Recent Posts

• Navigating Mental Health Parity: What Self-Funded Plans Need to Know
  
  April 24, 2025
  By: David Ostrowsky In 2008, under the George W. Bush administration, the Mental Health Parity and Addiction Equity Act (MHPAEA) was enacted to ensure that health insurance plans did not impose more restrictive limitations on mental health and substance use disorder (MH/SUD) benefits – assuming they were initially covered – than those imposed on medical and surgical (M/S) benefits. More specifically, health insurers were forbidden from applying limitations such as prior authorizations, unreasonably high copays, or visit restrictions to mental health/substance use disorder treatments when medical/surgical treatments did not have such imposing constraints. The 2008 law was hailed as a ...
• A Discussion of the Executive Order to Lower Drug Prices
  
  April 23, 2025
  By: Kendall Jackson The high costs associated with prescription drugs consistently provoke conversation in the self-funded healthcare industry. Not only is it an issue that most health plans encounter, but it is also a concern that trickles down to the member-level. Whether you’ve personally experienced the effects of high-cost drugs, or they have impacted a close family member, we can all empathize with the stress of having to pay for an expensive prescription. In an effort to minimize these concerns, President Trump issued an executive order (EO) titled “Lowering Drug Prices by Once Again Putting Americans First.” One goal of ...
• AI to the Rescue? How Machine Learning May Revolutionize Drug Repurposing
  
  April 15, 2025
  By: David Ostrowsky Without question, artificial intelligence beholds many downright frightening risks when implemented in the healthcare field. Without proper oversight, AI could have the final say in depriving a patient of a necessary procedure or steering them towards a suboptimal physician. Or the still nascent technology, if unchecked, could account for a HIPAA breach with the slapdash handling of PHI. Yet, that being said, AI is undoubtedly here to stay and as far as the healthcare industry is concerned, this technological revolution is brimming with astonishing potential, as evidenced by the recent development of AI expediting the repurposing of ...
• Tariff Talk - How Trump’s Pharmaceutical Tariffs Could Impact You (and How You Can Prepare)
  
  April 11, 2025
  By: Brady Bizarro, Esq. As the self-insurance industry braces for potential changes under President Trump’s administration, one issue looms large: impending tariffs on pharmaceutical drugs. These proposed tariffs, aimed at boosting domestic manufacturing, could ripple through the healthcare ecosystem, affecting employers sponsoring self-funded health plans, third-party administrators (TPAs), stop-loss carriers, brokers, and vendors. For an industry built on balancing cost control with quality care, understanding these impacts and preparing strategically is critical. More importantly, as we navigate these changes, we must remain steadfast in our commitment to ensuring that our members get access to quality, affordable prescription drugs. President Trump has ...
• Care Empowered Pricing as a Money Saver
  
  April 10, 2025
  By: David Ostrowsky For over a quarter century, The Phia Group has championed a broad spectrum of cost containment initiatives to empower health plans and ultimately, their respective participants. The Phia Group believes that its latest endeavor—Care Empowered Pricing (CEP)—may be its most robust cost containment program yet. At its core, CEP is engineered to, quite simply, save plans money and as you can see below, there are a number of ways our revolutionary offering does so. Firstly, in terms of program ownership, unlike traditional reference-based pricing (RBP) plans, in which the RBP vendor owns the program in a black box ...
• Overhauling HHS – Can a Leaner, Meaner HHS Make America Healthy Again?
  
