By: Philip Qualo, J.D.
Before COVID-19 became a common household name, the United States was already in the midst of a mental health crisis. Rates of suicides and drug overdoses have been climbing in recent years; for example, in 2017, 17.3 million adults in the U.S. had at least one major depressive episode. This staggering figure is likely not even a true reflection, as studies show many people don’t seek treatment at all finding that stigma and shame keep 80% of people out of treatment. As the COVID-19 pandemic has consumed the nation, and the world, many of us are learning the hard way that life during a pandemic has even the most resilient of us drowning in unprecedented levels of stress. School and work closures, as well as stay-at-home orders, feel like they might stretch on for months. The volatile economy and sudden job losses have added a layer of financial insecurity that wasn’t a factor in people’s lives just a few weeks ago. Meanwhile, the rates of COVID-19 infections are rising exponentially, creating intense anxiety about what day-to-day activities are even safe. For those at highest risk of developing complications or already ill, there’s the fear of getting sick, or sicker. In the worst cases, there’s the grief of losing loved ones. The combination of these stressors are common triggers for mental health disturbances and substance abuse disorders.
COVID-19 hasn’t just disrupted our daily lives; it has also disrupted how our minds work. As stay-at-home orders remain in effect, people aren’t only isolated from care, but from each other. In the U.S., more than 25% of people live alone, and studies have linked loneliness to substance abuse and mood disorders. Others are stuck inside with abusive partners or are living in already strained relationships. Those managing addiction risk a potential relapse without access to in-person meetings or substance abuse rehabilitation services. Some will likely bounce back when life returns to normal, but for others, unmanaged stresses could lead to bigger problems down the line.
On the brighter side, the American Psychiatric Association finds video-based sessions “equivalent” to in-person care for diagnosis, treatment, quality, and patient satisfaction. Demand for telehealth mental services has already spiked. Talkspace, a text and video chat therapy service, has seen a 65% increase in customers since mid-February. Winsberg’s Brightside, an app that offers treatment and medication for anxiety and depression, has seen a 50% bump in new users since the start of the quarter. More than 50 companies have signed up or expanded their use of telehealth mental services, including big employers such as Nike and Target.
The federal government has also relaxed some of its previously restrictive privacy standards. In March, the Department of Health and Human Services issued guidance that it would not impose penalties for providers unable to comply with HIPAA privacy rules during the COVID-19 nationwide public-health emergency. That means, for the time being, therapists can conduct sessions using free and widely available services including FaceTime, Google Hangouts, or Skype, making those services much easier to access for those with the greatest need for it.
Much like we’ve seen elsewhere in the U.S. health-care system, the sudden and growing need for care has left mental health providers overwhelmed. The root of this problem is that there aren’t enough therapists to go around. Historically, practitioners could only serve patients in states where they were licensed, but states are rapidly working to relax those requirements to accommodate the influx of need. Each locality has its own licensing permissions, though, leaving telehealth mental service providers having to wade through a patchwork of regulations.
Even with the recent expansion of coverage for telehealth services, it is important to keep in mind that not all behavioral health issues can be addressed from afar, and people who need more hands-on treatment could fall through the cracks. Employers, however, can help to bridge this gap. One of the most important things employers can do is provide an employee assistance program (EAP) or ensure their employer-sponsored health plans offer mental health coverage. If an EAP is part of the benefits package, now is a good time to remind employees of the availability of such services. Companies should also consider compiling and distributing lists of available local mental health resources like therapists, psychiatrists, suicide hotlines, and even online meditation and yoga classes.
For businesses that are operating completely remote, regularly scheduled video meetings and virtual social events can also help to defray the mental challenges that accompany long periods of isolation. Even simply allowing employees the opportunity to talk about their concerns and emotions can help. As the nation comes together to contain the spread of COVID-19 and protect our physical health, it is equally as important we be cognizant of our mental health as well as support our peers who may be experiencing emotional and challenges with substance abuse in these challenging times.
If you or someone you know is struggling, contact the National Suicide Prevention Lifeline at 800 273-8255.
