Blog

“Healthcare costs are a major concern for millions of people all over the nation, including you. Working for The Phia Group allows us to make a difference by containing those costs, and sharing what we've learned and done with a gracious audience.”
JENNIFER COSTA
Director, Claim Analysis, Customer Service & Training
Certified Subrogation Recovery Professional

Blog

Recent Posts

Hope for Self-funded Plans in Connecticut..
August 16, 2017
Subrogation is tough. Even the best language possible is susceptible to issues like limited funds, or worse, a Plaintiff’s attorney who refuses to acknowledge the realities of the law.
The Benchmark Shuffle
August 9, 2017
While ACA repeal and replace proposals have been in debate for months now, a consensus hasn’t been reached and it’s unclear what will be coming next on health care legislation.
A House Divided
August 7, 2017
In the world of self-funding, everyone plays a role. The broker advises, the employer customizes their plan and funds it, the claims administrator (TPA, ASO, etc.) processes claims, and stop-loss provides financial insurance.
Reverse Medical Tourism
July 31, 2017
US patients are seeking services abroad to obtain services and care at more affordable rates, while at the same time the international patients are seeking services in the US because they can afford to self pay.
Reference-based Pricing: Decisions, Decisions…
July 26, 2017
As medical costs continue to skyrocket, there are certain trends in the industry that have increased in popularity to try to combat the ever-growing costs. One of those trends is reference-based pricing, or RBP.
The Rise of Paid Family Leave Laws & Their Impact on Self-Funded Plans
July 24, 2017
The FMLA, like most other federal laws, applies whether an employer’s health plan is fully insured or self-funded.
Magical Words in Claim Negotiation: “Please Send Claim Back for Processing”
July 19, 2017
When a provider representative tells you to send the claim back, they know the insurer has to pay the benefits outlined in the health plan.
Can’t We All Just Get Along?
July 12, 2017
Every once in a while you come across a plan that doesn’t want to comply with its stop loss contracts and/or obligations. It’s important that everyone realizes that we need each other to survive.
Spinning the Web of the Plan Document
July 7, 2017
Plan documents have to be reviewed and revised for any number of reasons, including regulatory changes – but sometimes plan documents are changed when the plan moves to a different claims administrator.
Altogether Now… But Not a Single Payer
July 5, 2017
Health insurance is routinely ranked beneath the pharmaceutical industry, medical products and equipment, and even some hospital systems, when it comes to profitability.
It’s Time for a Wake-Up Call!
June 26, 2017
Healthcare can be expensive – particularly if you don’t pay attention.
Full Billed Charges: A Question of Geography
June 21, 2017
It is increasingly common within the self-funded industry for medical providers to demand full billed charges for non-contracted claims.
Behind Closed Doors
June 19, 2017
Anyone paying attention to national politics in the past six months knows that Washington has a problem with leaks.
“Stay away from Back Surgery”: A Warning from NBA Coach Steve Kerr
June 14, 2017
Steve Kerr is a powerful voice that is highlighting the importance of understanding pros/cons of surgery, exploring alternatives, and getting a second medical opinion.
A Win for the Good Guys!
June 7, 2017
Anytime the Supreme Court makes statements that may be subject to interpretation, a plan’s rights can be called into question until a court in that plan’s jurisdiction (or the Supreme Court itself) provides clarification.
The Rules of the Game are Still Changing
June 1, 2017
With this new Executive Order, it appears the rules of this game may change again, but it’s still unclear what will be changing. As always, stay tuned…
Bite the Hand
May 30, 2017
The term socialized medicine is often used to conjure up images of government bureaucratic interference in medical care.
It's Never Too Soon
May 22, 2017
Although the regulations may change, it's important to begin thinking about plan changes for the upcoming plan year.
Dear Stop-Loss: A Ballad
May 15, 2017
You carriers are sometimes great, all flexible and fair; But sometimes you issue denials That make me lose my hair.
You Are Not Going to Sue Us, Are You?
May 10, 2017
There could be a serious form of corporate addiction within the provider community.
Adam’s Key Takeaway from the 2017 MassAHU Benefest Conference
May 4, 2017
Find out what Adam Russo has to say about the 2017 MassAHU Benefest Conference.
A Call for Defensive Legislation
May 3, 2017
On April 5th, the House of Representatives passed the Self-Insurance Protection Act (SIPA; H.R. 1304) by a vote of 400 to 16.
Words with No Meaning...
May 1, 2017
Whether it’s in your everyday conversations or in the terms of an employee benefit plan – make sure you say what you mean and you mean what you say.
Transparency – It’s Not Just for Ghosts
April 26, 2017
It’s amazing to see the variances in the cost-to-charge ratio from provider to provider.
Pay the Cost to be the Boss!
April 24, 2017
Start explaining how your plan is funded, and take proactive measures to align employee and employer interests.
Cyborgs – Moving From Science Fiction to Science Fact
April 20, 2017
We are seeing advancements in the realm of prosthetic limbs, ocular augmentation, and even artificially grown organs.
