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Phia Group Media


Empowering Plans Segment 08 - Healthcares? Alternative Provider Payment Programs
The Phia Group’s CEO, Adam Russo, and Sr. VP & General Counsel, Ron Peck, discuss movements within the healthcare provider community to change how they charge (and receive payment) for services rendered.  For better or worse, change is on the way!

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Keeping PACE with Appeals, Trends and Fiduciary Responsibility
As TPAs, consultants, and Plan Sponsors utilizing The Phia Group's Plan Appointed Claim Evaluator service, you are entitled to exclusive educational material. Join The Phia Group's PACE legal team as they provide insight drawn from within the past 2 years of the PACE service.

During this webinar, you will be provided an insider's view into the latest health plan appeals trends, plan document best practices related to appeals and fiduciary concerns, as well as an update on the current, fiduciary landscape.

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It's Never Too Soon
By: Jen McCormick, Esq.

Although the regulations may change, it's important to begin thinking about plan changes for the upcoming plan year.  The specifics for compliance requirements may still be unclear, employers should already be in process of contemplating cost containment updates.

There are many ways to add value to an employee health benefit plan. An employer should perform an annual review of their plan to confirm that the plan takes advantage of as many cost containment opportunities as possible. For example, does the plan have strong third party recovery language? Overpayments language? Clearly defined terms? Appropriate definitions? Vendor program with corresponding language? If not, the plan should be cognizant of what's missing or not working, so updates can be made.

In addition to cost containment, and while some rules are in flux, there are many regulatory requirements a plan must be aware of and having corresponding language. For example, is the employer subject to ACA Section 1557? Employer Mandate? Does the plan comply with the MHPAEA? Did the plan pick a benchmark for defining essential health benefits? With all the regulatory changes, plans should stay alert and ready to make renewal modifications.

Last, but definitely not least, employers should ask their employees to weigh in on the plan. Remember it's an employee benefit to offer coverage - so employers should be offering beneficial coverage.  For example, is there a specific service that many employees wish was covered? Could that be added to the plan? Is there a trend in services for employees for which you may want to offer an incentive?  Being self funded allows you to be creative - take advantage!

Plans have freedom to design benefits to suit their needs. With this privilege comes the need to plan ahead and be creative.  Employers should be proactive and ensure this opportunity to annually update the plan design is taken seriously!


Decisions, Decisions: Which Plan Types Work Best for Which Groups, and Why?
Between a traditional PPO plan, a MEC or “skinny” plan, reference-based pricing, narrow network, cafeteria plan, or high-deductible health plan, who can choose? They all have their nuances, and which plan type is best for a given plan sponsor will depend on factors including risk tolerance, geographical location, employee base, and more.

Thank you for joining The Phia Group’s legal team on Tuesday, May 16, as they discussed the different plan options available to plan sponsors these days – including benefits, dangers, best practices, stop-loss and network considerations, and the future.

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Dear Stop-Loss: A Ballad
By: Jon Jablon, Esq.

Author’s Note: Written in ballad meter, this can be sung to the tune of “Gilligan’s Island.”

You carriers are sometimes great,
all flexible and fair;    
But sometimes you issue denials
That make me lose my hair.

Prevailing charge in the area
is what the policy allows;
Yet when presented with a claim,
some of you break your vows.

An auditor has been brought in
to reprice the group’s claim
based on Medicare or cost…
But carriers: for shame!

The promise to strictly abide
by the policy
goes out the window, and quickly
becomes a fallacy.

Each and every claim that’s denied
must be supported by
the policy your groups have bought
when they did apply.

All carriers must use good faith
in everything they do;
making things up as you go
is legally taboo.

To cap your risk with those objective
methodologies,
make sure you always use good faith…
Revise your policies!

When an employer signs with you,
you’re expected to pay out
benefits you have promised
in the policies you tout.

The whole entire industry
is worse-off when you fail
to follow your own written rules;
in court, you won’t prevail.

The Phia Group is here to help
all those who have been harmed;
info@phiagroup.com...
You’ll never be unarmed.

You Are Not Going to Sue Us, Are You?
By: Jason Davis

…is what a nice lady asked me when we were discussing the charges her office submitted for drug addiction treatments. You see, this office billed $3,800.00 per day for inpatient detox, and separately, under a different corporate name (but same billing office), they billed our client for drug screenings at a whopping $4,000.00 per screen – with one screen performed per day.

Our communication with their office (written and sent by one of our attorneys) was stern but professional; we seriously questioned the propriety of those charges and made it clear that our client would not pay for them since they are considered part of the per diem for detox.  

“You are not going to sue us, are you?”  They were worried about a class action.  Think about that.  The provider representative’s guilty conscience was palpable.  We settled the claims at a small percentage above the Medicare equivalent rate, and we closed the account...no lawsuit needed.  Everyone walked away happy.

We are seeing more and more of these types of billing practices sprouting up in sunbelt regions.  

Treating addiction is a serious issue, and I am absolutely not diminishing the need for this type of service. In fact, I am married to a family and marriage therapist, so I understand mental health issues better than most.  That said, it is somewhat ironic that this particular example is of addiction claims, as it would seem that such high billed charges and ridiculous margins are a serious form of corporate addiction within the provider community. Effectively, we have addicts treating addicts.

If you have claims from providers that are “getting high”… let us know. We can help.  


Empowering Plans Segment 07 - The American Health Care Act
Repeal and replace, the ACA, the AHCA - what does it all mean? How does it affect us? What’s next? Join The Phia Group's CEO, Adam V. Russo, Sr. VP, Ron E. Peck, and Attorney Brady Bizarro as they discuss the American Health Care Act, which passed the House of Representatives on 05/04/2017.