Together we are all enduring common trials. It is certainly one of the most difficult periods in our history – as an industry and as Americans; and yet, opportunities exist. Both presently, and heading down the pike, there are reasons for optimism. Join The Phia Group as they discuss the many GOOD and POSITIVE things that have both improved our industry since the end of 2019, and that are on the way. We will discuss opportunities that exist now, that are forthcoming, and why we foresee YOU flourishing post-COVID-19.
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Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo: From the Desk of the CEO
The world has changed for all of us, and we are all presently facing challenges and obstacles that none of us could have previously imagined. That being said, I’m not going to sit here in my basement office and cry a river. Instead, I see all of the amazing things that have happened over the past month. I see my kids as I teach them math, reading, and how to create anything that comes to their minds; (we are actually building a pretty awesome fort in the backyard). I see my Phia Group team members and their children during our weekly video calls, and my determination to ensure that we suffer no layoffs is renewed. I see the opportunities ahead of us, as a company, an industry, and as a nation.
I see what we can do as colleagues and as friends to emerge even stronger, blazing a path to an improved future. This experience will forever change us, but I choose to see how that change can be for the better. I do know that my Phia family has shown exceptional resilience and grown stronger through this ordeal - our employees believe in each other and our collective future is bright. I hope that our webinars, podcasts and articles have helped you and your clients do the same in these bizarre times. We are here for you. Be well, and stay in touch.
Service Focus of the Quarter: Phia Unwrapped Phia Fit to Print From the Blogosphere Webinars Podcasts The Phia Group’s 2020 Charity The Stacks Employee of the Quarter Phia News
Enhancement of the Quarter: Subrogation Value Reports
To the Phia Group’s valued recovery clients: rejoice! We have supplemented our already-extensive reporting suite to provide you with a brand new report. The Value Report is a new activity report that highlights recovery benchmarks for a particular group, or across your entire block. This report will provide the user with an easy-to-read summary of how much money The Phia Group has recovered for the client health plans, on a quarterly or yearly basis. The Value Report also contains metrics comparing this performance to The Phia Group’s entire book of business.
This new report presents as a clean, readable PDF; it can be run on-demand and is designed to give a comprehensive summary of the most valuable performance metrics, which can be an important retention and marketing tool for any user!
The Value Report will be added to our client-ready Tableau reporting suite, so recovery clients can run them as needed – and as with all our reports, they will be accurate as of the minute they were run.
Phia’s Latest Hire – Rebekah McGuire Dye, J.D.
Rebekah McGuire Dye was recently hired as the new Vice President of Client Solutions and Account Management with the Phia Group. Ms. Dye is leading the Phia Group’s client care service to the highest level of concierge client service ever established in the cost containment industry.
As a partner to clients’ senior leadership, Ms. Dye and her accomplished team provide an authentic level of customer caring to ensure every aspect of the Phia – client relationship is positive, productive and genuine.
Ms. Dye comes from a 25-year career with the largest cost containment provider in the industry. During her tenured career she has served over 150 health benefit providers in roles ranging from front line file handler to Group Vice President overseeing all Commercial subrogation operations for over 20 million benefit recipient lives. Her lengthy cost containment career, while focused on the Health Care line of business, also includes expertise in both Disability and Property & Casualty subrogation matters.
Ms. Dye is an active member of both IDS and NASP. You can find several published articles by Ms. Dye in the NASP Subrogator magazine and she is a frequent subject matter expert speaker on recovery matters.
While not pursuing cost containment endeavors, she is an avid reader, nature lover and family-centered person residing in rural Kentucky. Her favorite stewardship is serving as an elected member of the Nelson County Kentucky school board. Her passion for education and children make her an invaluable member of the Board.
Service Focus of the Quarter: Phia Unwrapped
Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited billing rights. With Phia Unwrapped, The Phia Group replaces wrap network access and modifies non-network payment methodologies, securing payable amounts that are unbeatably low, based upon fair market parameters.