My Trip to the Emergency Room
April 18, 2017
Since becoming a mom, I’ve experienced two pretty scary parenting adventures – taking a toddler to Disney World solo and taking a toddler to the emergency room.
I Fought The Law and…Unpredictable Results Ensued
April 12, 2017
Are there tactics and arguments that can be used to combat balance-billing? Of course there are!
Repeal and Replace Faces a False Start
April 10, 2017
The President himself took to social media to proclaim, “We are all going to make a deal on health care . . . that’s such an easy one.
Sometimes... The Truth Hurts...
April 5, 2017
As we sit back and observe a system that is rife with out-of-control billing, we have a duty to not only criticize but also look for causes and real solutions at every step, including those that directly involve us.
Trump’s Healthcare Bill Failed… Here’s Why
April 3, 2017
The only way that we can have a successful health plan for all Americans is by fighting the root of the problem.
U.S. Airways v. McCutchen – Where Are they Now?
March 29, 2017
Can a court override the terms of a private, self-funded benefit plan under the purview of ERISA?
Bidding Against Themselves: $750K Air Ambulance Claim Adventure
March 29, 2017
It is not uncommon for an AA carrier to argue that their charges are reasonable and even show us some so-called usual, customary, reasonable (UCR) charge data to justify their charges.
Bidding Against Themselves: $750K Air Ambulance Claim Adventure
March 28, 2017
It is not uncommon for an AA carrier to argue that their charges are reasonable and even show us some so-called usual, customary, reasonable (UCR) charge data to justify their charges.
Health Insurance is NOT Health Care
March 23, 2017
Phia Group Senior Vice President and General Counsel Ron E. Peck, Esq. discusses rising insurance premiums and what we need to do to evaluate those.
Keep Hands, Arms, Legs, and Feet Inside the Ride at All Times and Remain Seated Until the Ride Comes to a Complete Stop
March 22, 2017
Learn more about what to expect with all of the new changes in the healthcare industry.
If I Can Change, So Can The Average American
March 15, 2017
Learn more about why you should evaluate your health care plans and what to look for in your bills.
ACA to AHCA… A Look Back on the Past 7 Years
March 13, 2017
Learn more about how the American Health Care Act has evolved over the past 7 years.
The Cost-Containment Carve-Out Compliance Conundrum
March 8, 2017
Learn more about the compliance conundrum caused by health plans with "carve-outs"
Cornelius B. FAISON, Plaintiff–Appellee v. DONALSONVILLE HOSPITAL INC., Defendant–Appellant.
March 6, 2017
Appeal from the United States District Court For the Middle District of Georgia. D.C. Docket No. 1:11–cv–00010–WLS.
U.S. Supreme Court Rules Against Subrogation Rights … What Now?!!
March 6, 2017
The Supreme Court of the United States issued an 8-1 decision in favor of the plan participant in the case of Montanile v. Board of Trustee of the National Elevator Industry Health Benefit Plan
Montanile Changes Subrogation – How Will You Respond?
March 6, 2017
On January 20, 2016, The Supreme Court of the United States decided in favor of the plan participant in the case of Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan. Learn More.
Second Quarter Newsletter 2016 – The Stacks
March 6, 2017
The Cost of Healthcare in The US is Arbitrary and Out of Control
Don’t get cute when ERISA documents are requested
March 6, 2017
The Employee Retirement Income Security Act generally requires that plan participants get copies of summary plan descriptions, plan documents and annual reports when requested.
Can FMLA leave be involuntary? Court punts
March 6, 2017
A federal court hearing an FMLA interference case has sidestepped deciding whether it is legal for an employer to place an employee on involuntary FMLA leave.
Federal Judge Denies United Healthcare’s Motion to Dismiss in Case Brought by Texas General Hospital for Unpaid & Underpaid Claims
March 6, 2017
In January of 2015, Texas General was the subject of intense scrutiny after a FOX 4 investigation revealed multiple billing complaints. A woman who underwent gastric sleeve surgery was charged a total of $622,000, most of which her insurance company, United, refused to pay.
Employer-sponsored Plans Should Prepare to be Taxed
March 6, 2017
The latest news in the repeal and replace saga is that congressional Republicans are pushing to get a bill to the Senate by the end of this month.
It will be my pleasure to balance bill the patient $1.3 Million…
March 1, 2017
hospitals report their complete financial information to the Centers for Medicare and Medicaid Services (CMS). This publicly-available information is submitted in accordance with generally accepted accounting principles.
The Guilty Shall Remain Nameless – Yet I shall Shame Them… Again
February 27, 2017
In this second installment of “The Guilty Shall Remain Nameless” I can’t help but think back to an encounter I had with a walk-in clinic in Las Vegas, Nevada. Read More.
4 main tenets of the GOP’s ACA replacement plan
February 20, 2017
House Republicans gathered Thursday to discuss a policy memo detailing their ACA replacement plan. The details presented at the meeting did not comprise a full-on plan and instead created more of a roadmap.
