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Recent Posts

• Beware The “Lesser Of”
  
  April 23, 2019
  We’ve seen it a thousand times: a health plan document provides that the plan will pay the lesser of certain factors, including billed charges, the applicable network rate, and the plan’s U&C rate (however it may be calculated). The old way of thinking in the industry is that this language gave the Plan Administrator a lot of leeway in determining appropriate payments – but it’s “the old way of thinking” for a reason.
• Suicidality On the Rise Amongst Missouri’s Child Medicaid Population
  
  April 10, 2019
  Last month, the Missouri Hospital Association released a study which highlighted some alarming numbers relating to the rates of suicidal thoughts and actions among children covered by Missouri’s Medicaid program. Among the studies key findings was a notable increase it suicidality amongst Medicare-covered children, along with a decrease in average length of inpatient admissions after the state made a switch from traditional fee-for-service Medicaid to a managed care structure in May 2017. The study looked at 18 months of data prior to the change, and 19 after.
• New DOL Opinion Letter: Employers May Not Delay FMLA Leave Designations
  
  April 8, 2019
  On March 14, 2019, the U.S. Department of Labor (“DOL”) released an Opinion Letter advising that an employer may not delay designating a leave of absence, paid or unpaid, as a leave under the Family and Medical Leave Act ("FMLA”) (if the leave qualifies as an FMLA leave). In addition, this Opinion Letter details that an employer may not permit employees to extend FMLA leave beyond the 12-weeks (or 26 weeks for military caregiver leave) granted under the FMLA.
• Be Transparent – Tell Me What You Really Want!
  
  April 3, 2019
  At the risk of beating a dead horse, I want to address transparency – at least one more time. I’ve noticed of late calls from both our industry, and from Capitol Hill, for transparency. Of course, I don’t think these people really know for what they’re hollering. Let’s expand our focus from healthcare, and wag the finger at people who failed those noble spirits who crusaded for transparency already – and suffered the consequences.
• 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. The court has remanded the AHP Final Rule to the Department of Labor (“DOL”) for consideration on how the severability provision will affect the remaining portions of the Final Rule. The court detailed that “if a provision is found entirely invalid then ‘the provision shall be severable from [the Final Rule] and shall not affect the remainder thereof.’ 29 C.F.R. § 2510.3-5(g).”
• ERISA Violations Due to Restrictive Claim Guidelines
  
  March 25, 2019
  Whenever a self-funded health plan covers mental health/substance use disorder (“MH/SUD”) benefits, we review the plan to assess whether these benefits are covered in parity with medical/surgical benefits in order to ensure compliance with the Mental Health Parity and Addiction Equity Act (“MHPAEA”). A recent case, however, has added another layer to compliance when it comes to covering MH/SUD benefits.
• FDA Chief Resigns – Why It’s A Loss for Self-Funding
  
  March 20, 2019
  When President Trump nominated Scott Gottlieb to be commissioner of the Food and Drug Administration (“FDA”) in March of 2017, critics were quick to point out his deep ties to the pharmaceutical industry. They had little hope that he would have the wherewithal to overcome perceived conflicts of interest and challenge the industry on important issues facing consumers and payers. Scott Gottlieb, however, proved to be a rarity, seemingly immune to regulatory capture. He received bipartisan praise as one of the administration’s most effective regulators. His departure in April will be a loss for the self-funded industry and for ...
• RBP: Sticking It To The Man
  
  March 18, 2019
  Employers, TPAs, and brokers primarily choose to utilize reference-based pricing programs to cut costs. Instilling systemic changes in the industry can also be a goal of those utilizing this methodology, but cost-containment is a much more tangible goal.
• Foreign Drugs: Savings Worth Traveling For
  
  March 7, 2019
  In recent weeks, we have seen an influx of questions regarding the practice of procuring prescription drugs from abroad, particularly Mexico (Canada has historically been the most popular source). The issue has also been popping up in the news, and a program for public employees in Utah to venture to Tijuana to pick up their prescriptions is now live. The potential for significant savings compared to domestic pricing for (essentially) the same drugs is what is driving the popularity of this trend. We won’t get into the legal standing of this practice – feel free to ...
• 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. In fact, the Centers for Disease Control and Prevention (CDC) reported that deaths attributed to opioid abuse and addiction now exceed car crashes as the leading cause of unintentional death in the United States. Opioid addiction has grown exponentially in recent years and is now officially the deadliest drug crisis in American history, more than heroin and cocaine combined.
• Too Early to Worry About 2020? Never!
  
  February 27, 2019
  ACA changes are few and far between these days – a lot of talk, but not a lot of action…yet. There are two things health plans should pay attention to and one is likely a welcome change. The less exciting of the two is a quick update to the preventive care rules, while the more exciting proposal is relating to the exclusion of certain prescription drug charges from the out-of-pocket maximum. While this proposal doesn’t solve all the drug copay card problems at once, it’s a step to help plans control prescription drug spend.
• To RBP, or Not to RBP: That is (one) of the Question(s)
  
  February 25, 2019
  Why do employers offer health benefits to employees? Some might point to the Patient Protection and Affordable Care Act (“PPACA” or “ObamaCare”) and say the law forces them to do so. Yet, prior to the law’s passage in 2010, many (if not most) employers voluntarily offered health benefits to their employees. There are a number of reasons for this, but suffice it to say, it was meant to attract and retain the best talent.
• The New Medicare and Medicaid Bills
  
  February 19, 2019
  There has been a lot of talk lately about the progressive push for Medicare-for-All. For instance, Rep. Pramila Jayapal (D-Wash.) is seeking to introduce an updated bill called the Medicare for All Act of 2019. If passed, this bill would transform the U.S. health care system as it would essentially create a “single-payer” system run by the government. Medicare-for-All has also created a lot of uncertainty. For example, Medicare does not cover certain long-term care and does not include coverage for hearing, dental, vision or foot care, but supposedly the bill proposes to add some of these benefits.
• Hey, Watch Your Language!
  
  February 13, 2019
  This is a topic we’ve discussed numerous times in memos, phone calls, conferences, webinars, and any other time reference-based pricing is discussed – and it continues to be a relevant topic throughout the industry. A health plan utilizing some sort of RBP will get the most bang for its buck if the language in its SPD is strong – and of course if the language is weak, the plan’s payment methodology will be extremely difficult to enforce, and could even subject the Plan Administrator to liability.
• New Action on Drug Pricing: Medicare-Like Rates?
  
  February 11, 2019
  In 2012, the annual cost of insulin needed to treat patients with type 1 diabetes was $2,864. Today, the cost has risen to over $6,000. For working-class families already struggling to keep up with everyday expenses, this increased economic burden has forced some to choose between food and life-saving medication. CBS News has reported that more than one-quarter of Americans living with diabetes have cut back on their insulin usage to ration their supply, and that can be dangerous. Skyrocketing insulin prices are just one example of high prescription drug costs, which the Trump administration has made it a ...
• 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.
• 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.