“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.”

Director, Claim Analysis, Customer Service & Training
Certified Subrogation Recovery Professional

Recent Posts

  • The Government Shutdown's Impact on the Texas v. U.S. Case
    January 16, 2019
    By now, most Americans, especially those in the healthcare industry and proponents of the ACA, are aware of the December 14, 2018 decision in Texas v. United States by Judge O’Connor of the Northern District Court of Texas. This decision shook the healthcare industry as it ruled that the individual mandate was unconstitutional and not severable from the rest of the Affordable Care Act (“ACA”), thus concluding that the ACA itself is unconstitutional.
  • Blocking the Birth Control Rule
    January 15, 2019
    Coverage of contraceptives for women and the availability of a religious or moral exemption (or an accommodation) has been hotly debated recently – particularly due to a new Trump administration rule. Specifically, this rule would expand the pool of employers eligible to opt-out of providing birth control for women based on religious objections. The rule was set to take effect January 1, 2019, but judges in California and Pennsylvania recently blocked these rules from taking effect.
  • EEOC Vacates ADA and GINA Wellness Incentive Rules
    December 21, 2018
    On the verge of a potential government shutdown, the Equal Employment Opportunity Commission (“EEOC”) was quick to issue final rules December 19th on the Americans with Disabilities Act (“ADA”) and the Genetic Information Nondiscrimination Act (“GINA”). Issuing final rules at the end of the year is not a new trend, but the unique situation is that the final rules are vacating current provisions on wellness program incentives. With an effective date of January 1, 2019, we are left with less guidance than we had on December 18th.
  • Stop-Loss: The Forgotten Player in the Reference Based Pricing Game
    December 20, 2018
    Plan sponsors of self-funded health plans have a lot to think about. From deciding which services to cover to making tough claims determinations, there are lots of moving parts to consider and be mindful of. Plans that utilize reference-based pricing are in the same boat, of course, except they have added even more moving parts to their benefits programs.
  • A Texas Judge Strikes Down Obamacare – Our Take
    December 17, 2018
    We have been covering Texas v. United States since the case was filed in February of this year. The suit, brought by 18 state attorneys general and 2 Republican governors, represented the most serious threat to the Affordable Care Act (“ACA”) since the GOP’s efforts to repeal the healthcare law failed last summer. On Friday, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas ruled that the entire ACA is unconstitutional since Congress eliminated the individual mandate in a 2017 tax bill. His decision has rattled the markets, Democratic political leaders, advocacy groups, and ...
  • Take Two Premiums and Call Me in the Morning...
    December 6, 2018
    A friend and ally in the health benefits industry recently asked me if I had an up to date listing of the most costly health care expenses paid by health plans in 2018. I didn’t; so on a whim I brought up my handy dandy search engine and typed in: “the most costly health care expenses paid by health plans in 2018.” You know what the top results were? “Cost of Employer Health Coverage to Rise in 2019” … “Health Insurance: Premiums and Increases” … “How to Find Affordable Health Insurance in 2018” … and other, ...
  • Responding to a IRS Letter 226J: Considerations and Common Mistakes
    December 5, 2018
    If you are an applicable large employer (ALE), the Internal Revenue Service (IRS) could possibly be sending a Letter 226J notice your way. Will you be ready to respond accurately within 30 days of receipt if needed?
  • Objectives for the CVS Health and Aetna Merger
    December 3, 2018
    On November 28th, CVS Health closed on its acquisition of Aetna in a $69 billion merger. CVS Health and Aetna announced this deal in December 2017 and received preliminary approval from the Department of Justice in October. This merger will combine CVS’ pharmacies and Aetna’s insurance business, but it remains to be seen whether this merger will only benefit the companies themselves or if it will truly create positive change for patients as consumers of healthcare.
  • 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. At its core, it’s a simple enough idea: the plan changes what it pays for non-contracted claims. At its most basic level, it’s a way to redefine the traditional notion of U&C; generally, RBP plans base payment on some percentage of the Medicare rate. Guess what, though? If your plan defines U&C based on a database such as FairHealth (for instance), that’s a form of RBP too!