15 Things to Know About Stark Law
February 20, 2017
Enacted more than two decades ago with the simple purpose of curbing physician self-referral, Stark Law has evolved into a complex set of regulations.
Healthcare Need Not Be a Headache
February 20, 2017
My PCP is a great doctor, but I hate visiting him. I only live 2 minutes from his office, but somehow, my quick visits usually turn into long excursions. Read More.
Summary of Benefits and Coverage- NEW Template
February 17, 2017
The new Summary of Benefits and Coverage (SBC) template is applicable for plans that have open enrollment periods beginning on or after April 1, 2017. Read More.
House G.O.P. Leaders Outline Plan to Replace Obama Health Care Act
February 17, 2017
House Republican leaders on Thursday presented their rank-and-file members with the outlines of their plan to replace the Affordable Care Act.
In the Spotlight… Or the Crosshairs? Healthcare Discussion.
February 16, 2017
This is a time of political upheaval, and the powers that be are scrambling to find a replacement for the status quo. If self-funding is linked to these types of issues, conflict, and loss, we will not be the future of health benefits in America.
How expensive are knee replacements in the 20 largest US cities?
February 16, 2017
The total price includes hospital services, physician services and anesthesia, according to Healthcare Blue Book.
CMS projects next decade of health expenditures: 5 takeaways
February 16, 2017
National health spending is expected to grow at an average annual rate of 5.6 percent from 2016 through 2025, with expenditures projected to hit $5.5 trillion in 2025
First Proposed ACA Rule Changes
February 15, 2017
Today we got our first new proposed ACA rule changes from the Trump Administration. One of the proposals was to decrease the open enrollment window for individuals to sign up on the insurance exchanges.
IRS loosening enforcement of ObamaCare mandate
February 15, 2017
The IRS says it will not reject tax forms from people who fail to answer whether they had health insurance
A Canadian Pays Cash for Care
February 15, 2017
In spite of the fact that I did not use insurance at all, we can still take my personal experience as a case study about the benefits of real-time payment for medical care.
Humana Plans to Pull Out of Obamacare’s Insurance Exchanges
February 15, 2017
Humana announced on Tuesday that it would no longer offer health insurance coverage in the state marketplaces created under the federal health care law. Read More.
Land of 10,000 Stories: Cop and Homeless Veteran
February 15, 2017
Big medical bills are a problem for many Americans. But few services deliver a bigger surprise hit than a life-saving ride on an air ambulance.
The Guilty Shall Remain Nameless – Yet I Shall Shame Them
February 14, 2017
I went to the ever famous, “doc in the box.” Prior to walking into the reception area, I told myself I would report as self-pay, not tap my health insurance, and see how it all might shake out.
Empower Your Plans!
February 14, 2017
The United Benefit Advisors recently came out with the average cost of premiums for health insurance in every state. Let Phia help you empower your plan!
The Time of Uncertainty
February 13, 2017
At a recent Republican retreat, someone secretly recorded discussions regarding the repeal of the Affordable Care Act.
Ignorance Is Not A Defense
February 13, 2017
Healthcare is a bill that is oft footed by someone else – so why should we care? We all need to challenge ourselves to be open to viewpoints – listen, learn, and be educated.
We Have a New Secretary of HHS
February 10, 2017
In a rare overnight session, the Senate voted 52-47 (along party lines) to confirm Tom Price (R-GA) as Secretary of HHS. He will be managing a department with a $1 trillion budget and have the authority to rewrite ACA rules.
It’s Tax Time – Do You Know Your 6056 Deadlines?
February 10, 2017
The tax season is officially upon us. Reporting requirements under ACA Section 6055 and 6056 are still in effect for the 2016 calendar year.
From the Waiting Room: Health Insurance
February 9, 2017
I recently found myself in a doctor’s waiting room. I overheard another patient arguing with the office administrator. The gist of it was that he was being balance billed for an amount exceeding what insurance paid.
No News Is Good News For Healthcare Providers
February 9, 2017
Much like a pendulum, there is a swing from right to left with different sides trying to tell their message and incite a reaction; a swing not seen on such a public scale in our own Health Care Industry.
Overpayment Success Story: Dialysis Claim
February 9, 2017
A dialysis claim was adjudicated at the regular out-of-network rate instead of the dialysis carve-out rate of 130% of Medicare.
Self-Funded Employers Beware the Network!
February 8, 2017
Self-funded employers should be careful when selecting networks. In some cases, low discounts, anti-audit clauses, unseen provider agreements, and upside-down DRGs can cause more problems than the network access is worth.
The Details of Your Coverage Plan Matter
February 8, 2017
Employers face many, many regulatory burdens. There is an ever-increasing number of federal regulations to abide by, and each state maintains its own set of regulations
A Canadian Pays Cash for Care – Part One
February 8, 2017
I paid for the procedure, had no claim to worry about, and the care was excellent. Read more about how I did this.