Phia Unwrapped places no minimum threshold on claims to be repriced or potential balance billing to be negotiated. Additionally, The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full. – and if there’s pushback or balance-billing, our Provider Relations team is ready to handle it.
Phia Unwrapped implementation entails setting up an EDI feed with the claims administrator, so claims are flagged, transferred, and repriced automatically. Phia Unwrapped is billed based on a percent of actual savings, leading to fair rates and no excessive costs for unprecedented savings.
Out-of-network claims run through The Phia Group's Unwrapped program yielded an average savings of 74% off billed charges (three times the average wrap discount). On average, The Phia Group sees roughly 2% of claims result in some form of balance-billing; these results are similar throughout many different plan types and geographies, proving that this program and these results can be replicated nationwide.
Contact our Vice President of Sales and Marketing, attorney Tim Callender, to learn more about Phia Unwrapped. Tim can be reached by phone at 781-535-5631 or by email at TCallender@phiagroup.com.
New Service Offered by Phia: Patient Defender
The Phia Group is proud to introduce its “Patient Defender” program. For a small PEPM fee, every plan participant has access to legal representation against lawsuits targeting patients, or crippling balances being sent to collections, when efforts to amicably resolve these disputes fail, Patient Defender is the ultimate weapon in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by these increasingly aggressive tactics, Patient Defender will be there.
Patient Defender finally plugs the gap that has existed across the industry in relation to reference-based pricing programs and balance billing concerns. With Patient Defender, a small PEPM rate ensures that a trusted law firm is placed on retainer, ready and willing to assist the patient when balance-billing occurs. Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.
To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or tcallender@phiagroup.com. Success Story of the Quarter: Managing COVID-19
We have all heard enough about COVID-19 to last a lifetime, but in this difficult time, this quarter’s success story is designed to thank you for your contribution to stopping the spread of the virus.
We have been asked – or ordered – by our various governments to practice social distancing, or even true quarantining. This is neither easy nor convenient; the economy is suffering and many are getting laid off from their jobs, but humans are facing a dangerous threat against which we must unite.
This success story is ongoing. The Phia Group has committed to enabling all employees to work remotely to avoid the need to congregate in an office, to ensure that our valued clients and the industry can keep functioning as normally as possible, and we thank you for whatever actions you have taken to help stop the spread of the COVID-19 virus.
We wish you all good health.
Phia Case Study: Outpatient Detox Negotiation
A health plan utilized the Phia Unwrapped service, allowing out-of-network claims at the rate of 150% of Medicare. This plan did not use a large national network, but instead used a narrow, regional network (which was less expensive and yielded better discounts, since each provider was afforded greater steerage).
One particular out-of-network substance abuse provider billed $2,900 per day for outpatient detox, which is many times what Medicare would allow. The plan’s TPA had tried to secure a direct contract multiple times, but each time the provider stalled the conversation, and once the statutory timeframe to pay was about to toll, the provider denied the attempts to contract and forced the plan to pay the claim or watch its member be balance-billed.
When the matter was escalated to The Phia Group, the Provider Relations team leveraged certain data as well as innovative arguments and tactics to yield a result where the provider agreed to a flat fee of 175% of Medicare per day.
In just the first few weeks since this negotiation was finalized, the plan has already saved over $22,000.
Fiduciary Burden of the Quarter: The Black Box
Whether it’s Usual and Customary, Maximum Allowable Charge, billed charges (GASP – why?!) or a network rate, or something else entirely, health plans obviously need to pay some amount for claims. That much is obvious. What is not so obvious, however, is how some plans and administrators come up with these amounts. We have seen many instances of the “black box” approach, where a number goes in one side and another number comes out the other, with no indication of how that repricing was performed; what’s worse is when neither the SPD nor the EOB provides any indication of what the repricing is based on.
New York, for one, has historically taken issue with this approach. ERISA favors extreme transparency, as do state laws. ERISA provides a self-funded health plan with an extremely wide latitude to structure benefits however it chooses, as long as the plan explains what it’s going to do.
