who gets what (and when), and other subro-related issues can tie the elements of a strong plan together, or create gaping chasms between partners.</p> <p><a href="https://www.phiagroup.com/images/May-2014-Webinar_Dude-Wheres-My-Subro.pdf" rel="attachment wp-att-1443">PDF Version</a></p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/2014-05-15%2013.02%20_Dude...%20Where_s%20My%20Subro__%20-%20Integrating%20Subrogation%20-%20Sought%20by%20Employers%20_%20Loved%20by%20Administrators%281%29.wmv">View Webinar</a></p> </div>3041st Quarter Newsletter 2014https://www.phiagroup.com/Media/Posts/PostId/339/1st-quarter-newsletter-2014NewslettersFri, 09 May 2014 04:24:40 GMT<div class="entry"> <div> <div>Well&hellip; &ldquo;ObamaCare&rdquo; is here, and so are we. &nbsp;The sun continues to rise in the east, and set in the west; and business goes on. &nbsp;Some of you have reaped the benefits of change, while others have suffered; but the reality is that for most of the industry, not much has changed.</div> </div> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1116065824501.html" target="_blank">Read More</a></p> </div>339Taking It To The Limit - Accurately Identifying and Taking Advantage of Network Contractual Boundarieshttps://www.phiagroup.com/Media/Posts/PostId/303/taking-it-to-the-limit-accurately-identifying-and-taking-advantage-of-network-contractual-boundariesWebinarsThu, 27 Mar 2014 21:22:22 GMT<div class="entry"> <p>While it is true that some network contracts restrict a benefit plan’s ability to audit claims – or as is more often the case, simply prohibits the benefit plan from doing anything with the information so identified; some contracts apply unrealistic deadlines and still others contractually compel payment of claims otherwise excluded by the plan document… There are key provisions plan administrators can use to limit or eliminate the negative impact of such provisions.</p> </div> 303To Pay or Not To Pay - Examining Exclusions, Definitions, and Other Things That Really Matterhttps://www.phiagroup.com/Media/Posts/PostId/302/to-pay-or-not-to-pay-examining-exclusions-definitions-and-other-things-that-really-matterWebinarsWed, 12 Feb 2014 22:20:23 GMT<div class="entry"> <p>Whether you are a plan administrator or claims processor trying to determine eligibility of a claim, or a stop-loss carrier trying to determine whether a submission is reimbursable, how applicable provisions apply to specific facts make all the difference. From exclusions to definitions… from discretionary authority to applicable law… not only understanding what a great document says – but understanding those documents “mean” – is the difference between overpayments and financial stability. Join The Phia Group’s innovative leaders as they discuss the best and worst language, how it impacted real plans when theory met reality, and when we were forced to ask, “to pay, or not to pay?”</p> </div> 3024th Quarter Newsletter 2013https://www.phiagroup.com/Media/Posts/PostId/338/4th-quarter-newsletter-2013NewslettersTue, 14 Jan 2014 05:23:33 GMT<div class="entry"> <p>2014 is now upon us and I can&rsquo;t imagine it being any crazier, both personally and professionally, than 2013; of course, I&rsquo;ll probably say the same thing next year! Thanks to your concerns and needs, we have many exciting new opportunities coming your way this year. 2014 will be the year of self funding where we see the industry grow to heights never seen before. With growth comes many potential pit falls, as always, we are here to get you through them. It will be interesting to see how Obamacare fares in 2014 and what it does to the employer based healthcare system. I am optimistic that things will work out for us in the end and that we will be stronger for it. Just remember that through all the chaos, The Phia Group will be your one stop for all of your cost containment and consulting needs. 2013 was great &ndash; the prospects are even brighter for this year!!!! Happy reading!</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1116066020135.html" target="_blank">Read More</a></p> <p>&nbsp;</p> </div>338A Look Behind, A Look Ahead, Lessons Learned in 2013, and Predictions for the Coming Yearhttps://www.phiagroup.com/Media/Posts/PostId/301/a-look-behind-a-look-ahead-lessons-learned-in-2013-and-predictions-for-the-coming-yearWebinarsWed, 08 Jan 2014 22:17:56 GMT<div class="entry"> <p>As has seemingly been the case for almost every year in the last half-decade, 2013 – like its predecessors – was a busy year for those of us involved with health benefit plans. The continued (bumpy) rollout of PPACA and efforts made by legislators, regulators, and attorneys – both at the State and Federal levels – handicapped us as we attempted to adjust our plans to meet the requirements of law, while maintaining cost effectiveness. Now 2014 promises to be as eventful, if not more so. Join The Phia Group as we review the biggest issues dealt with in 2013, the lessons learned, and what we expect to be dealing with in the year to come.