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, Recovery Services

Blog

Recent Posts

More Thoughts on The Cigna Racketeering Case
January 28, 2020
You may have read the blog post that my colleague Andrew Silverio wrote about this case just a few days ago. (If you haven’t, check it out!) After doing a deep dive into this case, there are a few specific things I want to bring up – and to do so, I’ll do some quoting from the complaint. The plaintiffs – certain medical providers that feel they have been victimized by Cigna – have made many allegations, some very specific, and some more sweeping in nature. While we have no basis to question the facts presented by the plaintiffs, it ...
I Got a Fever, and the Only Prescription is More Transparency
January 23, 2020
With the Legislature moving at a glacial pace, the Trump administration has doubled down on its policy objective to reduce health care costs through executive action and administrative rulemaking. A key part of their strategy involves a push to increase transparency in the health care industry – taking special aim at hospitals and drug manufacturers. The apparent logic being that if hospitals and drug makers have to share their actual prices, patient reaction will be strong enough to drag prices down. Experts disagree as to how effective these strategies would be in theory, but we may never have the ...
Case to Watch – Advanced Gynecology and Laparoscopy of North Jersey, P.C. et al v. CIGNA
January 20, 2020
In the final hours of 2019, a coalition of New Jersey medical providers filed a voluminous, 150-page complaint against CIGNA in federal court in New Jersey. The providers, in general, are challenging the validity of CIGNA’s reference-based pricing (“RBP”) program, which guides the payments of numerous self-funded plans in and around New Jersey. As would be expected with such a lengthy and thorough complaint, there are various causes of action being pursued – some allege criminal activities like “embezzlement, theft, and unlawful conversion,” and “a pattern of racketeering activity” under RICO. Others strike more directly at ...
ACA PCORI FEES ARE BACK
January 14, 2020
The Trump Administration has been very transparent in their efforts to undermine and dismantle the Affordable Care Act (ACA). There have been several milestones in these efforts, such as essentially gutting the ACA Individual Mandate by reducing the penalty to $0 for individuals who forego health plan coverage for the tax year. The Trump Administration has also passed on the torch to the federal courts, as the 5th Circuit Court of Appeals has recently ruled that the Individual Mandate is unconstitutional, and has kicked the case back to the lower courts to determine whether other parts of the ACA ...
What Happens to a Health Plan during a Merger or Acquisition?
January 9, 2020
While businesses who are considering a potential merger or acquisition have a lot on their plates, one thing that should always be addressed is the impact that the transaction will have on the benefit plans of both the buyer and the seller. While it probably does not represent the biggest concern, overlooking the potential impact on benefit plans can cause major headaches when it comes to potential mergers and acquisitions.
Embracing the Pain, Avoiding the Suffering
January 6, 2020
I really enjoy the quote, attributed to Haruki Murakami, that “Pain is inevitable. Suffering is optional.” This really hits home for me for a few reasons, personal and professional, but for our purposes – let’s consider how it relates to the health benefits industry and healthcare as a whole. Anyone paying attention to the media and political debates will no doubt make note of the constant rhetoric regarding healthcare, and more to-the-point, the “cost” of healthcare. I’ve (here and elsewhere) discussed ad-nauseam my position that health “care” and health “insurance” are not the same. That ...
Robbing Peter to Pay Paul: The Trouble with Cross-Patient Offsetting
December 30, 2019
Our consulting team (via PGCReferral@phiagroup.com) is often presented with the following scenario: Patient A visits Hospital, and the Plan pays certain benefits to Hospital which are later discovered to have actually been excluded by the terms of the plan document. This is a classic overpayment scenario, except that Hospital refuses to refund the overpayment to the plan (which it is well within its rights to do). In response, to try to avoid the loss, the Plan decides to activate the right it has given itself to offset future benefits payable against amounts due to the Plan. The right to ...
Prescription Drug Pricing – On a Back Burner, but Still on the Stove
December 18, 2019
With Presidential impeachment eating up the above-the-fold coverage pretty much universally, it is important to remember that Congress has other pressing issues to attend to. While a number of Democratic candidates are worried their mandatory attendance at the Senate trial will eat up valuable campaign time on the ground in the early primary states, the rest of Congress is still trying to keep the country running.
WORLD AIDS DAY 2019: Three Decades of Progress in Treatment and Healthcare
December 11, 2019
December 1st marked the 31st observance of World AIDS Day, an opportunity for the world to unite in efforts to stop HIV, support those affected by HIV, and remember those who have lost their lives to HIV-related diseases. The Centers for Disease Control and Prevention (CDC) first called attention to what is now known as AIDS in 1981.
Washington’s “Surprise” Billing Law Goes Into Effect – January 2020
December 9, 2019
Starting in 2020, Washington’s new law aimed at putting an end to a particular form of balance billing, known as “surprise” billing, will go into effect. This includes situations where a patient has no reasonable opportunity to make an informed choice regarding their utilization of in-network versus out-of-network providers, for example in the case of emergency services or non-emergency surgical or ancillary services which are provided by an out-of-network provider within an in-network facility. In these cases, the patient has no way of choosing what providers to utilize, or may not know (and would have no reason ...