Mental Health Parity and Claim Negotiation
February 8, 2017
When choosing claims to have negotiated, don’t worry about mental health parity. While it’s an important set of laws, it primarily protects patients from having higher responsibility. Read More.
Call Me Corny: Discussion on Healthcare
February 6, 2017
Healthcare in our country is too expensive. The money is being spread around, and wasted. Is there greed? Sure. But there is also inefficiency.
10 Things to Know About Athena Health
February 6, 2017
Here are 10 things to know about Watertown, Mass.-based athena health, one of the largest publicly traded companies in the world providing medical record
As language shifts to ACA ‘repair,’ Pence reaffirms commitment to ‘repeal and replace’
February 6, 2017
Although some Republican lawmakers have begun to discuss a more tempered goal of “repairing” the ACA instead of tearing it down, Vice President Mike Pence on Thursday said the Trump administration is still committed to repealing and replacing it
I Have A Bridge to Sell You- Healthcare Discussion
February 6, 2017
As long as we make decisions based on extremes intended to sell headlines or keep an elected post, we’re missing the point.
ACA Section 1557 – Federal Court Injunctions, Executive Orders, Repeal/Replace, Oh my!
February 3, 2017
A federal court injunction related to 1557 was granted on 12/31/16, temporarily stopping portions of the rule—discrimination on the basis of gender identity & termination of pregnancy—from becoming effective.
Massachusetts Braces for ACA Repeal
February 3, 2017
A number of state lawmakers, consultants, and industry experts offered their opinions on how the Commonwealth could move forward in a post-ACA world.
Enough to be Dangerous- Benefit Plans discussion
February 2, 2017
One issue I’ve been running into relates to attorneys that “know” benefit plans are required by law to provide a notification of adverse benefit determination any time they pay less than the charged amount.
Change Often Starts with a Conversation
February 2, 2017
My wife, quite literally, has no idea what I do for a living. When friends and family ask, she normally replies, “…he does something with subrogation…and it involves health insurance.”
An Unlikely Recovery
February 2, 2017
The Phia Group’s overpayment specialists received two claims – same provider, same patient – totaling over $760,000. The reason for the refund was that the original repricing was incorrect.
Phia Group Consulting Is Always Ready to Help
February 1, 2017
Phia is continuously searching for ways to evolve and improve the plan drafting process for our clients, including notification of key compliance changes.
Relationships Matter in Resolving Claims Disputes
February 1, 2017
Phia received a $60K claim caused by a serious fall while the member was hiking. The member was taken to the nearest hospital which was out of network, and where the client had a history of 20% discounts.
For Some, the Affordable Care Act Is a Lifesaver. For Others, a Burden.
February 1, 2017
After President Trump and the Republican-controlled Congress vowed to repeal and replace the Affordable Care Act, millions of Americans have been left wondering about the future of their health care.
Diabetes patients sue 3 drug companies over alleged fraudulent insulin pricing
February 1, 2017
Eleven diabetes patients are suing several drug companies for alleged collusion on insulin pricing. Read More.
Industry Trends & Demands- Alaska to Maine
January 31, 2017
This week I will be lucky enough to be a speaker at the Alaska Association of Health Underwriters Annual Expo in Anchorage, Alaska. It will be my privilege to spend time with this great group and focus on innovating in the self-funded space.
Billing Itemization Required?
January 31, 2017
Question: is a medical provider required to give an itemization as part of the billing? Answer: Generally no.
Beth Israel, Lahey in advanced merger talks
January 30, 2017
Beth Israel Deaconess Medical Center and Lahey Health have announced plans to combine forces for the fourth time, a move that would create an entity rivaling the size of Partners HealthCare.
What is ‘Repeal and Replace?’ A Guide to Trump’s Health Care Buzzwords
January 30, 2017
President Donald Trump and GOP lawmakers have yet to come up with a plan to repeal and replace the Affordable Care Act.
Innovation at Its Finest- Cash Only Payment Model
January 30, 2017
Read about Dr. Smith's journey to a cash-only payment model. Contact The Phia Group to find out how you can innovate and contain costs within your employee benefit plan.
A Personal Experience- Self-funded Employee Benefit Plan
January 30, 2017
The Phia Group’s self-funded employee benefit plan is not just the plan my employees are on, it’s the plan my wife, four kids, and I are on.
Concerns about Health Care Coverage Mandates
January 27, 2017
One of the biggest unknowns of the Trump Administration’s health policy priorities is whether or not the new administration plans to repeal the individual and employer mandate.
LOA = Continuation of Coverage, or does it? One of the “Gap Traps”
January 27, 2017
It’s intuitive to think that a leave of absence (LOA) from employment is coupled with a continuation of health plan coverage (CoC), especially if the leave is illness related
Egregious Billing Hits the Common Man – Who Now Has a Place to Vent Their Frustration
January 26, 2017
For those of us who are embedded in the health care industry, we know that the greatest issue with health care in America is the price tag.