</p> <p> </p> </div> 301For the Fourth Year in a Row, The Phia Group, LLC has been named to Inc. Magazine's List of America's Fastest Growing Private Companieshttps://www.phiagroup.com/Media/Posts/PostId/346/for-the-fourth-year-in-a-row-the-phia-group-llc-has-been-named-to-inc-magazines-list-of-americas-fastest-growing-private-companiesPress ReleasesSun, 15 Dec 2013 06:16:40 GMT<div class="entry"> <p><a href="/portals/phiagroup/images/INC_Press_Release.pdf" target="_blank">Click here</a></p> </div>346The Phia Group's Adam Russo Fires at WSJ Article 'When Insurance Fails...'https://www.phiagroup.com/Media/Posts/PostId/345/the-phia-groups-adam-russo-fires-at-wsj-article-when-insurance-failsPress ReleasesSun, 15 Dec 2013 06:13:24 GMT<div class="entry"> <p>MyHealthGuide Source: Adam V. Russo, CEO, The Phia Group, 2/6/2012</p> <p><span id="more-129"></span></p> <p><a href="/portals/phiagroup/images/Press_Release_WSJ.pdf" target="_blank">Click here to download</a></p> </div>345What You Don't Know Can Hurt You!https://www.phiagroup.com/Media/Posts/PostId/300/what-you-dont-know-can-hurt-youWebinarsWed, 20 Nov 2013 22:16:00 GMT<div class="entry"> <p>As with the Loch Ness Monster and Bigfoot, we have all long believed that Provider Network Agreements exist solely in myth alone, never to be seen by human eyes… until now! From legend to reality; The Phia Group has obtained many provider network agreements, gone through them with a fine tooth comb, and present to you their expert analysis. Wonder at the disparity between plan documents and contracts. Be amazed by the provisions you never knew could be turned in your favor. Most of all, learn of invaluable contract-based arguments you can use to support plan document enforcement. This is a webinar you will certainly not want to miss!</p> </div> 3003rd Quarter Newsletter 2013https://www.phiagroup.com/Media/Posts/PostId/337/3rd-quarter-newsletter-2013NewslettersTue, 29 Oct 2013 04:19:21 GMT<div class="entry"> <p>Ill be honest with all of you &ndash; did I think back in 1999 when I formed The Phia Group with my college buddy Mike Branco that this company would become what it is today?&nbsp; The answer is I had no idea what I expected this company to become.&nbsp; I was just doing something that I loved and thought if I could make a living doing it then that would be &ldquo;wicked&rdquo; cool.&nbsp; We have blown away any expectations we have 14 years ago and the fact remains we have much more to do.</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1115215832326.html" target="_blank">Read More</a></p> <p>&nbsp;</p> </div>3372014 & Beyond - Reacting to PPACA's Volatile Evolutionhttps://www.phiagroup.com/Media/Posts/PostId/299/2014-beyond-reacting-to-ppacas-volatile-evolutionWebinarsWed, 25 Sep 2013 21:15:00 GMT<div class="entry"> <p>Health Insurance Reform (aka Obamacare, aka PPACA, aka Healthcare Reform) has not enjoyed a smooth implementation.  In fact, its birth has been quite turbulent.  Are you surprised?  Like many in our industry, The Phia Group’s CEO – Adam V. Russo, Esq. – as well as its Sr. VP & General Counsel – Ron E. Peck, Esq. – were not shocked to see the many issues developing in the law’s rollout, but even we have been impressed by some of the hurdles.  From the “Pay or Play” employer mandate being delayed by a year, to a complete lack of guidance regarding the many costs, fees, and expenses of the law, join us as we – along with our special guest – The Phia Group’s legal counsel and VP of Consulting, Jennifer McCormick, Esq., analyze the volatile evolution of this controversial law.</p> </div> 2992nd Quarter Newsletter 2013https://www.phiagroup.com/Media/Posts/PostId/336/2nd-quarter-newsletter-2013NewslettersThu, 29 Aug 2013 04:19:21 GMT<div class="entry"> <div style="text-align: justify;">It&rsquo;s been a crazy few months for the health insurance industry as you all know. &nbsp;All I can tell you is that we are here for you with your questions and needs. &nbsp;We attempt to stay ahead of the curve and I can tell you confidently that more changes are ahead, so be sure to tune into our webinars over the next few months.