The More You Know, the More You Save: How Transparency in Health Care Can Help Empower Patients and Plans
December 5, 2019
On November 15, 2019, the Department of Health and Human Services, along with the Department of the Treasury, and the Department of Labor, issued proposed rules related to "Transparency in Coverage." These proposed rules come fresh off the heels of the executive order issued by President Trump in June of this year calling for increased transparency in the cost of health care, and the cost of coverage.
New Transparency Rules Released, But Will They Last?
December 2, 2019
On Friday, November 15th, the Trump administration released two long-expected rules: one final rule on hospital price transparency and one proposed rule on “transparency in coverage.” The final rule on hospital pricing is set to go into effect on January 1, 2021. The proposed rule is currently in the notice and comment period in which the Centers for Medicare and Medicaid Services (“CMS”) is accepting comments from interested parties. Both rules are meant to deliver on a promise made by the administration; that consumers would receive “A+ healthcare transparency.” For a variety of reasons, however, the long-term fate of ...
RBP: Why Litigate?
November 22, 2019
For those of you who have a player in the reference-based pricing game, you know that circumstances can arise when things don't go as planned. There are some providers, for instance, that are so dead-set on penalizing RBP plans and their members that they will accept nothing short of the full billed charge. As we all know, though, nobody gets paid full billed charges, and it's wildly unreasonable for anyone to expect that. But what is the end game, then, when a provider makes unreasonable demands and refuses to settle?
Theories v. Practicality: The Simplest Answer is Often the Best!
November 18, 2019
Whether you believe that a breach of contract action against a plan participant is allowed, it’s better to be able to prevent the money from being put at risk.
Warren and Buttigieg Cross Swords Over Health Care
November 15, 2019
The Democratic candidate, Elizabeth Warren, known for her multitude of plans and granular policy detail, has officially unveiled her Medicare for All plan.
An Objective Analysis and Response to Elizabeth Warren’s “Ending the Stranglehold of Health Care Costs on American Families”
November 7, 2019
Ron Peck provides an objective analysis on Senator Elizabeth Warren's policy paper, “Ending the Stranglehold of Health Care Costs on American Families.”
Happy (Almost) New Plan Year!
November 6, 2019
Don't let the hectic Fall season bring you down - we've compiled helpful tips for employers to keep in mind as they review health plans for the new year.
Hospitals Jump Into the Fray – New Lawsuits Against Opioid Manufacturers
November 4, 2019
A drug manufacturer is being tried for its role in America's opioid crisis. Since, hospitals have joined up in a handful of lawsuits in state courts.
The Tower of Babel – Talking Heads Talking Past Each Other
October 31, 2019
As the 2020 Presidential Election approaches, healthcare is one issue that everyone is talking about; but are they speaking the same language?
Don’t Get Bit: Avoid Falling Into the COBRA Snake Pit.
October 28, 2019
Despite its relative simplicity in a qualified beneficiary's perspective, COBRA is a lot less simple when viewed through the eyes of an employer.
Battle Lines Drawn over Medicare for All in the Latest Democratic Debate
October 21, 2019
Healthcare played an essential role in how the audience identified distinctions in candidates in the most recent Democratic debate.
The “Greatest of Three” Rule & Barriers to Compliance
October 17, 2019
Seeing a plan get sued over a denial isn't good, but can compel useful guidance. The issue is its failure to provide information needed to comply.
The Health Care Tug-of-War
October 15, 2019
The conversations around impeachment, gun control, immigration are pertinent, but it is important to recognize the roll of politics in the healthcare debate.
The Art of the Pill: Will Trump Fully Buy Into an International Price Index?
October 7, 2019
The discussion of lowering prescription drug costs is certainly on the raise, but will Trump fully buy into an International Price Index?
Patients are Increasingly Being Sent to Collections and Finding Themselves In Court – Sued by the Providers That Swore to Protect Them
September 20, 2019
Court clerks in various geographic regions witnessed an undeniable uptick in the number of lawsuits being filed by hospitals and providers against patients.
Department of Labor Issues FAQs to Clarify Mental Health Parity Regulations
September 19, 2019
The Department of Labor (DOL) issued FAQs in an effort to promote compliance and clarify the confusion surrounding the final mental health parity regulations. The Department of Labor (DOL) issued FAQs in an effort to promote compliance and clarify the confusion surrounding the final mental health parity regulations.
Number of Uninsured Increases for First Time Since Passage of the ACA
September 16, 2019
The Census Bureau's 2018 Health Insurance Coverage report found that the number of Americans without health insurance increased for the first time since 2009.
Lots of Moving Parts
September 11, 2019
As self-funders know, there are multiple considerations involved in most decisions. Even negotiating a pre-payment bill can involve many questions.
Controversy Surrounds the Most Expensive Drug in the World
August 13, 2019
In May of this year, the Federal Drug Administration (FDA) approved the most expensive drug in the world, Zolgensma. The drug was developed by Swiss drug maker, Novartis, and costs $2.1 million for the one-time single dose. The drug maker will spread the burden of the high cost by allocating payments for the drug over a 5- year plan at $425,000 a year.
Don’t Confuse Appeals with Balance-Billing!
August 6, 2019
https://www.phiagroup.com/Media/Posts/PostId/878/controversy-surrounds-the-most-expensive-drug-in-the-world
There’s a New Notice on the Block
July 31, 2019
Prepare your HAS-qualified high deductible health plan offering groups informed about the new IRS notice on the block. Stay tuned for more IRS regulations.