The Phia Group is proud to introduce its “Patient Defender” program. For a PEPM fee, every plan participant has access to legal representation against collections lawsuits or crippling balances being sent to collections before legal action ensues. Patient Defender is a key tool in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by aggressive tactics, Patient Defender will be there.
To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or tcallender@phiagroup.com.
Phia Fit to Print:
• BenefitsPro – Expanded paid sick leave requirements under the Families First Coronavirus Response Act – March 17, 2020 • Self-Insurers Publishing Corp. – Utah Goes To Mexico - A First For The Drug Importation – March 3, 2020 • BenefitsPro – The 'cost of care' contradiction – February 25, 2020 • Self-Insurers Publishing Corp. – A Case Study In Savings: How The Phia Group is Offering Employees Free Healthcare – February 6, 2020 • BenefitsPro – Changing perceptions of health benefits, one pregnancy at a time – February 4, 2020 • BenefitsPro – California’s new FSA notice requirement not so clear – January 14, 2020 Back to top ^
From the Blogosphere:
• EMPLOYERS BEWARE: Handling Employee Absences Resulting from Coronavirus Quarantine. Facts you should know about this pandemic.
• New Insight on Provider Surprise Billing. These state-based laws have limited applicability.
• I Got a Fever, and the Only Prescription is More Transparency. Another transparency-minded federal rule is getting some push back.
• “Incur”-aging a Review of the Term “Incurred.” Make sure you know the meaning of this word when it comes to your plan documents and stop-loss policies!
• What Happens to a Health Plan during a Merger or Acquisition? There are typically three types of transactions when it comes to mergers and acquisitions.
To stay up to date on other industry news, please visit our blog.
Back to top ^
Webinars
• On March 30, 2020, The Phia Group presented, “COVID-19: The CARES Act & Workplace Safety FAQs,” where we discussed the impact of this historic federal legislation on our industry and answer your questions about workplace safety.
• On March 23, 2020, The Phia Group presented, “Special Edition - The Phia Group and COVID-19 FAQs Answered,” where we addressed the COVID-19 pandemic and the industry's most frequently asked questions.
• On March 10, 2020, The Phia Group presented, “The Top 10 of 2020: Cost Containment Measures to Implement Right Now,” where we discussed the cost-containment measures they encounter most frequently, and tell some success stories, some horror stories, and how you can make the best decisions for your clients’ bank accounts.
• On February 12, 2020, The Phia Group presented, “Double Dose: Revisiting Rx Drugs and Answering Your Questions,” where we took a deeper dive on the topic of Rx drugs, tackle the difficult questions asked in last month’s webinar, and help plans protect themselves while staying ahead of the curve.
• On January 21, 2020, The Phia Group presented, “A Dose of Savings – Addressing Drugs, PBMs, and the Controversies Surrounding Them,” where we discussed the Rx trends to watch for, the biggest threats to health plans, cost-containment strategies to implement, political efforts underway, and an injection of information you can’t do without.
Be sure to check out all of our past webinars!
Podcasts:
Empowering Plans • On March 31, 2020, The Phia Group presented, “COVID-19: Provider & State Impact,” where our hosts, Kelly Dempsey and Brady Bizarro discuss the unique responses we have seen from individual states and providers while evaluating their impact on the self-funded industry.
• On March 19, 2020, The Phia Group presented, “COVID-19: Latest Updates & Legislation,” where our hosts, Ron Peck and Brady Bizarro discuss the latest developments related to COVID-19, the impact on the self-funded industry, and review the contours of the Families First Coronavirus Response Act, which guarantees free coronavirus testing for all Americans as well as an expansion of paid sick days for a subset of workers.
• On March 11, 2020, The Phia Group presented, “COVID-19 Preparedness: What Self-Funded Plans Should Be Doing Right Now,” where our hosts, Brady Bizarro and Jennifer McCormick discuss the recent outbreak of COVID-19 (coronavirus), and provide insight into how you should be preparing, what concerns you should have about your benefits documents, and how to navigate applicable law.