  April 7, 2025
  By: Nicholas Bonds, Esq. The second Trump administration has not been shy about taking steps to shake up U.S. health policy. There has been a flurry of executive orders on a range of healthcare topics, including stepping up enforcement of price transparency rules; a push to expand coverage for and lower the out-of-pocket costs for in vitro fertilization; and taking steps to redefine sex-based discrimination in federal policy and to discourage treatments for gender dysphoria. Even so, the executive action poised to have the broadest impact on health policy may just be the sweeping changes being made to the ...
• The Social Impact of Mental Health Parity Testing Explained
  
  March 24, 2025
  By: Bryan M. Dunton, Esq. Unknown to many of us, celebrities suffer from mental health and substance use disorders just like anyone else. Recently, country music megastar Luke Combs openly discussed his struggles with obsessive compulsive disorder (OCD). Combs hopes that his discussion of the topic will reduce stigma that often comes with a mental health diagnosis. Taylor Swift has previously discussed her own struggles with an eating disorder for similar reasons. Before Robert Downey Jr. became Iron Man on the big screen, he suffered from substance use disorders for years before seeking treatment, ultimately becoming sober and remaining so ...
• Pancreatic Cancer Vaccine | A New Hope on the Horizon
  
  March 17, 2025
  By: Kate MacDonald Chances are that cancer has touched the lives of nearly every American. Maybe it’s a suspicious mole that turns out to be a carcinoma, an old high school friend’s social media post raising awareness of the need for mammograms after a scare, or a grandparent who battled lung cancer after years of smoking. As the years go by, studies show that the frequency is increasing. The National Cancer Institute estimated that last year alone, more than two million Americans were diagnosed with a form of cancer, and 600,000 lost their fight. This can be compared to a ...
• RBP vs. PPO Plans | Understanding the Key Differences
  
  February 27, 2025
  By: David Ostrowsky A preferred provider organization, known colloquially as a “PPO,” is a network of contracted – or preferred – providers who offer care at a minimal out-of-pocket cost compared to rates offered by out-of-network providers. A PPO plan is a very popular type of health insurance in which the insurance plan pays its network of preferred providers a set fee to provide certain healthcare services, enabling plan participants to pay a reduced copay or coinsurance when they receive care within said network. Patients can still see providers out of their preferred network, but they will likely be subject ...
• Struggling to Breathe | The Global Medical Oxygen Crisis
  
  February 26, 2025
  By: David Ostrowsky For well over a century, medical oxygen has been used for treating patients with an assortment of medical needs, most notably respiratory issues such as pneumonia, as well as those undergoing surgery, experiencing heart failure, and receiving maternal care. Utilized by over 370 million medical patients worldwide, medical oxygen was, in fact, added to the World Health Organization’s Essential Medicines List in 2017. And yet, according to a recent report published in The Lancet medical journal, well over half of the world’s population does not have access to safe and affordable medical oxygen services; unsurprisingly, this segment ...
• Journavx | A New Non-Opioid Solution for Pain Management
  
  February 11, 2025
  By: David Ostrowsky Every year, tens of millions of opioid prescriptions are written for Americans experiencing searing pain caused by broken bones, burns, procedures, and wounds. In most cases, the medications produce efficacious results without causing patients to become overly dependent and ultimately addicted. Still, there is a relatively small percentage of users (numbering in the tens of thousands) who develop severe – and sometimes fatal – addictions, hence the well-chronicled national opioid crisis that has descended on humanity this century. Though health insurers and healthcare providers may continue steering patients toward these affordable, generally effective opioid prescriptions, an intriguing ...
• Care Empowered Pricing | Future of Reference-Based Pricing
  
  January 30, 2025
  By: Ron E. Peck, Esq. and David Ostrowsky Traditional health benefit plans and insurance carriers pay medical bills that generally fall into one of two buckets, based on the “network status” of the applicable healthcare services provider. If the benefit plan or carrier is utilizing a network (such as a PPO) and the applicable provider is a participating provider, then the provider is deemed to be “in-network.” When a provider is in- network, the plan or carrier will pay the provider’s billed charges minus a discount defined by the network agreements. If the provider is not participating in the ...
• House Republicans Propose Changes to HSA-Qualified HDHPs
  