Health Care “Cadillac Tax” Repeal Bill Passed by the House
July 24, 2019
The House of Representatives voted to abolish the "Cadillac Tax" on high-valued health plans that when named a law, will put an end to tax threat to employers.
Final Individual Coverage HRA Rule Released
July 22, 2019
The Trump Administration finalized a rule in which employers can use HRAs to subsidize their employees' purchase of individual coverage.
The Conscience Rule’s Effective Date is Delayed
July 10, 2019
The HHS published the Final Conscience Rule which allows the denial of healthcare services for religious reasons. Its intent is to protect religious obligations.
Network Contract Drafting: You’re Doin’ It Wrong
July 1, 2019
Our consulting team came across a network agreement that had the nuance of indicating that the provider would bill amounts in line with market standards.
Everything I Ever Needed to Learn, I learned in Pre-School!
June 26, 2019
Our ability to use words to convey information effectively. The same goes for your healthcare plan. It's important to use words that everyone can understand!
IP Law vs. Drug Prices – Round Two, Fight!
June 24, 2019
It's no surprise that drug prices are far too high. New IP laws are attempting to change this with drug price transparency. Learn more about its impact!
No No-fault – Michigan Revamps its Auto Insurance Rules
June 19, 2019
Michigan's Senate passed sweeping legislation to get the state's auto insurance rates under control. Learn more about this new law and how it can impact you.
MA PAID FAMILY & MEDICAL LEAVE UPDATE: Required Contributions Delayed…and Increased
June 17, 2019
Massachusetts has delayed its contributions for its Paid Family & Medical Leave program. Stay up to date on upcoming changes to coverage plans and policies.
Will Sex Discrimination be Re-Defined?
June 6, 2019
Learn more about the US Department of Health & Human Services' (HHS) proposed revision of the Affordable Care Act to exclude terms within sexual discrimination.
List Prices in TV Ads: Will This Help?
May 31, 2019
Big changes are coming to drug advertisements on TV. Learn how price transparency will affect the healthcare industry & its manufacturers.
Denial & Appeal Case Study: A Deep Dive (Literally)
May 28, 2019
When you analyze a Plan Document, how can you know which words to rely on? Read this denial & appeal case study to learn how to better approach the situation.
IP Law vs. Drug Prices
May 20, 2019
Are you being overcharged by your healthcare plan for your own prescriptions? Learn more about IP Law and Drug prices. Call us for a claim negotiation!
CMS Finalizes Drug Price Transparency Rule
May 17, 2019
New rules in drug pricing transparency will require prescription manufacturers to provide wholesale prices to consumers in television ads. Learn its impact!
Big Pharma Executives Testify Before Congress (Again)
May 3, 2019
Executives from major drug companies testified before the Senate Finance Committee. Read about their proposed solutions for price increases & transparency.
The Final AHP Rules Take a Hard Hit (Part 2)
April 29, 2019
The courts recently vacated the provisions set by the AHP rules. Learn more about future implications these changes may have for you and your employer.
Beware The “Lesser Of”
April 23, 2019
Learn more about avoiding problems with the plan document obligating the Plan Administrator to pay less than the amount required by a separate contract.
Suicidality On the Rise Amongst Missouri’s Child Medicaid Population
April 10, 2019
A recently released study highlighted some alarming numbers relating to the rates of suicidal thoughts and actions among children. Click to read more.
New DOL Opinion Letter: Employers May Not Delay FMLA Leave Designations
April 8, 2019
The Department of Labor recently stated that an employer may not delay designating a leave of absence, as a leave under FMLA. Learn what this means for you.
Be Transparent – Tell Me What You Really Want!
April 3, 2019
Diving deeper into the transparency of healthcare costs, what do you really want? The best or the most expensive?
The Final AHP Rules Take a Hard Hit
April 1, 2019
A federal court has ordered certain provisions of President Trump’s Association Health Plan (“AHP”) Final Rule to be vacated. Learn what that means for you.
ERISA Violations Due to Restrictive Claim Guidelines
March 25, 2019
A recent case development has added another layer to compliance when it comes to covering mental health benefits. Click to read more.
FDA Chief Resigns – Why It’s A Loss for Self-Funding
March 20, 2019
Scott Gottlieb was recently relieved of his duties as the commissioner of the FDA. Learn more about what his departure means for the healthcare system
RBP: Sticking It To The Man
March 18, 2019
Employers primarily choose to utilize reference-based pricing programs to cut costs. Learn more about the real benefits of these methodologies.
Drug Importation: A Word of Caution
March 7, 2019
A rising trend has been the procuring prescription drugs from abroad. Learn more about the potential risk most employers don't consider with these programs.
The Opioid Crisis: How Employers & Self-Funded Health Plans Can Combat This Epidemic
March 5, 2019
Each year more and more Americans overdose on prescription opioid drugs. Learn more about how employers can combat the epidemic.
Too Early to Worry About 2020? Never!
February 27, 2019
It's never too early to start planning. Learn more about the two things health plans should pay attention to with the recent and future ACA changes.
To RBP, or Not to RBP: That is (one) of the Question(s)
February 25, 2019
It’s assumed health insurance is included in an employment package. What was once a benefit is now an entitlement. Learn if RBP is for your business.
The New Medicare and Medicaid Bills
February 19, 2019
Learn more about the Medicare for All Act of 2019 and how it would transform U.S. health care system if it is passed.