&nbsp;&nbsp;</div> <div style="text-align: justify;">&nbsp;</div> <p>As always, thank you for your support of The Phia Group. &nbsp;We promise to keep you informed so you can protect yourselves and your clients. Happy reading.&nbsp;</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1114184140511.html" target="_blank">Read More</a></p> <p>&nbsp;</p> </div>336What's Good for the Goose is Good for the Gander? Analyzing BUCA-ASO PPO Agreements!https://www.phiagroup.com/Media/Posts/PostId/298/whats-good-for-the-goose-is-good-for-the-gander-analyzing-buca-aso-ppo-agreementsWebinarsTue, 20 Aug 2013 21:13:00 GMT<div class="entry"> <p>We are all familiar with the contractual restrictions, limitations, and prohibitions imposed upon independent benefit plans and third party administrators utilizing major PPO networks.  Whether it is restrictive deadlines, an inability to negotiate directly with providers, a prohibition on audits, or an obligation to pay in accordance with terms you’ll never see, many have complained about the apparent inequity established by these contracts.  Few, however, have analyzed the network contracts existing between major carriers and their own network providers.  One might be surprised to learn that these major carriers and ASOs not only recognize the importance of these items, but assert these rights for themselves!  Join The Phia Group’s CEO – Adam V. Russo, Esq. – as well as its Sr. VP & General Counsel – Ron E. Peck, Esq. – as they dissect contractual terms existing between carriers and their network providers, and share the realization that they know exactly what is important to you.</p> </div> 298Ensuring Cost Containment Success - Member Outreach & Supporthttps://www.phiagroup.com/Media/Posts/PostId/297/ensuring-cost-containment-success-member-outreach-supportWebinarsWed, 31 Jul 2013 21:12:00 GMT<div class="entry"> <p>On July 31st at 1 PM EST, The Phia Group’s CEO – Attorney Adam V. Russo – and The Phia Group’s Sr. VP and General Counsel – Attorney Ron E. Peck – will address one of the most pressing issues facing our industry today – balance billing.  In particular, they will discuss what benefit plan administrators can do to assist their participants and push back against this problem.<br /> To maintain benefit program viability, employers are cracking down on excessive spending through auditing and implementing new methodologies, such as cost based reimbursement and Medicare pricing, in addition to traditional network policies.  In this new environment, participants will be thrust into the fray like never before; exposed to the threat of balance billing.</p> <p>Topics that will be discussed include, but are not limited to –</p> <p>•           When strict enforcement of the plan terms and preventing balance billing may not be harmonious goals</p> <p>•           Undertaking efforts on behalf of benefit plans to resolve disputes with providers so that participants benefit as well, compared to “patient advocacy”</p> <p>•           Providing support to participants facing balance billing by explaining why the payments were capped, describing the appeals process in detail, and providing arguments they can raise against the provider</p> </div> 297Rain Delay – Postponing Play (or Pay)https://www.phiagroup.com/Media/Posts/PostId/335/rain-delay-postponing-play-or-payNewslettersThu, 04 Jul 2013 04:18:18 GMT<div class="entry"> <p><strong>A Delay In Play (or Pay) &ndash; The News Isn&rsquo;t As Good As You May Think</strong></p> <p>The Obama administration announced that it is postponing the requirement that employers provide employees robust, affordable health plans; also known as &ldquo;pay or play.&rdquo; You may think that this is good news&hellip; It&rsquo;s another year to consider options, prepare funds, and study the intricacies of PPACA. DON&rsquo;T BE FOOLED!</p> <p>Regulatory officials have stated that the delay was prompted by so-called &ldquo;compliance complexity concerns.&rdquo; Employers have attacked the rule from every angle; targeting unrealistic expectations, costs, and difficulties in reporting. In addition, many employers have threatened to &ldquo;trim&rdquo; their employment rosters. Employers with fewer than 50 employees (or full-time equivalent employees) are exempt from the rule. It should have come as no surprise, then, that some employers were going to cut employees&rsquo; hours or terminate staff, dropping below 50 lives. With all of this in mind, the administration &ndash; &ldquo;thankfully&rdquo; &ndash; pulled back on the reins. Great news, right? Wrong!