  January 24, 2025
  By: Kendall Jackson, Esq. As we close out the first month of 2025 with a new administration, the vast number of new proposals related to reducing government spending is unsurprising. Only a week ago, two documents were leaked related to House Republicans’ “Spending Reform Options,” which provided insight into their policy objectives. One proposal that was particularly significant was the goal to pass H.R. 5688, referred to as the Bipartisan HSA Improvement Act of 2023. While this bill has several objectives, the most notable may perhaps be to allow an individual to continue contributing to a health savings account (HSA), ...
• The Invisible Truth of Healthcare | Cost vs. Quality
  
  January 24, 2025
  By: David Ostrowsky When you’re shopping for a new car, you expect that shelling out more money will correlate with a more high-powered, fancier, and durable vehicle. The same logic – that price and quality run parallel to one another – would seemingly apply to flat screen TVs, smartphones, stereo systems, laptops, vacuum cleaners, snowblowers, and every other item that Americans race to the stores to purchase on Black Friday. It is human nature to assume that a higher price equates to higher quality . . . unless information is provided to the contrary. As savvy shoppers are well aware, ...
• The Phia Group's Role in Transforming Healthcare with AI
  
  January 13, 2025
  By: David Ostrowsky Unfortunately, there has long been a widely held perception that the healthcare industry is largely antiquated and riddled with inefficient processes. Perhaps that can explain why last week’s announcement – that Machinify, a provider of artificial intelligence (AI)-powered software for streamlining the healthcare claims lifecycle, will become an integral part of the company recently formed through the merger of The Rawlings Group (“Rawlings”), Apixio’s Payment Integrity business (“Apixio PI”), and VARIS – was deemed particularly newsworthy. That this new conglomerate, to be named Machinify, will be leveraging next generation technology and a wealth of data to further ...
• An App for What Ails You
  
  January 13, 2025
  By: Nick Bonds, Esq. Feeling under the weather? There’s an app for that. Sort of. This is the future presaged by “PDURS” (Prescription Drug Use-Related Software). One of the sillier acronyms to grace the healthcare industry in recent memory, PDURS are defined by the FSDA as “software disseminated by or on behalf of a drug sponsor that accompanies one or more of the sponsor’s prescription drugs, including biological drug products.” Essentially, most patients will encounter this software as an app, paired with marquee prescription drugs, that is designed to “assist” patients and healthcare providers in the prescription and use of ...
• Wesco v. BCBSM | Understanding Implications for Healthcare
  
  January 8, 2025
  By: David Ostrowsky Was it a standard administrative cost or a true “phantom tax” allegedly stifling competition? Back in November, Wesco, a 55-year-old privately-held gas station chain, and the benefits fund for the Utility Workers Union of America filed a class action lawsuit, alleging that Blue Cross Blue Shield of Michigan (BCBSM), an insurance carrier serving over six million Midwesterners, engaged in an anticompetitive practice by charging an additional PEPM (“per-employee, per-month”) fee to any group that opted to use a stop-loss carrier other than BCBS. For BCBS of Michigan, the fee represents a fairly standard industry practice for charging ...
• No Extension for Telehealth Safe Harbor in HDHPs for 2025
  
  January 6, 2025
  By: Kelly Dempsey, Esq. It’s not the news any of us wanted to hear, but 2025 has arrived with no extension to the telehealth services safe harbor for high deductible health plans that are HSA-qualified. As such, the safe harbor officially expires for plan years starting on or after January 1, 2025. There were numerous reports that an extension was included in early drafts of the bill to keep the government funded in December, but the bill passed and signed by President Biden on December 21, 2024, did not include this extension.  This safe harbor was originally created by ...
• Anthem Blue Cross Blue Shield Reverses Anesthesia Policy
  