Hey, Watch Your Language!
February 13, 2019
Learn more about why using clear and accurate language is important in reference-based pricing plans.
New Action on Drug Pricing: Medicare-Like Rates?
February 11, 2019
The cost of insulin to treat patients with type 1 diabetes has doubled since 2012. Learn more about the bill that could help prevent further increases.
Self-Funding Comes in Many Forms - When Describing, Take Care to do so Accurately!
January 29, 2019
The Phia Group understands that many self-funded plans do not utilize the hybrid approach. Learn more about self-funded health plans.
Not An Enemy
January 23, 2019
The Phia Group explains how the insurance providers are not always your enemy and the hospitals' role in health coverage pricing. Click to read more.
Your Plans to Offset May be Offset
January 21, 2019
The self-funded industry took a hit when UnitedHealth won a lawsuit about their cross-plan offsetting. Learn more about the case & cross-plan offsetting.
The Government Shutdown's Impact on the Texas v. U.S. Case
January 16, 2019
The Phia Group shares their expert opinion on how the government shutdown's impact on the Texas v. U.S. Case. Click to read more!
Blocking the Birth Control Rule
January 15, 2019
Contraception for women has been a hotly debated topic due to a new Trump administration rule. Learn more about the states that blocked these rules.
EEOC Vacates ADA and GINA Wellness Incentive Rules
December 21, 2018
The Phia Group explains how the new EEOC's final rules on ADA and GINA will affect you. With a lack of rules, employers may have compliances risks.
Stop-Loss: The Forgotten Player in the Reference Based Pricing Game
December 20, 2018
Learn why you need to put stop-loss high up on the laundry list of considerations when choosing to adopt referenced-based-pricing.
A Texas Judge Strikes Down Obamacare – Our Take
December 17, 2018
The Phia Groups shares their expert opinion on Texas striking down on Obamacare. Learn more about how it could affect your future healthcare coverage.
Take Two Premiums and Call Me in the Morning...
December 6, 2018
Too many people are confusing the term ‘health care’ with ‘health insurance.' Learn more about how we break down the difference at Phia Group.
Responding to a IRS Letter 226J: Considerations and Common Mistakes
December 5, 2018
If you are an applicable large employer, IRS could possibly be sending a Letter 226J notice your way. Will you be ready to respond accurately within 30 days?
Objectives for the CVS Health and Aetna Merger
December 3, 2018
The CVS Health and Aetna merger was granted preliminary approval from the DOJ in October. Will it benefit them or the patients more? Click to learn more!
You Down with RBP? (You May Already Be!)
November 28, 2018
Reference-based pricing is one of the most mysterious self-funding structures out there. Learn if your plan falls under RBP, today!
Trump Administration Finalizes ACA Contraceptive Mandate Exemption Rules
November 26, 2018
The Trump Administration recently released new rules that expand the scope of contraceptive mandate exemptions. Click to learn more about the rules.
OSHA Publishes Guidance on Post-Accident Drug Testing
November 14, 2018
OSHA recently released an official memorandum regarding their stance on drug testing. We break it down in more depth and tell you what you need to now!
Healthcare on the Ballot, and a Free Side of Fries
November 5, 2018
Phia Group takes a step back and takes a deeper look of healthcare and political promises. Learn how these pledges affect your insurance expense.
The Proposed HRA Rules v. the Current Regulatory Landscape
October 31, 2018
In October of 2018 the government issued proposed regulations on health reimbursement arrangements. It's not too late! Learn how this may affect you.
SUPPORT for Patients and Communities Act
October 29, 2018
It is no secret that this country has an opioid epidemic that has a rising death toll and price tag attached to it. Click here to learn more.
HHS Proposes Drug Transparency Rules for TV Advertisements
October 17, 2018
Drug transparency rules have been proposed for TV advertisements. Find out more about these potential industry-changing regulations, today!
Is Your Life Insurance Policy Subject to ERISA?
October 3, 2018
Is your life insurance policy subject to ERISA? Learn how to find out if it is and what that might mean for you if your insurance policy is subject to it.
Communication Breakdown – More Lessons Learned from My Wife’s Battle Against Lymphoma
October 1, 2018
Listen to Phia Group's podcast, "Empowering Plans." This episode discusses the importance of communication & diligence when dealing with cancer medication.
Wilderness Therapy Exclusions Causing Mental Health Parity Concerns
September 26, 2018
The plan exclusion of wilderness therapy has spurred some lawsuits based on alleged violations of the MHPAEA. Click here to learn more about the lawsuits.
REMINDER: Medicare Part D Creditable Coverage Notices Due to Certain Employees by October 14th
September 24, 2018
Do you deserve to be receiving these benefits? Find out more about the Medicare coverage that is due to employees by October 14th. Learn more today!
A Contract By Any Other Name
September 19, 2018
Are you using reference-based pricing? If you answered yes, make sure you're doing it right. Click here to contact Phia Group's Consulting team & learn more!
The Kavanaugh Hearings: The Future of Abortion and Obamacare at Stake
September 17, 2018
Abortion and Obamacare are 2 of the most debated subjects in the world. Click here to learn why the future of both may be at stake at the Kavanaugh hearings.
Texas v. U.S. Serves as Latest Threat to ACA’s Pre-Existing Condition Protections
September 12, 2018
The Affordable Care Act is under attack again, being called unconstitutional. Click here to learn more about the latest developments with the Texas v. US case.