</p> <p>At The Phia Group, we hope for the best but plan for the worst. For the following reasons, now is not the time to disregard cost containment efforts.&nbsp; &ndash; <a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1114027288212.html" target="_blank">Read More</a></p> </div>3351st Quarter Newsletter 2013https://www.phiagroup.com/Media/Posts/PostId/334/1st-quarter-newsletter-2013NewslettersTue, 18 Jun 2013 04:17:16 GMT<div class="entry"> <p>As you have no doubt heard by now, on April 15, 2013 &ndash; two bombs were detonated just before 3 P.M. Eastern Standard Time in the Copley Square area of Boston, MA.</p> <p>Since the news broke, many of you have reached out to us to ascertain our situation and confirm our wellbeing. I am pleased to advise you that our entire team is whole and healthy. The outpouring of support from you, our industry partners, has been moving.</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112803984547.html" target="_blank">Read more</a></p> </div>334Providing For The Future - The Evolution of Plans' Provider Relationships & Exposing Conflicts Between Plans & Providershttps://www.phiagroup.com/Media/Posts/PostId/296/providing-for-the-future-the-evolution-of-plans-provider-relationships-exposing-conflicts-between-plans-providersWebinarsWed, 22 May 2013 21:10:50 GMT<div class="entry"> <p>For those that are invested in maintaining health benefits, inventing new cost saving methodologies is the “holy grail.”  Enter the provider – hospitals, physicians, and other health care facilities.  From specialty networks to direct provider negotiations; from medical tourism to ACOs… The way we receive care is changing.  While some providers embrace the opportunity to shake things up, others cling to the status quo.  Conflicts inevitably result from such changes, including: contract disputes, provider appeals, audits and refund requests…  Join The Phia Group’s CEO, Adam V. Russo, Esq. as well as its Senior VP and General Counsel, Ron E. Peck, Esq., as they confront these and other provider conflicts on the rise. </p> </div> 296Get In Line Before You're Out Of Time - How To Thrive in a Post-PPACA World...https://www.phiagroup.com/Media/Posts/PostId/295/get-in-line-before-youre-out-of-time-how-to-thrive-in-a-post-ppaca-worldWebinarsThu, 25 Apr 2013 21:10:50 GMT<div class="entry"> <p>In a world dominated by reform and regulation, there are those who master compliance and thrive, and those who stumble under the burden.  Thriving in the post PPACA era requires innovation, and a proactive attitude.  Predicting what mandated benefits will be required from your benefit plans, discovering the most cost effective methods to maintain a benefit program and thereby “play” rather than “pay,” and other issues haunting every member of the industry will be discussed.  Join The Phia Group’s CEO, Adam V. Russo, and Sr. Vice President, Ron E. Peck, as they share the secrets of regulatory compliance success.</p> </div> 295Getting Employers To Self-Fund In The PPACA Era - Keep Existing Clients Self-Funding... Get New Employers To Self-Fund...https://www.phiagroup.com/Media/Posts/PostId/294/getting-employers-to-self-fund-in-the-ppaca-era-keep-existing-clients-self-funding-get-new-employers-to-self-fundWebinarsWed, 13 Mar 2013 21:09:04 GMT<div class="entry"> <p>As time passes and elements of PPACA are triggered, the cost of purchasing insurance has become too great.  Meanwhile, employers see an opportunity to drop coverage, pay a relatively small penalty, and exile employees to the exchanges.  The reasons to offer employment based benefit plans hasn’t changed.  For those that self-fund, they need to know why self-funding remains the best option for them.  For those leaving fully funded insurance, self-funding may be an option they haven’t considered.  Join The Phia Group’s CEO, Adam V. Russo, and Sr. VP, Ron E. Peck, as they discuss the many reasons to keep health benefits in-house, and how self-funding allows employers to “play” the game in a PPACA era!</p> </div> 294February 2013 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/333/february-2013-newsletterNewslettersTue, 05 Mar 2013 05:13:54 GMT<div class="entry"> <p>It&rsquo;s only February and I&rsquo;m already getting sick of the snow. Thankfully spring training is underway and for the first time in years, my beloved Indians have a chance to win! We here at The Phia Group want all of you to win new clients and increase your profitability and that&rsquo;s why our services are catered to you.