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Adam’s Key Takeaway from the 2017 MassAHU Benefest Conference
By: Adam Russo, Esq.

I spoke at the 2017 MassAHU Benefest Conference today in Westborough, MA, where I was lucky enough to see 9 of the CEOs for the various insurance carriers in our state.  I was pleasantly surprised to hear what they had to say.  They not only talked about transparency needs and the fact that pharmacy costs are out of control, many of them actually stated that we need to increase the incentives that we offer employees and members, in order to get them to care about the cost of care.  

This wasn’t just some vendor saying this, or a self-funded employer, these were actual carriers who said the word “empower”.  We do need to empower our plans and their employees to care about the actual cost of care, and the best way to do this is through real and valuable incentives – not just some small co-pay differential.  This is what The Phia Group has been preaching for years.  Words are a great start - so let’s hope for some action!

A Call for Defensive Legislation
By: Brady Bizarro, Esq.

On April 5th, the House of Representatives passed the Self-Insurance Protection Act (SIPA; H.R. 1304) by a vote of 400 to 16. This was the third iteration of this bill, originally introduced at the suggestion of the Self-Insurance Institute of America (“SIIA”). This legislation is very important for our industry because it blocks federal efforts to regulate small stop-loss plans as health insurance by excluding the plans from the federal definition of “health insurance coverage.” If you were struggling to think of a federal law which redefines stop-loss as health insurance, that is okay. There is no such federal law on the books. Indeed, there has been no legislative proposal at the federal level to redefine stop-loss insurance in this way. This was defensive legislation, designed to ensure that federal regulators do not try to redefine stop-loss insurance. State legislatures around the country should take notice of this approach before it’s too late.

At the state level, we have already seen numerous efforts (often successful) at redefining stop-loss insurance or placing restrictions on coverage. Why are states pushing this kind of legislation? One development that added fuel to the fire was the U.S. Department of Labor’s Technical Release on November 6, 2014. It expressed the opinion that states should not be concerned that stop-loss regulation restricting policies based on attachment points would be preempted by the Employee Retirement Income Security Act (“ERISA”). Since that time, we have seen efforts to restrict stop-loss coverage in California, the District of Columbia, Maryland, New York, New Mexico, Florida, Delaware, Washington, Connecticut, and Utah.

In states where restrictions have not been put in place, or where the restrictions are not severe, employers and insurers alike should be pushing for defensive legislation to reaffirm that stop-loss insurance is not health insurance.

Words with No Meaning...
By: Chris Aguiar, Esq.

Google “average words spoken per day” and you might see some interesting entries – such as, men use 7,000 words a day on average, as compared to women’s 20,000.  When deciding what to write about today – it struck me that so much of my day handling issues on behalf of the benefit plans I represent have to do with words; which ones are used, the context in which they are used, and what they mean.  When having discussions with the Phia Team, we always find ourselves asking, “what does that mean”?  That’s because so much of the law, especially in health plan law, rests on just how clear the terms of the Plan are.  It’s important that everyone be on the same page.  When someone uses the word “normal”, everyone thinks they know what that means – but in reality, it means something slightly different to everyone.  Norms are subjective, so use of the word isn’t necessarily sending the same message universally.  When viewed that way, of course there are misunderstandings.

This whole line of thinking stemmed from a subrogation investigation I was involved in a few weeks ago.  Interestingly, it wasn’t on behalf of a client - I was involved in it for my sister.  My sister fell down the stairs at home and sprained her ankle– and of course, she received an accident questionnaire; naturally, she called me and the following conversation ensued:

… Cell phone rings …

Sister: Hi Chris, I got a letter from my insurance company asking about my ankle.  Isn’t this what you do for a living?

Me:  Yes, it is.  What do you need?

Sister:  Why are they asking me this?

Me:  … Gives long detailed explanation about subrogation and why the insurance company would be asking this question… (Omitted in the interests of brevity)

Sister:  I don’t want to deal with this, what do I do?

Me:  Put that you fell at home and let’s see if they ask any more questions.

As it turns out, the insurance company didn’t ask any more questions.  You might be thinking, “of course they didn’t, Chris – your sister fell at home”.  Well, that’s only partly true.  See, to my sister she was “home” but as far as the insurance company is concerned, she wasn’t.  That’s because my sister doesn’t own her home – she lives in the 2nd floor walk-up apartment owned by my immigrant parents.  Technically, she could bring a claim against my parents and as we know, so could the insurance company.  See “home” is another word on a list of words I call “words with no meaning.”  “Home” is where you lay your head at night, but depending on the context in which it’s being used – it isn’t necessarily something you own, and that has implications on a subrogation investigation.

But I knew what any good subrogation investigator knows – and that is that most of the time, the insurance company will get an accident letter that reads “fell at home” and they close the investigation without further research.  It may not have been a lot of money, but for my immigrant parents, it was a headache I didn’t want them to have to deal with, and it was definitely a lost recovery opportunity for the insurance company.  If you just take the words that people say at face value, you may misunderstand what they actually mean because the fact of the matter is, you have a different idea in your head of what was meant when they used certain words.  Whether it’s in your everyday conversations or in the terms of an employee benefit plan – make sure you say what you mean and you mean what you say.  In your day to day life, it most often leads to minor misunderstandings and maybe some hurt feelings, but in the world of health benefits, it could lead to lengthy legal disputes and significant losses in Plan assets.