  • Trump Administration Finalizes ACA Contraceptive Mandate Exemption Rules
    November 26, 2018
    Amid broader health policy discussions around the Affordable Care Act (ACA), the Trump Administration recently, and somewhat quietly, released new final rules that would expand the scope of the ACA contraceptive mandate exemption to potentially include more types of employers. The two rules are “Exemptions for Religious Beliefs” (CMS-9940-F2), aimed at large, publicly traded companies, and “Exemptions for Moral Convictions” (CMS-9925-F), which is geared toward nonprofit organizations and small businesses.
  • OSHA Publishes Guidance on Post-Accident Drug Testing
    November 14, 2018
    The Occupational Safety and Health Administration (OSHA) released a memorandum last month clarifying the agency’s position on post-incident drug testing under 29 C.F.R. § 1904.35(b)(1)(iv). Although OSHA requirements are generally set by statute, standards and regulations, memorandums from the agency are helpful as they explain these requirements and how they apply to particular circumstances.
  • Healthcare on the Ballot, and a Free Side of Fries
    November 5, 2018
    If you are looking for a blog post listing specific healthcare related questions appearing on ballots, and a technical assessment of each, look elsewhere. If you were hoping for a dissection of candidates advertising heavily their support or opposition to the Affordable Care Act, and how that position will likely effect their likelihood of being elected (and what they says about the population’s attitude regarding healthcare and “Obamacare”), you can find a million articles on that topic somewhere else. My goal is to step back and assess the big picture.
  • The Proposed HRA Rules v. the Current Regulatory Landscape
    October 31, 2018
    On October 23rd, the Department of Labor (“DOL”), Department of the Treasury (“Treasury Department”), and the Department of Health and Human Services (“HHS”) issued proposed regulations on health reimbursement arrangements (“HRAs”). An HRA is a tax-free account coordinated with a group health plan, funded by the employer that reimburses employees for health care costs.
  • 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. According to the Center for Disease Control, there were approximately 63,632 deaths resulting from drug overdoses in 2016 with 40% of those deaths involving prescription opioids. A study conducted by Altarum, a health care research non-profit, found that the opioid epidemic, for years 2001-2017, cost this country $1 trillion. The total cost includes not just lost tax revenue and spending on health care, but also of lost wages, lost productivity, and social ...
  • HHS Proposes Drug Transparency Rules for TV Advertisements
    October 17, 2018
    In a move geared toward making drug prices more visible to consumers, the Department of Health and Human Services (HHS) recently released a proposed regulation that would force drug companies to include prices in their television advertisements of prescription drugs and biological products. HHS focused the proposal on drugs in which payment is available through or under Medicare or Medicaid to include the Wholesale Acquisition Cost (WAC, or “list price”) of that drug or biological product.
  • Is Your Life Insurance Policy Subject to ERISA?
    October 3, 2018
    You may think this is a ridiculous question; however, Plan Sponsors and employers may want to reconsider this inquiry in light of a recent Seventh Circuit ruling. The case, Cehovic-Dixneuf v. Wong (7th Cir. July 11, 2018), involved a dispute as to the true identity of the beneficiary of a life insurance policy. The defendants argued that the policy was NOT governed by ERISA, thus the policy was not the controlling document. However, the Court disagreed and explained that the life insurance policy was in fact subject to ERISA because it satisfied the five requirements outlined under ...
  • Communication Breakdown – More Lessons Learned from My Wife’s Battle Against Lymphoma
    October 1, 2018
    For those who did not tune into the “Empowering Plans” podcast, wherein I revealed why I’ve been absent from other recent Phia Group podcasts and webinars, please do check it out. In that recording, I describe my wife’s diagnosis (the specific type of Non-Hodgkin’s Lymphoma she’s fighting), and early lessons learned through her diagnosis. Key among them is the need for second (and even third opinions) to ensure the right diagnosis is ultimately achieved. I implore plan sponsors to pay for – and advocate for – second (and third) opinions. The funds expended on these ...
  • Wilderness Therapy Exclusions Causing Mental Health Parity Concerns
    September 26, 2018
    The plan exclusion of wilderness therapy has spurred some lawsuits over the past year. These lawsuits are based on alleged violations of the Mental Health Parity and Addiction Equity Act (MHPAEA). By way of background, the MHPAEA does not require that self-funded group health plans cover mental health or substance use disorder (MH/SUD) benefits, but if the plan chooses to cover those MH/SUD benefits then they must be covered in parity with the medical/surgical benefits. Among other items, pursuant to the MHPAEA, if a plan offers mental health and substance use disorder benefits in any classification, then those benefits ...