Keeping the “Benefit” in Benefit Plans
January 26, 2017
Once upon a time, employers offered employees “benefit plans,” with an eye toward attracting and retaining a talented workforce. The word – benefit – literally means something good; positive; of added value.
The Big Elephant in the Room….
January 26, 2017
From day one, over 16 years ago, we have offered overpayment recovery services, but over the last year, I have seen the largest growth in this service.
HIPAA Special Enrollment vs. Section 125 Permitted Election Change – There is a difference!
January 25, 2017
An individual may want to adjust their health plan enrollment. For example, if a plan member’s spouse loses plan coverage due a reduction in hours it will likely trigger a HIPAA special enrollment under the health plan.
Want to improve health care? Focus on hospitals
January 25, 2017
As Congress and the Trump administration debate the future of America’s health care system they should go beyond the issues of access and cost and recognize an equally important priority
HHS nominee Dr. Tom Price’s 2nd confirmation hearing: 5 things to know
January 25, 2017
Rep. Tom Price, MD, R-Ga., faced another four hours of cross-examination Tuesday, this time with the Senate finance committee. Here are 5 things you need to know about the hearing.
Another Successful Balance Billing Negotiation
January 25, 2017
Phia received a $167,000 claim from a Surgery Center (Spinal Decompression) where a client tried to negotiate it on their own and were unsuccessful.
The Gap Trap
January 24, 2017
We work closely with some excellent carriers that look for reasons to pay claims and are a pleasure to interact with – but there are also carriers and MGUs out there that will do whatever they can to deny claims.
The ACA, a New Congress, and President Trump – Oh My….
January 24, 2017
On Friday January 20th, President Donald Trump signed his first executive order, directing agencies to give more leeway to the states in the way that states implement (“carry out”) the Affordable Care Act.
Attack on ERISA Preemption Continues…
January 23, 2017
ERISA preemption seems like such a simple concept; further proof that reasonable minds can disagree
Welcome to our New Blog!
January 23, 2017
Welcome to the newly updated passionforsubro blog. Starting today, you all will get daily updates, comments, tidbits, opinions, and fun facts from the many outstanding team members here at The Phia Group.
GOP on ACA replacement: Who wants what?
January 23, 2017
Republicans in Congress have already laid the foundation for an ACA repeal through the reconciliation process, but what will replace the law still remains uncertain.
With executive order, Trump tosses a ‘bomb’ into fragile health insurance markets
January 23, 2017
President Trump’s executive order instructing federal agencies to grant relief to constituencies affected by the Affordable Care Act has begun to reverberate throughout the nation’s health-care system
Pressure mounts on GOP for post-Obamacare plan following CBO report
January 18, 2017
at least 18 million people could lose health insurance in the first year if Congress repeals the Affordable Care Act without replacing it
Health Secretary Pick Tom Price Faces Questions on Stock Trades, Obamacare Plans at Confirmation Hearing
January 18, 2017
Tom Price vowed at a Senate hearing Wednesday to fight government regulations he said burden doctors and patients while Democrats voiced alarm his policies would gut federal health insurance programs.
Congress Eliminates Huge Penalties On Small Employers’ Health Insurance Reimbursement Arrangements
January 17, 2017
First it was no problem. Then it was a huge problem. Then it was going to be a huge problem. And now it’s no problem again. Read More
Trump vows ‘insurance for everybody’ in replacing Obamacare
January 17, 2017
U.S. President-elect Donald Trump aims to replace Obamacare with a plan that would envisage “insurance for everybody.”
Cigna CEO: ACA health plans perform best under ACO model
January 16, 2017
Cigna CEO David Cordani said the payer’s ACA health plans made the most financial sense when they networked with ACOs.
What insurance market fixes can the GOP cram into an ACA repeal bill?
January 16, 2017
Republicans risk crashing the individual insurance markets and causing 30 million Americans to lose coverage if they repeal the Affordable Care Act without replacing it
Why Trump’s Obamacare Promise Will Be So Hard to Keep
January 16, 2017
As a candidate back in July 2015, Donald J. Trump promised that he would repeal Obamacare and replace it with “something terrific.”
We Asked People What They Know About Obamacare. See If You Know The Answers
January 16, 2017
The Affordable Care Act brought the rate of uninsured Americans to a record low 9 percent in 2015.
Kaiser Health Tracking Poll: Health Care Priorities for 2017
January 12, 2017
The latest Kaiser Health Tracking Poll finds that health care is among the top issues, with the economy and jobs and immigration, Americans want President-elect Donald Trump and the next Congress to address in 2017.
US Sen. Rand Paul casts protest vote as Senate takes first step toward ACA repeal
January 12, 2017
Republican Sen. Rand Paul, MD, of Kentucky, on Wednesday voted against legislation designed to aid in the repeal of the ACA, reports USA Today.
100-year-old doctor still working at Mass General Hospital
January 5, 2017
After decades of work at Massachusetts General Hospital in Boston, Dr. Walter Guralnick cut back.