</p> <p>The industry is going through much change and our expertise can and will guide you through the storms. Our recent webinar on cost plus offerings was the highest attended to date and we expect to beat that number with our next two on how to convince employers that self funding is right for them. Thanks for choosing us and happy reading.</p> <p>&nbsp;</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112163395757.html" target="_blank">Read more</a></p> <a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112163395757.html" target="_blank"> </a> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112163395757.html" target="_blank"></a></p> </div>333Medicare-Plus & Other Cost-Plus Methodologies - The Controversyhttps://www.phiagroup.com/Media/Posts/PostId/293/medicare-plus-other-cost-plus-methodologies-the-controversyWebinarsTue, 12 Feb 2013 22:06:50 GMT<div class="entry"> <p>The survival of self-funding in the face of PPACA, stricter stop-loss regulation, and the exchanges, is reliant upon doing more for less.&nbsp; Plan administrators are now thinking outside the box, developing payment methodologies that draw upon both old and new practices. Change, however, invites upheaval; in a world dominated by PPO networks and provider agreements, anyone who strays from the norm has a fight on their hands.&nbsp; Join The Phia Group&rsquo;s CEO, Adam V. Russo, and Sr. Vice President, Ron E. Peck, as they dissect these new concepts, consider the pros and cons, and share their experiences as advocates of these new theories.</p> <p><a href="https://www.phiagroup.com/images/February_MedicarePlus.pdf" target="_blank">Click here to download PDF</a></p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/medicare_plus.wmv">Click here to download Audio</a></p> <a href="https://www.phiagroup.com/portals/phiagroup/webinars/medicare_plus.wmv"> </a> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/medicare_plus.wmv"></a></p> </div>293California / Recovering Benefits from Workers' Compensationhttps://www.phiagroup.com/Media/Posts/PostId/292/california-recovering-benefits-from-workers-compensationWebinarsWed, 23 Jan 2013 22:04:57 GMT<div class="entry"> <p>In May of 2012, the California Workers&rsquo; Compensation Appeals Board (&ldquo;WCAB&rdquo;) adopted amendments, which impact the ability of lien claimants to obtain recovery.</p> <p>&bull; &nbsp;To secure reimbursement when filing a &ldquo;green-lien,&rdquo; lien claimants must pay a fee of $150.00.</p> <p>&bull; &nbsp;To secure reimbursement when filing a &ldquo;green-lien,&rdquo; &ldquo;&hellip;lien claimants must appear at a lien conference and/or trial &hellip;&rdquo;</p> <p>We have already developed a strategy to ensure a smooth progression in light of these rules, and have the legal expertise in place to secure recovery.&nbsp; Please note, however, that the filing fee and appearance by local counsel will result in additional expense to the Plan.&nbsp; In an effort to maximize recoveries for our clients while minimizing costs, The Phia Group and its clients will have to conduct a cost-benefit analysis when deciding whether to pursue reimbursement, on a case by case basis.</p> <p>PLEASE MARK YOUR CALENDAR!&nbsp; The Phia Group will be hosting a webinar specifically regarding these issues on January 23, 2013 at 4 PM EST / 1 PM PST.&nbsp; We have limited invitations to you and entities like you, directly impacted by these new rules.&nbsp; We will be discussing the new rules in greater detail, will field your questions, and will discuss the many issues benefit plans should keep in mind when assessing their options.&nbsp; It is important to us that you attend.</p> <p><a href="https://www.phiagroup.com/images/Workers-Compensation.pdf" target="_blank">Download PDF Version</a></p> <a href="https://www.phiagroup.com/images/Workers-Compensation.pdf" target="_blank"> </a> <p><a href="https://www.phiagroup.com/images/Workers-Compensation.pdf" target="_blank"></a></p> </div>292January 2013 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/332/january-2013-newsletterNewslettersTue, 22 Jan 2013 05:12:57 GMT<div class="entry"> <div style="text-align: justify;">I cannot believe that New Year&rsquo;s Eve was over 2 weeks ago &ndash; where have these days gone?&nbsp; Time certainly seems to fly by when I keep myself busy working to ensure that all of you are protected this year. I have been spending much time researching the options available to employers in 2014.&nbsp; Where will they go?&nbsp; Will they decide to self fund or will they join the exchanges?