  • REMINDER: Medicare Part D Creditable Coverage Notices Due to Certain Employees by October 14th
    September 24, 2018
    Find out more about the Medicare coverage that is due to employees by October 14th. Do you deserve to be receiving these benefits? Click here to learn more.
  • 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.
  • Industry Trends & Demands- Alaska to Maine
    January 31, 2017
    This week I will be lucky enough to be a speaker at the Alaska Association of Health Underwriters Annual Expo in Anchorage, Alaska. It will be my privilege to spend time with this great group and focus on innovating in the self-funded space.
  • Billing Itemization Required?
    January 31, 2017
    Question: is a medical provider required to give an itemization as part of the billing? Answer: Generally no.
  • Beth Israel, Lahey in advanced merger talks
    January 30, 2017
    Beth Israel Deaconess Medical Center and Lahey Health have announced plans to combine forces for the fourth time, a move that would create an entity rivaling the size of Partners HealthCare.
  • What is ‘Repeal and Replace?’ A Guide to Trump’s Health Care Buzzwords
    January 30, 2017
    President Donald Trump and GOP lawmakers have yet to come up with a plan to repeal and replace the Affordable Care Act.
  • Innovation at Its Finest- Cash Only Payment Model
    January 30, 2017
    Read about Dr. Smith's journey to a cash-only payment model. Contact The Phia Group to find out how you can innovate and contain costs within your employee benefit plan.
  • A Personal Experience- Self-funded Employee Benefit Plan
    January 30, 2017
    The Phia Group’s self-funded employee benefit plan is not just the plan my employees are on, it’s the plan my wife, four kids, and I are on.
  • Concerns about Health Care Coverage Mandates
    January 27, 2017
    One of the biggest unknowns of the Trump Administration’s health policy priorities is whether or not the new administration plans to repeal the individual and employer mandate.
  • LOA = Continuation of Coverage, or does it? One of the “Gap Traps”
    January 27, 2017
    It’s intuitive to think that a leave of absence (LOA) from employment is coupled with a continuation of health plan coverage (CoC), especially if the leave is illness related
  • Egregious Billing Hits the Common Man – Who Now Has a Place to Vent Their Frustration
    January 26, 2017
    For those of us who are embedded in the health care industry, we know that the greatest issue with health care in America is the price tag.
  • Keeping the “Benefit” in Benefit Plans
    January 26, 2017
    Once upon a time, employers offered employees “benefit plans,” with an eye toward attracting and retaining a talented workforce. The word – benefit – literally means something good; positive; of added value.
  • The Big Elephant in the Room….
    January 26, 2017
    From day one, over 16 years ago, we have offered overpayment recovery services, but over the last year, I have seen the largest growth in this service.
  • HIPAA Special Enrollment vs. Section 125 Permitted Election Change – There is a difference!
    January 25, 2017
    An individual may want to adjust their health plan enrollment. For example, if a plan member’s spouse loses plan coverage due a reduction in hours it will likely trigger a HIPAA special enrollment under the health plan.
  • Want to improve health care? Focus on hospitals
    January 25, 2017
    As Congress and the Trump administration debate the future of America’s health care system they should go beyond the issues of access and cost and recognize an equally important priority
  • HHS nominee Dr. Tom Price’s 2nd confirmation hearing: 5 things to know
    January 25, 2017
    Rep. Tom Price, MD, R-Ga., faced another four hours of cross-examination Tuesday, this time with the Senate finance committee. Here are 5 things you need to know about the hearing.
  • Another Successful Balance Billing Negotiation
    January 25, 2017
    Phia received a $167,000 claim from a Surgery Center (Spinal Decompression) where a client tried to negotiate it on their own and were unsuccessful.
  • The Gap Trap
    January 24, 2017
    We work closely with some excellent carriers that look for reasons to pay claims and are a pleasure to interact with – but there are also carriers and MGUs out there that will do whatever they can to deny claims.
  • The ACA, a New Congress, and President Trump – Oh My….
    January 24, 2017
    On Friday January 20th, President Donald Trump signed his first executive order, directing agencies to give more leeway to the states in the way that states implement (“carry out”) the Affordable Care Act.
  • Attack on ERISA Preemption Continues…
    January 23, 2017
    ERISA preemption seems like such a simple concept; further proof that reasonable minds can disagree