Has the Life Expectancy of Drug Rebates Been Reduced?
August 29, 2018
We all know drug prices are sky-high with seemingly no end in sight. Click here to learn more about the Trump Administration's attempt to reduce drug costs.
With the Lack of Guidance on AHPs, States Take Matters into Their Own Hands
August 22, 2018
The final Association Health Plan has left states with more questions than answers. With the rules becoming effective on Aug 20th, learn how you will be affected.
Patient Assistance Programs: Friend or Foe?
August 15, 2018
Have you been wondering the reality behind patient assistance programs to help pay for your prescriptions? Learn more about PAPs & how it may affect you today.
CMS Requires Hospitals to Post Standard Charges Online
August 9, 2018
Price transparency has never really been synonymous with health care. Click here to see how CMS's is attempting to address this on-going healthcare issue.
Paid Bereavement Leave for New Yorkers
August 7, 2018
New York has recently passed a bill amending the Paid Leave Law to include bereavement leave. Learn more about how it may affect you by clicking here.
Know when to fold ‘em
July 30, 2018
Winning a case does not always equate to the best outcome. Learn more about the "made whole" doctrine in MA and effective cost containment by clicking here.
FDA Approves Marijuana-Derived Drug for Seizures
July 25, 2018
The FDA issued the nation's first approval for a drug derived from marijuana-based compounds to treat seizures. Click here to learn more about the drug.
Trump Administration Halts Billions in ACA Payments
July 18, 2018
The Trump Administration has taken quite a beating from the Affordable Care Act. Click here to know what insurance companies will be forced to do.
Which path will the EEOC take in August?
July 16, 2018
Are you curious about the court case between the AARP & EEOC on wellness programs? If so, read here!
You Probably Can!
July 11, 2018
Have your clients ever decided not to utilize wrap networking? Research shows that wrap networks offer the best bang for your buck! Read here to learn more.
What Does FDA CBD Approval Mean For Self-Funded Plans?
July 2, 2018
The FDA recently approved medical marijuana for the United States. Read more to see how CBD will impact self-funded health insurance plans.
Expansive Paid Leave Legislation for Massachusetts Employers
June 29, 2018
Governor Charlie Baker recently signed new legislation that will directly impact employers of Massachusetts. Learn more about what this includes!
A Bit of Relief From the 2nd Circuit
June 27, 2018
The subrogation industry has taken a toll from the 2nd Circuit relating to the provision of employee benefits. Learn more about the issues of subrogation today!
Right to Try... Right for You? Understanding What is Right, and Wrong, for Self-Funded Plans in Response to the New Right to Try Law
June 21, 2018
Are you seeking insurance coverage options for drug treatment? If so, this article will explain everything about the new Right To Try legislation.
The MHP Hits Just Keep on Coming
June 20, 2018
Mental Health Parity violations keep resurfacing in court cases more frequently. Learn more about the recent case involving Catholic Health Initiatives here.
An Addiction to Health Insurance
June 18, 2018
Health insurance continually blinds people from the actual cost of healthcare. Read why more people are more addicted to health insurance more than ever.
The Complicated Issue of ACA’s Section 1557 and Gender Identity Protections
June 13, 2018
The Affordable Care Act prohibits health programs to discriminate people based on their attributes. But is gender identity protected? Click here to find out!
May Day: Two States Enact Individual Health Insurance Mandates
June 11, 2018
Many states have defied the Trump Administration’s repeal of Obamacare, but why? Click here to learn more.
Bridging the Gaps Between...Everything
June 4, 2018
Our new Phia Certification Program is to ensure all our employees understand our industry and how we operate. Click here to learn more.
How About Some Evidence? - Montanile v Board of Trustees
May 23, 2018
You may be curious about the decisions made in the Montanile v Board of Trustees Supreme Court case. Read more about the new approach to third-party liability.
MHP – Are You Still Paying Attention?
May 16, 2018
Lawsuits and Department of Labor audits related to Mental Health Parity violations are still arising. Read more about the recent Munnelly v Fordham case!
One Shot at This
May 14, 2018
When writing plan documents, make sure to get it right the first time before handing to clients. Click here for everything I have learned & my story.
The Gap Doesn't Stop At the Document
May 9, 2018
There are many types of gaps within coverage including plan documents & network agreements. Click here to learn about all the gaps you should be aware of.
The Complications Surrounding Intermittent FMLA Leave
May 7, 2018
There are many complications dealing with Intermittent FMLA Leave. Click here to learn everything you need to ensure to administer this properly.
North Cypress Medical Center: What Does it Mean for RBP?
May 2, 2018
Reference-based pricing has a lot of hurdles for businesses and legality. Read here about the recent court case regarding patient pricing.
The Fax Machine and a Lesson in Incentives
April 30, 2018
Faxing is a very inefficient way to share records with doctors and insurance providers. However, there may be a better solution! Click here to learn more.
Senate Health Committee Hones in on Mental Health Parity Enforcement
April 26, 2018
The Senate Health Committee is working hard to strengthen mental health parity in insurance plans. Click here to see the effect on the self-funded industry.
Stories from the Front Lines…
April 17, 2018
The Phia Group constantly fights for the rights of their clients every single day. Read our amazing story on how we got our clients 2nd lien reinstated.