</div> <div style="text-align: justify;">&nbsp;</div> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112153239778.html" target="_blank"></a></p> <a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112153239778.html" target="_blank"> <div style="text-align: justify;">Read More</div> </a> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1112153239778.html" target="_blank"></a></p> </div>332The State of the Subro-Union Addresshttps://www.phiagroup.com/Media/Posts/PostId/291/the-state-of-the-subro-union-addressWebinarsWed, 16 Jan 2013 22:02:25 GMT<div class="entry"> <p>The Phia Group’s CEO (Adam V. Russo), Sr. VP and General Counsel (Ron E. Peck), and resident subrogation litigation expert (Christopher Aguiar) will delve into current events, litigation, and changes in law (official and otherwise), as they share the current state of affairs for anyone and everyone interested in subrogation.  You may think your time-tested methods for cost containment via claims recovery are safe and sound… and you’d be wrong.  This is a discussion you will not want to miss.</p> </div> 291December 2012 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/331/december-2012-newsletterNewslettersSun, 30 Dec 2012 05:12:05 GMT<div class="entry"> <p>Happy Holidays to all of you!&nbsp; As we enter 2013, I just wanted to say thank you for the opportunity to serve you and the entire industry over the past 12 years and I look forward to doing so in 2013.</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1111895493830.html" target="_blank">Read more</a></p> </div>331Looking Forward to 2013 - The Phia Group Looks Back at 2012 and Forward to 2013https://www.phiagroup.com/Media/Posts/PostId/290/looking-forward-to-2013-the-phia-group-looks-back-at-2012-and-forward-to-2013WebinarsMon, 26 Nov 2012 21:59:21 GMT<div class="entry"> <p>If you thought 2012 was a wild ride, wait until you see 2013.&nbsp; Obamacare is the law of the land, and it&rsquo;s here to stay.&nbsp; The entities empowered by PPACA to issue mandates are prepared to unleash a tidal wave of regulations in 2013.&nbsp; Subrogation and coordination of benefits once again appear before the Supreme Court.&nbsp; The very definition of self-funding, rights under ERISA, and access to stop-loss have come under attack.&nbsp; Join The Phia Group&rsquo;s CEO, Adam V. Russo, Sr. V.P. and General Counsel, Ron E. Peck, and V.P. of Consulting Services, Jennifer McCormick, as they discuss what we can expect to see in 2013, and how best to prepare for what&rsquo;s coming.</p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/Looking forward to 2013.wmv" target="_blank">Click here to download webinar</a></p> </div>290November 2012 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/330/november-2012-newsletterNewslettersThu, 22 Nov 2012 05:11:00 GMT<div class="entry"> <p>The elections are over and regardless of who you voted for, the fact remains that PPACA is here to stay.&nbsp; While many of you have been utilizing our firm to assist in your compliance needs, we have never publicly announced that our team of experts can assist your organization with Regulatory Compliance issues until now.</p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1111583872312.html" target="_blank">Read more</a></p> </div>330The Bay State Crystal Ball - How Massachusetts May Predict the Future for America's Healthcarehttps://www.phiagroup.com/Media/Posts/PostId/289/the-bay-state-crystal-ball-how-massachusetts-may-predict-the-future-for-americas-healthcareWebinarsWed, 14 Nov 2012 21:57:34 GMT<div class="entry"> <p><a href="https://www.phiagroup.com/images/Massachusetts.pdf" target="_blank">Click here</a> to download webinar</p> <p>Mitt Romney has been distancing himself from the healthcare reform he signed into law whilst governing Massachusetts.&nbsp; His team has responded to comparisons between &ldquo;Romneycare&rdquo; and &ldquo;Obamacare,&rdquo; stating that the two laws are vastly different, and vary based on scope of coverage, communities they apply to, and terms themselves.&nbsp; That being said, we can still draw many parallels between the two.&nbsp; Those of us who fail to look at the Bay State as a prototype for post-PPACA America are missing an opportunity to gaze into the future.&nbsp; From early successes, to a gradual bloating of the program&hellip; from red-tape, to recent moves to address the actual cost of care&hellip; the Commonwealth of Massachusetts is certainly a crystal ball.&nbsp; Join us as we dissect The Phia Group&rsquo;s home state, and attempt to predict the nation&rsquo;s future.