  December 26, 2024
  By: David Ostrowsky Earlier this month, as the healthcare industry was receiving an inordinate amount of unwanted public attention and scrutiny, there was actually a positive development stemming from one of the country’s largest health insurers. Indeed, lost in the shuffle amidst the chaotic aftermath of the murder of UnitedHealthcare CEO Brian Thompson was Anthem Blue Cross Blue Shield’s reversal of its initial decision to stop paying for anesthesia care in certain states if the surgery or procedure extends beyond a particular time limit. Had such a titan of the health insurance industry proceeded in not paying for medically necessary ...
• Health Disparities in Appalachia After Hurricane Helene
  
  December 2, 2024
  By: David Ostrowsky Well before Hurricane Helene, one of the deadliest storms in modern American history, ripped through Western North Carolina earlier this autumn, decimating scores of residences and businesses and washing away entire neighborhoods, the largely impoverished Appalachian region was grappling with a precarious healthcare infrastructure. To this day, Asheville, North Carolina, and its surrounding mountainous communities have never fully recovered from the devastation of the Great Recession of 2008, resulting in a grave health disparity among other societal ills. And, yes, the recent ferocious tempest of which Western North Carolina bore the brunt has only exacerbated the region’s ...
• Understanding New MHPAEA Requirements for Compliance
  
  November 20, 2024
  By: Kendall Jackson, Esq. The deadline to comply with several of the new final rules regarding the Mental Health Parity and Addiction Equity Act (“MHPAEA”) is quickly approaching. On September 9, 2024, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released new final rules that updated existing regulations to provide additional clarity for plans and their vendors on what is required and what will be considered compliant and non-compliant for parity purposes when performing a nonquantitative treatment limitation (NQTL) comparative analysis. The final rules generally apply to group health plans, including self-funded non-Federal governmental health ...
• Addressing Balance Billing and Payment Disputes for TPAs
  
  November 14, 2024
  By: Scott Bennett and David Ostrowsky As rising healthcare costs continue to challenge employers and third-party administrators (TPAs), Reference-Based Pricing (RBP) has emerged as a powerful strategy for cost containment. However, RBP, while promising, is not without its pitfalls. Chief among them is balance billing, in which providers charge patients for the difference between their billed charges and the RBP plan’s payment. Additionally, the No Surprises Act (NSA) has introduced Open Negotiations and Independent Dispute Resolution (IDR) processes, which, while protecting patients, expose employers to post-payment disputes. Addressing these concerns effectively requires comprehensive tools, support, and strategic implementation. Addressing the Challenges ...
• Having NSA Problems? Better Call The Phia Group
  
  October 31, 2024
  By: David Ostrowsky The Independent Dispute Resolution (“IDR”) process was designed to be a cornerstone of the No Surprises Act (“NSA”), a means for resolving claims for payment for out-of-network items and services and a vital mechanism for buttressing the NSA’s protection for plan members against potentially devastating balance billing expenses. Unfortunately, since the NSA took effect on January 1, 2022, things have gone awry on many fronts. The case volume has overloaded the IDR process; courts have been split over whether and how parties can enforce arbitration awards; payers, including group health plans, have paid close to four times ...
• The Future of Birth Control in America
  
  October 28, 2024
  By: David Ostrowsky Since the US Supreme Court decided to undo nationwide abortion rights in summer 2022, women’s reproductive rights has arguably been the most pressing topic in healthcare. Naturally, as we enter the final stretch of election season – as well as the Biden administration – the all-important, polarizing matter has resurfaced. Earlier this month, the departments of Health and Human Services, Labor and Treasury proposed to broaden a federal mandate (under the Affordable Care Act) obligating private health insurers to cover condoms, birth control pills, and “morning after” pills for women on private health insurance plans – even ...
• Cobenfy: A Game-Changer for Schizophrenia Treatment Costs
  
  October 9, 2024
  By: David Ostrowsky As you’re reading this blog, millions worldwide are suffering from the horrors of schizophrenia, one of the most complex, debilitating, and stigmatized mental disorders inflicted on humanity, the symptoms of which typically manifest themselves in early adulthood, though they are not always so easy to detect. Those afflicted by this condition are desperately trying to manage an array of frightening symptoms (hearing voices, delusions, memory lapses to name a few) while carrying on with their lives. In this country alone there are approximately 2.8 million Americans living with schizophrenia; tragically, many of those 2.8 million Americans won’t ...
• Healthcare and Politics… Ugh. Old News!
  