The Tangled Web of Eligibility
April 11, 2018
In this article, we talk about the BIG picture of eligibility issues, subsequent gaps, & continuation of coverage. Read here to get the BIG picture!
Hope Springs Eternal
April 9, 2018
Employers are moving to a self-funded model for their health benefits. Click here to understand that it is more robust and less costly for everyone!
Don’t Miss the Most Dynamic Healthcare Industry Event in New England!
April 4, 2018
The Phia Group is going to Benefest 2018! The purpose is to reshape and disrupt the entire healthcare industry. Read more for additional details!
The Phia Group Saves an Employer Thousands of Dollars
March 30, 2018
Have you received a letter from the IRS saying that you violated employer mandate rules and owe an ESRP penalty? Read here to get all the details.
Negotiated Rates Are King
March 29, 2018
Negotiated rates are extremely important in the self-funded insurance industry. Click here to see all the benefits!
Freedom Blue II: The ACA’s Unlikely Ally
March 26, 2018
The Trump Administration recently shut down Idaho’s conservative governor from ignoring the ACA. Read here to know exactly why this happened.
Responding to a IRS Letter 226J: Considerations and Common Mistakes
March 21, 2018
If you are an applicable large employer, the IRS could possibly be sending a letter. Read more about the 2 types of ESRP penalties that may affect you.
Freedom Fighters Abound…
March 14, 2018
There is no question that the vast majority of folks in self-funding, whether benefit or service providers, have a goal in mind; providing cost effective benefits to the insured.
Contraceptive Update – Appeals and Intervenors
March 7, 2018
Contraceptive update! Two lawsuits that have challenged the contraceptive coverage rule have created changed issued by the Trump administration. Read more about these and if they could be affecting your situation.
Clearly it’s (Not) Transparency
March 5, 2018
If the consumer of healthcare (the patient) is different than the purchaser of healthcare (the plan or insurance carrier), how will knowing the price change the consumer’s behavior?
What do All These New Paid Sick Laws Mean for Employers?
February 28, 2018
What do all these new paid sick laws mean for employers? As many states are starting to beginning to enact paid sick or leave time regulations, employers will need to understand this. If you are an employer or employee that would like to know more about your paid sick laws contact The Phia Group.
Freedom Blue: Idaho’s Challenge to the ACA Gets Serious
February 19, 2018
The Department of Insurance (“DOI”) have made announcements in regards to what insurers are able to do in the ACA. Learn more about the details of Governor Butch Otter's executive order that would let health insurers in his state sell new plans to market that did not comply with ACA rules.
Employer Mandate Enforcement: IRS Turning Up The Heat
February 15, 2018
The Employer Shared Responsibility Provision of the Affordable Care Act (ACA) continues to serve as a polarizing topic among employers and ACA supporters as the Internal Revenue Service (IRS) moves forward with its compliance efforts. If you have 50 or more full-time employees you could be affected.
The DOL’s Proposed Rule … A Sleeper Provision for Self-Funding?
February 12, 2018
Proposed regulations by the Department of Labor (DOL) make two important modifications to self-funding. Learn about them here and how they could be affecting you or your business.
Even the best Plans can backfire!
February 7, 2018
Success is not a given in the world of subrogation/reimbursement. Choose a subrogation firm like The Phia Group who will try to secure everything that is needed for a client. Contact us today to get started!
Your Plan isn’t a Cadillac …Yet
January 31, 2018
The most notable in the self-funded industry is the ACA’s High Cost Employer-Sponsored Health Coverage Excise Tax (“Cadillac Tax”). The Cadillac Tax was originally set to begin in 2018, but has been delayed again. Find out when your plan will become a Cadillac from The Phia Group.
Sick (Leave) Day: Maryland Revamps Paid Sick Leave Law
January 23, 2018
Maryland has become the latest state to mandate paid sick leave for employers with 15 or more employees. Learn about the permissible uses for earned sick and safe leave options that are stated in the law. The Phia Group offers their key takeaways and the ability to read the full Act here.
The Reference Based Pricing Stew
January 17, 2018
Reference-based pricing tends to be something you will love or hate. It is put together like a stew by compiling a ton of different ideas which can result in good stew or a very bland one. It can become very complex due to the industry and other factors. Read more about RBP with The Phia Group
A Backdoor Employer Mandate? Massachusetts Targets Employers to Shore Up the State’s Medicaid Program
January 15, 2018
Since 2011, approximately 450,000 people have lost their employer-sponsored insurance in Massachusetts. In the same time period, MassHealth enrollment increased by just over 500,000. The MassHealth program is literally drowning the state in debt, and so last year, Governor Charlie Baked signed H. 3822, which has two major components (beginning in 2018).
NOT SO FAST! Don’t Change Contraceptive Coverage Just Yet
January 10, 2018
Changing Contraceptive Coverage? You might want to wait. The new rules essentially allow any company that is not publically traded the ability to refuse to cover contraceptives on moral or religious grounds. The process for the exemption is also much more relaxed than the accommodation process.
Nice to see you, 2018. Should we Expect more of the same?
January 2, 2018
Avoiding reimbursement rights, self-funded plan structure, prudent management of plan assets or disbursement of settlement funds? No one can predict what will happen in 2018 but The Phia Group will be here to handle any subrogation law needs.