AMA to Congress: Lay out ACA replacement before repeal
January 5, 2017
The American Medical Association called on Congressional leaders to outline an ACA replacement plan before repealing the healthcare reform law.
FACT CHECK: Once Again, Lawmakers Are Stretching The Facts On Obamacare
January 5, 2017
President Obama and Vice President-elect Mike Pence were both on Capitol Hill, making competing cases for and against Obama’s signature health care law.
Opinion: I’m a former health insurance CEO and this is what Obamacare repeal will do
January 3, 2017
There’s a joke among insurers that there are two things that health insurance companies hate to do — take risks and pay claims. But, of course, these are the essence of their business!
Aetna to subsidize Apple Watch for health monitoring
September 28, 2016
Health insurer Aetna will subsidize Apple Watches for select large employers and individual policyholders during November’s open enrollment as a healthy living initiative.
Recoupment or Embezzlement? Cross-plan Offsets in the Crosshairs
September 26, 2016
When a self funded employee benefit plan, or indeed any payer of health benefits, overpays a benefit claim to a medical provider, it is often a tall task to later secure refunds.
California Senate Approves Reference Based Pricing
September 8, 2016
A measure to protect California consumers from surprise medical bills moved closer than it’s ever been to becoming law when the Senate approved it Monday with a 35-1 vote.
Federal regulators may try to kill critical illness insurance
June 10, 2016
Officials are thinking about the possibility of banning the sale of critical illness policies and other policies that cover two or more specific diseases.
ER docs sue HHS over out-of-network payments
May 18, 2016
The American College of Emergency Physicians is suing HHS, claiming a provision of the Affordable Care Act allows insurers to underpay for out-of-network emergency medical services.
Reference-Based Pricing Webinar: Unraveling FAQ #31
April 28, 2016
Reference-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
Why Plan Sponsors should be Upfront with Workers about Self-funding
April 26, 2016
Self-funded health plans don’t have health insurers, only health plan administrators. Learn more about why plan sponsors should be upfront with workers about self-funding.
Sky-Rage: Bills, Debt, Lawsuits Follow Helicopter Medevac Trips
March 18, 2016
The helicopter ambulance that rushed Shauna Laswell to a Las Vegas hospital after a heart attack may have saved her life. Read More.
TPA of Self-Insured Health Plan Not Subject to Texas Prompt-Pay Law
February 24, 2016
The Fifth Circuit has ruled that a third-party administrator (TPA) of employer-sponsored self-insured health plans is not an insurer subject to the Texas Prompt Payment Act.
Montanile Changes Subrogation – How Will You Respond?
January 27, 2016
On January 20, 2016, The Supreme Court of the United States decided in favor of the plan participant in the case of Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan
ERISA Plan Cannot Recover Settlement Funds That Have Been Spent
January 25, 2016
The U.S. Supreme Court has narrowed, ever so slightly, the ever-changing definition of “appropriate equitable relief” under ERISA Section 502(a)(3).
How to Proactively Manage Self-Funded Employer Health Plans Recommendations by a Hospital Legal Advisor
January 25, 2016
As more patients join self-funded plans, hospitals face new challenges regarding billing and collection. The increase in self-funded employer health plans has triggered an unintended consequence for hospitals with respect to payment for services.
Secrets to Making Reference-based Pricing Work
January 18, 2016
Employers, administrators, brokers and courts have begun to realize that determining the value of a health care service must involve something more than considering only a provider’s billed charges.
Anti-Assignment Clauses Bar Provider’s ERISA Claims
January 7, 2016
An out-of-network health-care provider can’t continue with her claims under the Employee Retirement Income Security Act for unpaid benefits, fiduciary breach and failure to disclose documents against four health benefit plans, the U.S. Court of Appeals for the Eleventh Circuit ruled.
Court Nixes Health Plan’s Subrogation Claim
December 23, 2015
A health plan isn’t entitled to reimbursement of $48,000 in medical expenses it paid on behalf of a minor beneficiary who was injured in an all-terrain vehicle accident
The Supreme Court Seeks Solutions to the Latest Challenges to Subrogation Rights in Montanile Case
December 4, 2015
The facts of the latest healthcare subrogation challenge on the SupremeCourt’s docket will be familiar to many.
FEHBA Preempts Kansas Anti-Subrogation Regulation
November 3, 2015
The Federal Employees Health Benefits Act preempts a Kansas administrative regulation prohibiting subrogation and reimbursement clauses in health insurance contracts of federal government employees, the U.S. Court of Appeals for the Tenth Circuit ruled
The Phia Group’s Overpayment Recovery Service Suite
October 8, 2015
Why are most TPAs merely sending a few letters to providers and filing away cases that fail to result in a refund? Because they feel that there is no other option available to them… until now.
Second Quarter Newsletter 2015 – Phia News
July 15, 2015
Phia News. New faces, Acknowledgements, Additions to the team, and Charity Updates.