  September 27, 2024
  By: Ron Peck, Esq. Donald Trump recently stated that while he will never give up on repealing the Affordable Care Act (ACA), he was not running on terminating the ACA.  This is likely a smart decision, given that a recent Kaiser Family Foundation (KFF) poll[1] revealed that for Republican voters, repealing Obamacare was an important issue for a very small percentage of respondents. Is this demonstrative of a more widespread loss of interest in healthcare as a political talking point? As someone whose day-to-day career is centered around health benefit plans, cost containment, and the attempt to ensure plan participants ...
• Medicare's First Ten Negotiated Drug Prices Announced
  
  September 16, 2024
  By: David Ostrowsky Last month, while many of us were busy vacationing or doing last-minute back-to-school shopping, the Biden administration announced that it had reached an agreement with the titans of the pharma industry to lower prices on the 10 costliest prescription drugs under Medicare, thus bringing to fruition Democrats' decades-long push to allow the government to negotiate directly with pharmaceutical manufacturers. While individual plans had previously been able to haggle over prices with Big Pharma, this development marks a seminal moment as it is the first time that Medicare used its clout to be able to negotiate for ...
• Section 1557 Final Rule | Current Status and Implications
  
  August 30, 2024
  By: Kendall Jackson, Esq. The implications of the Section 1557 Final Rule are currently in flux since the Final Rule was issued on April 26, 2024. The purpose of the Final Rule was to extend the protections against discrimination in healthcare, with a particular emphasis on gender identity. The inclusion of gender-affirming care within the protection against sex discrimination was a huge step forward in strengthening the scope of Section 1557 beyond what was originally afforded when the rule first passed. Unfortunately, there have been several challenges to the Final Rule where various district courts either stayed or enjoined particular ...
• Healthcare in Rural America | Overcoming Access Barriers
  
  August 19, 2024
  By: David Ostrowsky Whether it’s met with great anticipation or utter dread, summer will soon be giving way to autumn. For many people living in picturesque New England, where The Phia Group is headquartered, seasonal change means an upcoming weekend of leaf-peeping. But when we’re checking out apple orchards and roadside maple sugar shacks, it’s easy to forget the sobering reality: life isn’t always so sweet for residents in these one-stoplight rural outposts as many face imposing barriers to healthcare. Healthcare inequality is a glaring problem across our nation, but the issue is particularly acute in rural America where folks grapple ...
• Health Over Wealth Act | Protecting Patients from PE Firms
  
  August 5, 2024
  By: David Ostrowsky In 2017, New York Times medical journalist Dr. Elisabeth Rosenthal published “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” It quickly became one of this century’s most influential healthcare books, enlightening the masses about the corporate greed embedded in a trillion-dollar industry, one that is ostensibly grounded in altruistic endeavors. Unfortunately, little has changed in the seven years since Rosenthal’s best-seller hit the shelves of your local Barnes & Noble. If anything, the industry has only become further riddled with opportunities for captains of industry, such as those leading private ...
• What the Overturning of Chevron Means for Healthcare
  
  July 19, 2024
  By: David Ostrowsky   For the past forty years, federal agencies have had considerable latitude to interpret and enforce regulations and subsequently advance regulatory initiatives. Per the precedent established in the Supreme Court’s 1984 decision in Chevron U.S.A., Inc. v. Natural Resources Defense Council, courts have had to defer to federal agencies regarding legal challenges over ambiguously written laws passed by Congress. The rationale was as follows: The public servants employed by the federal agencies, whether they be scientists, engineers, law enforcement officials, economists, or experts in another field, have more specialized expertise in the given matter – even more so ...
• Impact of Supreme Court on Gender-Affirming Care Bans
  