Pin the Tail on the Donkey & Other Blindfolded Games of Placement
December 27, 2017
Our industry (that being the self funded health benefits industry) is primarily a web-work of relationships. Unlike a large, traditional health insurance carrier, where all functions are located under one roof, in our industry key pieces of the greater whole are comprised of various independent entities.
House Bill Assumes Air Ambulance Providers are Underpaid
December 13, 2017
"Ensuring Access to Air Ambulance Services Act of 2017" this bill is designed primarily to alter the Medicare reimbursement to air ambulance providers. If you would like to learn more about this bill or if it has been impacting you, read about it here with The Phia Group.
Sacrificing the Individual Mandate on the Alter of Tax Reform
December 11, 2017
Want to know more about the glue of Obamacare? Perhaps the single most important piece of the Affordable Care Act (“ACA”) is its “individual mandate" Learn about how Americans have been required to obtain health insurance coverage that meets the government's definition of "minimum essential coverage" or pay a penalty.
Year Up at Phia!
December 1, 2017
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 – we feel truly blessed to call them a part of the Phia Family. We sat down with them to hear their thoughts and experiences.
A Little 2017 Holiday Cheer… Subrogation Style!
November 29, 2017
Everything in the subrogation world in 2016 was viewed through the prism of the Montanile decision from the Supreme Court. We take a look back at 2017 and how the Montanile decision was carried out and any other cases that factored into the court's decision. Read more here
Not all Illegal Act Exclusions are Created Equal
November 22, 2017
Want to know more about Illegal Act Exclusions? Not all of them are created equal. Illegal acts and illegal drug exclusions are prevalent in self-funded plan documents, but does the plan document wording align with the plan's intent? Learn more about Illegal Act Exclusions with us.
Welcome to the Fiduciary Jungle!
November 20, 2017
Welcome to the Fiduciary Jungle! Fiduciaries are being accused by the employees of wasting the plan's money on less-than advisable investments. Learn how this could be coming to the health benefits arena to shape up and take action now! Contact the Phia Group to learn how you can stay protected
MA Contraceptive Reform Update
November 13, 2017
Jen McCormick, Esq. reviews the bill the MA House passed ensuring that women retain access to no cost contraceptives.
Massachusetts on Track to Pass a Significant Cost Containment Bill
November 8, 2017
Brady C. Bizarro, Esq. explains the Massachusetts State Senators proposed comprehensive reform bill focused on health care cost containment.
Montana SB44 and State Efforts to…Do What, Exactly?
November 6, 2017
Jon Jablon, Esq. discusses Montana's recently passed SB44 and its impact on payment amounts due to out-of-network air ambulance providers in Montana.
Phia Undercover: Two Chargemasters at Addiction Centers
November 1, 2017
Phia shares a recent experience dealing with a high rate biller and how they were able to rethink the process to close the accounts for a fair rate.
The Irony of Equity – It’s Almost Never Fair
October 25, 2017
Chris Aguiar, Esq. shares a recent case involving equitable claims and the importance of having trusted advisors.
More Rule Changes?
October 18, 2017
Kelly Dempsey, Esq. provides an overview of recent rule changes released by federal agencies and the Trump administration affecting the 2018 renewal season.
An Appealing Option - Affordable Care Act Review
October 16, 2017
Ron Peck, Esq. discusses the likeliness of facing a final appeal, possibly resulting in a plan being penalized.
Trump Administration Birth Control Roll Back
October 9, 2017
Jen McCormick, Esq. reviews the new HHS regulations allowing more employers to opt out of ACA preventive care contraception requirements.
Usually and Customarily Denied
October 4, 2017
Jon Jablon, Esq. discusses the importance of understanding how your stop-loss policy defines U&C before a portion of your paid claim is denied.
Another One Bites the Dust
October 2, 2017
Brady C. Bizarro, Esq. explains the collapse of the Graham-Cassidy repeal bill that would have replaced the Affordable Care Act.
In God We Trust; All Others Pay CASH…I wish…
September 25, 2017
Do healthcare providers offer discounts for cash payment? Learn more about the growing rate of physicians in the US who contract directly with their patients.
Natural Disasters (Hurricanes Harvey and Irma) - Don’t Let Them Wreak Havoc on Your Health Plan
September 13, 2017
Kelly Dempsey, Esq. shares the Department issued guidance related to Hurricane Harvey and what it means to employers and employees.
Stop Loss and My Infinite Sadness
September 11, 2017
Ron Peck, Esq. discusses potential savings opportunities when choosing stop loss coverage associated with your self funded healthcare plan.
Change is Good
September 5, 2017
Learn more about designing a valuable benefit plan for employees with ERISA in mind.
Uncertainty Prevails in the Health Care Debate
August 30, 2017
Review a detailed recap of changes thus far concerning the Affordable Care Act (ACA) for the 2017-2018 enrollment period.
Reference Based Pricing Bloopers & Blunders
August 28, 2017
Find out what to focus on and what to avoid when setting up your company's health plan reference based pricing. Learn more today.
Hope for Self-funded Plans in Connecticut..
August 16, 2017
Check out our article on what you need to know about Connecticut law HB 6221 and how it affects you.
The Benchmark Shuffle
August 9, 2017
Ensure your company is compliant with revised health care benchmark summaries released in 2017. Learn more today.
A House Divided
August 7, 2017
Find out how to avoid health plan and stop loss disagreements for self-funded health insurance claims with this helpful article.