Beating Medical Trend – Managed Care vs Reference Based Pricing
July 6, 2015
Medical inflation continues to rise. Facing rate increases year after year, plan sponsors, with their financial backs to the wall, have historically resorted to cost shifting
The Problem with Wraps
July 6, 2015
TPAs and self funded plans complain about their networks all the time.Everyone seemed to complain about them yet need them to attract clients that aren’t willing to go the reference based pricing route. Read More.
The Road to Recovery: Subrogation Gets Its Day In Court
July 6, 2015
Most might be surprised when they realize the amount of attention that subrogation has received in The Supreme Court of the United States, the highest court in the land, over the last 25 years.
Size Doesn’t Matter- But the Regulators Do
July 6, 2015
What is the perfect size for a self-funded plan? This is one of my favorite questions and I love to ask it at any conference at which I happen to have the pleasure of attending and speaking.
Texas Prompt Pay Law Not Preempted; Enforceable Against Self-Insured Health Plan TPAs
June 17, 2015
A federal district court has ruled that ERISA does not preempt the Texas Prompt Payment Act as it applies to TPAs of self-insured benefit plans.
The Phia Group, LLC – 1st Quarter Newsletter – 2015
April 8, 2015
The Book of Russo, Letter from the Editor, Free Monthly Webinar, SCOTUS
The Phia Group, LLC – 1st Quarter 2015 – The Stacks
April 8, 2015
one of the primary goals of ERISA is to establish a uniform statutory framework for employee benefit plans, a major feature is the preemption of most state regulation which touches on employee benefit plans falling within its scope.
SIIA State Legislative/Regulatory Update Report
March 17, 2015
In the face of stiff opposition by SIIA and allied stakeholders, the principal backers of HB 552/SB 703 proposed significant changes to the legislation, including lower attachment points and a study of several issues.
Anthem Data Breach Implications for Employers
February 10, 2015
As has now been widely reported, Anthem, Inc. was the unfortunate target of a cyber-attack potentially impacting 80 million current and former customers.
Federal Court Keeps TPA As Third-Party Defendant in Suit Between Stop Loss Carrier and Group
January 14, 2015
This case is a federal civil procedure professor’s dream. One can easily imagine it as a part of a first-year law student’s final exam. I discuss it because the backdrop for all the procedural issues is a stop loss dispute between a carrier and a group and its TPA
4th Quarter 2015 Newsletter – Phia News
January 13, 2015
4th Quarter 2015 Newsletter for The Phia Group. New Faces, Giving Back, Announcements
FAQs about Affordable Care Act Implementation (Part XXII)
November 11, 2014
Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of the Affordable Care Act.
The Phia Group, LLC Comments on Recent Industry Developments
October 22, 2014
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.
SIIA State Legislative/Regulatory Update Report
October 21, 2014
This is your weekly update of state legislative/regulatory developments affecting companies involved in the self-insurance/alternative risk transfer marketplace.
Supreme Court of California Case Notification for Children’s Hospital Central California v. Blue Cross of California
October 17, 2014
In an important legal development in the healthcare cost debate, the California Supreme Court has denied a petition for review of the recent decision in Children’s Hospital of Central California v. Blue Cross of California
Final Part of Self-Funded White Paper Series Released
October 9, 2014
This is the third and final installment of a three-part series examining the self-funded insurance market.
3rd Quarter Newsletter – Phia News
October 3, 2014
As is our tradition for the past several years, The Phia Group partners with a local charity where we invest our time, money and support to ensure a successful program and other news.
The Phia Group, LLC Announces The Release of its New “Phia Document Management” (PDM) Software
October 2, 2014
For years, The Phia Group’s clients have asked them to not only draft plan documents, but also review and revise documents prepared by others; including vendors’ online templates and in-house efforts.
NAIC White Paper
September 22, 2014
One concern about the potential impact of the ACA is that if employers self-fund, it will leave the older, sicker population to the fully insured, small employer group market.
Texas C.P.R.C. c. 140: The New Standard for Subrogation Rights
September 17, 2014
C.P.R.C. c. 140, governing subrogation, went into effect January 1, 2014; enacting H.B. 1869, which was passed months prior; but the finer points are still being explored.
SIIA State Legislative/Regulatory Update Report
September 16, 2014
This is your weekly update of state legislative/regulatory developments affecting companies involved in the self-insurance/alternative risk transfer marketplace. Read More.
Stop-Loss Market Expected to Grow to $14 Billion by 2018
August 13, 2014
A new report published by the ratings agency A.M. Best finds that rising demand for stop-loss insurance will come from small and midsize employers as self-insured insurance plans are not subject to certain requirements of the Affordable Care Act
2nd Quarter 2014 Newsletter – Phia News
July 8, 2014
Phia gives back, new faces at phia and all you need to know about Phia for quarter two of 2014. Read More.
Are Overpayments Over?
June 6, 2014
we provide a brief summary of the case and its impact on our valued clients. Upon reviewing the facts, you’ll likely agree with us that a detailed approach to overpayment refunds is needed.