  June 26, 2024
  By: David Ostrowsky Samantha and Brian Williams of Nashville are no different from any other parents in that they want what’s best for their 15-year-old daughter. The Williams’ situation, however, is different from that of many parents as their child identifies as transgender while residing in a state that restricts access to puberty blockers, hormone therapies, and surgeries for minors undergoing gender transitioning. Per the American Civil Liberties Union, the Williams’ daughter is one of approximately 3,000 transgender adolescents in Tennessee where, by law, medical providers cannot perform procedures that “enable a minor to identify with, or live as, a purported ...
• Direct Contracting and Occam’s Razor
  
  June 21, 2024
  By: Jon Jablon, Esq. Maybe I should be, but I’m not ashamed to admit that when I first heard of Occam’s Razor, I assumed it had something to do with shaving. Whatever the context, many know Occam’s Razor as a principle of decision-making holding that “the simplest explanation is the best one”. Although the real idea is similar, William of Ockham’s logic is a bit more formulaic than that. To paraphrase, Occam’s Razor suggests that when choosing between multiple options, the best choice is the one that requires the fewest assumptions to reach. Put another way, the best option ...
• Section 1557 Final Rule | Key Implications for Health Plans
  
  June 17, 2024
  By: Kendall Jackson, Esq. The non-discrimination protections of Section 1557 of the Affordable Care Act are not new, as the Affordable Care Act was originally enacted in 2010. However, the recent Final Rule published on May 5, 2024, provided clarification and additional requirements as they relate to strengthening civil rights protections for individuals. First, it is important to remember that Section 1557 is not applicable to all health plans. Section 1557 applies to “covered entities,” which are health programs or activities that receive HHS funding. “Covered entities” also include HHS-administered health programs or activities, and the health insurance Marketplace. The ...
• 2024 Benefest: Not Just Massachusetts in Focus
  
  June 14, 2024
  By: David Ostrowsky Earlier this month, 2024 Benefest, hosted by the Massachusetts Chapter of the National Association of Benefits and Insurance Professionals (NABIP), took place at the DoubleTree by Hilton Hotel Boston-Westborough. While the conference largely focused on the Massachusetts healthcare ecosystem – panel discussions of which reached the general consensus that, from an affordability and access perspective, these are incredibly challenging times due to unprecedented staffing shortages reducing providers’ daily bandwidth – there was considerable time spent examining federal healthcare developments, including how November’s election will impact employer-sponsored benefit plans. Some takeaways from the discussion: Prescription drug pricing: The ...
• The Price is Wrong, Y’all
  
  June 4, 2024
  By: Nick Bonds, Esq. National spending on healthcare was approximately $74 billion in 1970. Fast-forward to 2022, the growth alone on healthcare spending from 2021 was $175 billion, topping out around $4.5 trillion total spending for that year. It’s a well-worn saying in the healthcare industry but it still rings true: “It’s the prices, stupid.” Every ounce of work and creativity that we at The Phia Group, and many of our colleagues in the industry, pour into trying to reduce healthcare costs may ultimately be for naught if the prices continue to rise indefinitely. One of the driving factors ...
• HIPAA Final Rule Safeguards Reproductive Health Privacy
  
  May 28, 2024
  By: Andrew Silverio, Esq. On April 26, 2024, HHS Office for Civil Rights (OCR) released a HIPAA Privacy Rule to Support Reproductive Health Care Privacy (Final Rule). This modifies the HIPAA Privacy Rule to enhance the privacy safeguards around protected health information (PHI) related to reproductive health care and serves to protect access to this care in the wake of the Supreme Court’s Dobbs v. Jackson Women’s Health Organization (Dobbs) decision. This decision, overturning the constitutional right to abortion, led to renewed efforts by many states to more heavily restrict and criminalize certain types of reproductive health care, particularly abortion ...
• The Stewardship of Hospitals
  