</p> </div>289Trick Or Treathttps://www.phiagroup.com/Media/Posts/PostId/288/trick-or-treatWebinarsSun, 11 Nov 2012 23:41:44 GMT<p>Plan sponsors are looking for ways to cut costs without limiting benefits. New solutions are popping up everywhere, from medical tourism, to carving out dialysis; from placing a Medicare + cap on allowable expenses, to having outside auditors reprice claims. The industry is shifting from a pure PPO focus, but with change comes uncertainty. Believe it or not, but these programs present risks along with rewards. Conflicts with providers, balance billing, accusations of discrimination, stop-loss denials, and other negative repercussions are only some of the &ldquo;tricks&rdquo; we will help you avoid as you seek to indulge in the newest, innovative &ldquo;treats&rdquo; our industry has to offer.</p> <p><a href="https://www.phiagroup.com/portals/phiagroup/webinars/Trick or Treat_ The Pros and Cons of Todays Most Trendy Cost Containment Schemes.wmv" target="_blank">Click here to download webinar</a></p>288Doing It For Ourselveshttps://www.phiagroup.com/Media/Posts/PostId/287/doing-it-for-ourselvesWebinarsSun, 11 Nov 2012 22:41:00 GMT<div class="entry"> <p>June 28th, 2012 is a date that will not live on in infamy or otherwise. On that date The Supreme Court of the United States (“SCOTUS”) took the path of least resistance, declaring that The Patient Protection and Affordable Care Act (“PPACA”) is Constitutional, while tearing the claws from the so-called “mandate’s” enforceability. In one fell swoop, SCOTUS both locked PPACA in as the law of the land, and eliminated the government’s ability to enforce the mandate against individuals. With the smoke clearing, and exchanges advancing nationwide, the eyes of regulators now shift to employers and self-funded plans. State commissioners, who since ERISA’s passage in 1974 have sought to control self-funded benefits, now wave the Obamacare flag in efforts to advance their long held desires. As the cost of providing insurance increases, and employers – long since thought untouchable by the self-funded industry – must decide between exiling employees to the exchange, or sampling self-funding, self-funded plans that implement cost containment solutions can position themselves to reap the rewards of this paradigm shift.</p> <p> </p> </div> 287The Supreme Court Opinion on PPACAhttps://www.phiagroup.com/Media/Posts/PostId/286/the-supreme-court-opinion-on-ppacaWebinarsSun, 11 Nov 2012 21:41:00 GMT<div class="entry"> <p>The US Supreme Court upheld the sweeping 2010 healthcare law, declaring that Obama and Congress acted within their powers in requiring most Americans to obtain health insurance.</p> <p>The ruling reaffirms the most ambitious and controversial undertaking of President Obama’s first term: attempting to guarantee that most of the 45 million Americans without insurance will get better access to medical care.</p> <p> </p> </div> 286October 2012 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/329/october-2012-newsletterNewslettersSat, 20 Oct 2012 04:09:40 GMT<div class="entry"> <p><span id="more-534"></span><br /> Well, it&rsquo;s that time of year where here in New England the leaves are turning colors, the summer outdoor furniture is being put away, and by the time I leave the office its already dark outside. So depressing, yet I feel so inspired by what I see happening across the industry. People are getting creative with their cost containment ideas and I see more and more innovative approaches to reducing the cost of health care. But we have to be diligent in how we do these things. </p> <p><a href="http://archive.constantcontact.com/fs172/1103630262203/archive/1111293372779.html" target="_blank">Read more</a></p> </div>329September 2012 Newsletterhttps://www.phiagroup.com/Media/Posts/PostId/328/september-2012-newsletterNewslettersSat, 20 Oct 2012 04:08:47 GMT<div class="entry"> <p><span id="more-532"></span><br /> Fall is in the air here in New England but the conference schedule is heating up earlier than ever for me. I&rsquo;m doing the nationwide tour and the focus from audience questions is on two areas &ndash; health care reform and self funding. The same people who ask me about reform then follow up with whether self funding is a good move to lower their costs. The interest in self funding is the highest I have seen in my life time so we here at The Phia Group will continue to preach the virtues of this option and how to make it work right. </p> <p><a href="http://archive.constantcontact.com/fs076/1103630262203/archive/1111019031629.html" target="_blank">Read more</a></p> </div>328