State/Legislative Regulatory News
May 9, 2014
This is your weekly update of state legislative/regulatory developments affecting companies involved in the self-insurance/alternative risk transfer marketplace.
Supreme Court upholds ERISA plan document statute of limitations
December 20, 2013
The Supreme Court ruled that statute of limitation periods written into plan documents are valid, as long as those periods are “reasonable.” Find out more.
Pushing Back Against Prompt Pay Laws
December 4, 2013
You may be aware of recent growing efforts by providers and vendors to leverage prompt pay laws as they seek to obtain additional funds from you and benefit plans across the nation.
Hospitals facing big divide in pro- and anti-ACA states
December 2, 2013
Bradford Regional Medical Center and Olean General Hospital sit just 20 miles apart on opposite sides of the Pennsylvania/New York border.
New York Governor Signs Legislation Prohibiting ERISA Liens on Settlement Proceeds
November 19, 2013
On November 13, 2013, the Governor of New York signed legislation which clarifies the scope of General Obligations Law (“GOL”) Section 5-335.
Amicus Update: New York Governor signs into law anti-subrogation bill
November 15, 2013
Governor Andrew Cuomo signed into law New York Assembly Bill to tighten perceived loopholes in NY Gen. Obl. 5-535
Adding Another Weapon to the Subrogation Arsenal
October 31, 2013
It may only be October, but Christmas has come early for self-insured health plans. A recent court decision out of Washington affirms a self-insured plan’s right to offset claims as part of its subrogation and reimbursement rights.
Letter from The Phia Group’s editior, Andrew Milesky
October 14, 2013
Since the passing of the law, various waves of reform have impacted our industry, sending many of our clients into panic mode as they hustle and bustle to update their plans and implement measures to ensure compliance. Learn More.
The Domestic Partnership Benefits and Obligations Act of 2013 Seeks to Amend Federal Law
October 14, 2013
United States Senate Bill 1529, the Domestic Partnership Benefits and Obligations Act of 2013, seeks to amend federal law to provide insurance benefits for federal employees in a same-sex domestic partnership and their domestic partners.
How the Supreme Court’s ruling on DOMA affects self-funded plans
October 10, 2013
On June 26, 2013, the U.S. Supreme Court in United States v. Windsor struck down “Section Three” of the Defense of Marriage Act (DOMA), which prevented the federal government from recognizing any marriages between gay or lesbian couples for the purpose of federal laws or programs
Attack of the Killer P’s – Providers Paying Patients’ Premiums
October 10, 2013
A recent and unsettling trend in the healthcare industry involves medical providers paying insurance premiums or contributions on behalf of their patients in order to ensure that the patient’s coverage remains active.
Insurers Commissioners Signal Retreat on New Stop-Loss Insurance Regulation and Discuss MEWA Issues
August 26, 2013
Comments made by regulators over the weekend at the summer meeting of the National Association of Insurance Commissioners (NAIC) in Indianapolis made it clear that ongoing pushback by SIIA and other stakeholder groups has dampened enthusiasm for new stop-loss regulation.
New York Assembly Bill 7828 (Companion Senate Bill 5715)
June 28, 2013
One federal court in the case of Wurtz v. Rawlings, 2013 WL1248631 (E.D.N.Y.), recently held an insured ERISA plan was protected by preemption and the carrier was able to pursue subrogation and reimbursement claims.
SIIA Provides Analysis on “Skinny” Health Plans in Response to WSJ Article
May 31, 2013
The Wall Street Journal on May 20th ran a news story describing a strategy that an increasing number of employers are reportedly examining. SIIA responds. Read More.
Maine Amends Anti Subrogation Bill
May 23, 2013
Maine recently introduced a bill, Maine Legislative Document 756, which attempted to eliminate Med Pay subrogation claims.
Government Plans are Exempt from ERISA. What is the Definition of "Government"?
May 20, 2013
Some employers may not actually be government entities, and public private partnership may inject ERISA back into the framework.
TEXAS HOUSE BILL 1869 AND SENATE BILL 1339
April 11, 2013
One of our members has personally met with representatives in both the House and the Senate, but these bills appear to be gliding through committees without opposition.
Stop-Loss Battle Expands to Four States
March 12, 2013
Utah has become the fourth state that is considering legislation that would make it more difficult for employers to operate self-insured group health plans by restricting the availability of stop-loss insurance.
Anti-Subrogation Bill Emerges in Texas
February 28, 2013
Texas House Bill 1869 seeks to limit health subrogation recoveries! The bill allows a carrier to create the right to subrogation or the right to reimbursement by contract
9 Secrets For Coordinating Leave Under the FMLA and ADA
December 27, 2012
The employer granted the full 12 weeks allowed by the FMLA, so it is free to terminate, right?
Missouri Slayer Law Preempted by ERISA
December 26, 2012
The allegation is that Mr. Robinson killed his wife. The wife had $121,000.00 in life insurance through her employer, Unilever, and insurer MetLife.

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