  May 16, 2024
  By: David Ostrowsky Hospitals, ambulatory surgery centers, long-term care facilities, primary care physician practices, nursing homes, hospice care. They are the most indispensable institutions of any functioning society, but unlike a Fortune 500 company or professional sports franchise, the identity of their respective owners often remains an afterthought. That is, unless you work for or are served by a financially distressed health care system, such as for example Steward Health Care, the massive private-for-profit healthcare conglomerate that recently filed for Chapter 11 bankruptcy protection. Steward’s sad demise, one of the most impactful health care stories this spring, serves as a cautionary ...
• The End of a (Brief) Era
  
  May 2, 2024
  By: David Ostrowsky It was a nice feel-good story of corporate America helping the commonfolk. Five years ago, Walmart, the multi-billion-dollar retail behemoth, opened its first-ever health clinic in Georgia. Soon, dozens more Walmart-sponsored clinics started opening their doors across not just Georgia, but also Arkansas, Florida, Illinois, Missouri, and Texas. Most of these pop-up clinics operated in rural communities where chronic diseases were rampant and (affordable) primary care options were scarce. Irrespective of the pandemic soon unfolding, they served their purpose: customers shopping for microwaveable dinners and bath supplies could stop by for a doctor’s appointment, get stitched up, ...
• Understanding IDR | Key Insights on the No Surprises Act
  
  April 8, 2024
  By: Jon Jablon, Esq. It seems like every day that The Phia Group's consulting team is presented with an IDR-related issue brought up by either a provider in an appeal or simply a TPA trying to iron out or streamline its processes. Sometimes the question centers around the specifics of the IDR process, but sometimes the question instead focuses on the very concept of IDR itself and when it becomes applicable to begin with. By definition, the IDR process, as prescribed by the No Surprises Act, is intended specifically and only to choose between two competing offers. For IDR ...
• Medicaid Estate Recovery | Understanding the Implications
  
  April 3, 2024
  By: David Ostrowsky It is the most nightmarish version of a wolf at the door. Imagine that you have recently lost a loved one, are still in the midst of grieving, feeling sleep deprived, dealing with a bevy of uncomfortable logistical issues, and then told . . . that you may have to forfeit your house. Such a dire predicament befalls tens of thousands of Americans whose recently deceased relatives were Medicaid beneficiaries who received long-term care services (i.e., nursing home care or in-home healthcare) and never reimbursed their respective state of residence. (Although it should be noted that ...
• Lenmeldy | Exploring the Price of the New Gene Therapy
  
  April 1, 2024
  By: Kendall Jackson, Esq. The U.S. Food and Drug Administration (FDA) stoked the fire that is the ever-present discussion surrounding gene therapy when it approved Lenmeldy on March 18, 2024. Lenmeldy is the first FDA- approved gene therapy to treat metachromatic leukodystrophy (MLD), a rare disease that affects the brains and nervous systems of children in their late infantile and early juvenile years. Lenmeldy is just one of several gene and cell therapies that, due to their high cost, lead plans to consider implementing plan exclusions for these therapies. While a self-funded plan has broad discretion as to what ...
• Wegovy: Not Just a Weight Loss Drug
  
  March 20, 2024
  By: David Ostrowsky As if there weren’t enough buzz surrounding Wegovy. Earlier this month, the wildly popular weight loss medication was approved in the US to help prevent life-jeopardizing cardiovascular events in people who are overweight, obese, and/or have a history of cardiovascular disease. The FDA’s stamp of approval for drugmaker Novo Nordisk to include cardiovascular benefits to Wegovy’s label meant it was the first weight loss drug to market itself in this manner. Now the million-dollar question (no pun, intended) becomes, will this label expansion make insurers feel more inclined to provide coverage? For good measure, will Medicare, currently ...
• Significant Effects of a Recent Healthcare Cyberattack
  