Reverse Medical Tourism
July 31, 2017
Medical tourism offers many cost-containment options in reducing health care costs. Find out if this makes sense for you.
Reference-based Pricing: Decisions, Decisions…
July 26, 2017
Sort through the RBP pricing confusion and ask these questions to make the best decision for your company. Learn more.
The Rise of Paid Family Leave Laws & Their Impact on Self-Funded Plans
July 24, 2017
Understand the evolution of paid family leave laws. See which states passed laws and how much paid time they're required to offer. Learn more today.
Magical Words in Claim Negotiation: “Please Send Claim Back for Processing”
July 19, 2017
Jason Davis shares his 15 years experience in healthcare negotiation and offers ways to handle pushback from seemingly abusive providers.
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
Kelly explains the importance of reviewing plan revisions for errors causing gaps in stop loss policies and further complications. Learn more.
Altogether Now… But Not a Single Payer
July 5, 2017
Ron Peck, Esq. explains the problems with a Single Payer System, the differences between types of insurance and how costs are determined. Read more now.
It’s Time for a Wake-Up Call!
June 26, 2017
Learn more about how to educate your employees and get them involved in making healthy choices to benefit themselves and their healthcare costs.
Full Billed Charges: A Question of Geography
June 21, 2017
Do providers reserve the right to receive full billed charges from your plan? How is your plan set up? Find out with this helpful article.
Behind Closed Doors
June 19, 2017
Brady C. Bizarro, Esq. discusses the leaked bits of healthcare information from our government so far in 2017. What does this mean for you? Learn more today.
“Stay away from Back Surgery”: A Warning from NBA Coach Steve Kerr
June 14, 2017
As orthopedic surgeries are more commonly recommended, the cost continues to increase. Will we see a 400% increase by 2030? Learn more.
A Win for the Good Guys!
June 7, 2017
Is an SPD enough when standing up against benefit plan reimbursement rights? We explain why the 5th Circuit ruling helps. Read more now.
The Rules of the Game are Still Changing
June 1, 2017
Find out how the executive order passed May 4th, 2017 instructs involved agencies when making decisions about contraceptives.
Bite the Hand
May 30, 2017
Ron Peck, Esq. discusses the issue of private payers being charged inflated amounts and what the future can hold. Read more today.
It's Never Too Soon
May 22, 2017
Learn more about how to properly plan for upcoming healthcare changes and look at cost containment measures with these questions and feedback.
Dear Stop-Loss: A Ballad
May 15, 2017
With all the concern surrounding healthcare changes, read this ballad about insurance and stop-loss for a laugh...
You Are Not Going to Sue Us, Are You?
May 10, 2017
We take a look at a case where a client was billed thousands per day for similar treatments under different company names. Learn more.
Adam’s Key Takeaway from the 2017 MassAHU Benefest Conference
May 4, 2017
We discuss the importance of empowering employees understand the actual cost of care and making healthy changes. Read more today.
A Call for Defensive Legislation
May 3, 2017
Find out more about how the House of Representatives bill passed April 5th, 2017 helps regulate stop-loss insurance redefinition.
Words With No Meaning - Subrogation Accident Questionnaire
May 1, 2017
Chris shares an example of why it's important to choose your words wisely and make sure you say what you mean when it comes to subrogation accident questionnaires.
Transparency – It’s Not Just for Ghosts
April 26, 2017
Kelly Dempsey, Esq. shares a personal experience with different charges for the same services. Learn more today.
Pay the Cost to be the Boss!
April 24, 2017
Educate your staff and empower them to make the best choices, as illustrated by Ron Peck, Esq.'s example. Read more now.
Cyborgs – Moving From Science Fiction to Science Fact
April 20, 2017
The cost of prosthetics developed from new technology are expensive, but trend shows costs reduce as new technology develops. Learn more.
My Trip to the Emergency Room
April 18, 2017
Jen McCormick, Esq. shares an experience with her toddler and a family physician recommendation to the ER. Read more.
I Fought The Law and…Unpredictable Results Ensued
April 12, 2017
Jon Jablon, Esq. discusses whether it's worth the risk to involve legal parties with billing due to unpredictable results. Learn more today.
Repeal and Replace Faces a False Start - Affordable Care Act Review
April 10, 2017
A look at the possible impact on employer-sponsored health insurance with developing government decisions. Learn more.
Sometimes... The Truth Hurts...
April 5, 2017
Out-of-control billing is a huge problem in our healthcare system today. Learn more about what you can do to take control.
Trump’s Healthcare Bill Failed… Here’s Why
April 3, 2017
Until we challenge hospital costs, specialty drug charges and others, we'll continue overpaying. Learn more about what you can do.
U.S. Airways v. McCutchen – Where Are they Now?
March 29, 2017
We discuss the differences of known self-funded healthcare plans and compare them to U.S. Airways Vs. McCutchen. Learn more.
Bidding Against Themselves: $750K Air Ambulance Claim Adventure
March 29, 2017
Phia explains the importance of having good legal representation in this case about a $750,000 Air Ambulance Charge. Read more.
Bidding Against Themselves: $750K Air Ambulance Claim Adventure
March 28, 2017
The Phia Group explains the importance of having good legal representation in this case about a $750,000 Air Ambulance Charge. Read more.
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.

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