  March 11, 2024
  By: Andrew Silverio, Esq. 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.”  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, ...
• How a Major Cyberattack Affects Healthcare Benefit Plans
  
  March 7, 2024
  By: David Ostrowsky 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 ...
• Millions Losing Medicaid Coverage | What You Need to Know
  
  February 22, 2024
  By: David Ostrowsky 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. 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 ...
• Welcome to the Subrogation Sphere
  
  February 9, 2024
  By: Cindy Merrell, Esq. The Subrogation Sphere Is a Place Where Opponents Become Allies   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 ...
• Are Measles Making a Comeback | Key Insights and Impacts
  
  January 31, 2024
  By: David Ostrowsky When Dr. Michael Osterholm speaks, people listen – even if many do so begrudgingly. 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: “We're going to start seeing more and more of these outbreaks,” Osterholm told USA TODAY last month. “We're going to see more kids seriously ill, hospitalized and even die. And ...
• A New Year Brings New (Higher) Prescription Drug Prices
  
  January 18, 2024
  By: David Ostrowsky 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. And, yes, pharmaceutical companies are hiking prices on their drugs. This time of year, when insurance plans turnover, 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. On December 29 -- as many were making last-minute New Year’s Eve plans – the unsettling news dropped: ...
• Understanding Gender-Affirming Care Exclusions in Plans
  
  January 16, 2024
  By: Kendall Jackson, Esq. 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. 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 ...
• Understanding Cross-Plan Offsetting & DOL's Recent Actions
  
  January 3, 2024
  By: David Ostrowsky As if Americans on employer-based health plans didn’t face enough obstacles in trying to obtain reasonably priced healthcare. 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. First, a quick primer on cross-plan offsetting: There ...
• Time’s Up! It’s Gag Clause Attestation Season
  
  December 26, 2023
  By: Andrew Silverio, Esq. 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 ...
• Sickle Cell Disease Treatments | Cost of Casgevy & Lyfgenia
  
  December 21, 2023
  By: Kelly E. Dempsey, Esq. For generations of sickle cell disease (SCD) patients, the suffering has been unbearable – with no end in sight. SCD, an 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. Until last month, that is. ...
• AI in Healthcare | Revolutionizing Patient Care and Access
  
  December 12, 2023
  By: David Ostrowsky The ills of the American healthcare system, namely an undue administrative burden on healthcare providers and a labor supply not keeping pace with the demand for services, 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 ...
• MAHP 2023 Annual Health Care Conference: Health Care Affordability, Quality and Equity in a Post Pandemic World
  
  November 28, 2023
  By: David Ostrowsky A year later … and how (relatively) little has changed in the state of Massachusetts healthcare. 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 ...
• Minor Members and Third-Party Settlements | Key Insights
  
  November 27, 2023
  By: Cindy Merrell, Esq. Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? 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. Who? What? When? Where? Any subrogation professional is aware that good plan language is important to a plan’s successful ...
• Being Mindful of Telemedicine Access
  
  November 9, 2023
  By Jen McCormick, Esq. and David Ostrowsky From a healthcare standpoint, two of the most significant byproducts of the COVID-19 pandemic have been the exploding popularity of Telemedicine, the practice of providing medical and 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 ...
• Update on the Federal IDR Process
  
  October 27, 2023
  By: Kendall Jackson, Esq. 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. In Texas Medical Association v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK (TMA IV), the U.S. District Court for the Eastern District of ...
• Empowering the 2023 SIIA National Conference
  
  October 26, 2023
  By: David Ostrowsky 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 (SIIA) National Conference at the JW Marriott Phoenix Desert Ridge Resort & Spa. The SIIA National Conference, 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, is widely considered to be the self-insurance industry’s annual marquee event, bringing together hundreds of industry professionals including TPAs, vendors (there were over 950 booths representing industry vendors stationed in ...