• On March 6, 2020, The Phia Group presented, “Debating the Debates,” where our hosts, Ron Peck and Brady Bizarro assess candidates’ (and EX-candidate’s) proposals, and what it all means for our industry.
• On January 31, 2020, The Phia Group presented, “Care Where? Care Everywhere!,” where our hosts, Adam Russo and Ron Peck interview industry legend, Ernie Clevenger, regarding CareHere, LLC, the future of consumer-centric medicine, technology – and most importantly – the MyHealthGuide newsletter!
• On January 24, 2020, The Phia Group presented, “Taking the Stage in 2020,” where our hosts, Ron Peck and Brady Bizarro discuss the first Democratic debate of 2020 and the latest ruling from a federal appeals court on Obamacare.
• On January 3, 2020, The Phia Group presented, “Free Health Benefits at Phia,” where our hosts, Adam Russo and Ron Peck discuss the different tactics used to offer Phia's employees FREE health benefits!
Be sure to check out all of our latest podcasts!
The Phia Group’s 2020 Charity
At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us. The Phia Group's 2020 charity is the Boys & Girls Club of Metro South.
The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.
The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8-18, signed up as club members. In the 25 years since, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club. Since their founding, more than 20,000 Brockton youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.
Youth of the Year
Each year, the Boys & Girls Clubs of Metro South holds a competition to award the most prestigious honor that a teenager can receive as a member of their local Boys & Girls Club. The Youth of the Year award is the Boys & Girls Club signature effort to foster a new generation of leaders, fully prepared to live and lead in a diverse, global and integrated world economy.
One of these lucky kids will be awarded a $5,000 scholarship and a new laptop, courtesy of The Phia Group. Good luck to all of these amazing students and we wish you the very best in your future endeavors!
The Stacks
Utah Goes To Mexico - A First For The Drug Importation
By: Brady Bizarro, Esq. – March 2020- Self-Insurers Publishing Corp.
Much ink has been spilled about prescription drug importation as a strategy for combating America’s exorbitant drug prices. Despite this practice being technically illegal, many self-funded plans have engaged in it for years without facing any repercussions. With Congress and the Trump administration still unable to agree on a drug pricing reform bill, these programs will almost certainly become more widespread. As they proliferate, they are likely to attract more scrutiny from the Food and Drug Administration (“FDA”), which, although it has rarely enforced the law in this area, has recently taken action against vendors engaged in drug importation. One large insurer, the state of Utah, has become the first to deliberately adopt a type of drug importation program which is much less likely to attract the attention of the FDA and might serve as a roadmap for other self-funded plans in search of relief.
Click here to read the rest of this article
A Case Study In Savings: How The Phia Group is Offering Employees Free Healthcare
By: Philip Qualo, J.D. – February 2020 – Self-Insurers Publishing Corp.
The Founder and Chief Executive Officer (CEO) of The Phia Group, LLC, Adam V. Russo, Esq., made an announcement at our most recent Christmas party that caused a reaction that could be heard all throughout the New England region. An overwhelming explosion of applauses, screams, and in some cases, tears and sobs, shook the entire venue as the CEO described a major milestone that made Phia history. What was this groundbreaking announcement? The Phia Group has joined the ranks of only a handful of employers in the United States that offers free healthcare… yes… FREE… healthcare coverage to their employees! Despite astronomical increases in healthcare and prescription drug costs throughout the nation, and soaring insurance premiums, Phia now offers free healthcare coverage to all employees who have been enrolled in the group health plan for a period of time. We did this without raising out-of-pocket costs or employee contributions!
To stay up to date on other industry news, please visit our blog. Back to top ^
Get to Know Our Employee of the Quarter: Cindy Monfils
In addition to her daily tasks, Cindy has been coming into the office to handle all faxes & outgoing mail to ensure the company is functioning as normal. In addition to helping with the annual Phia Forum, she helps to manage all aspects of The Phia Group’s office. Cindy comes in on weekends and helps with other tasks such as painting and putting together chairs. Cindy goes out of her way to make Phia a great place to work. She is a phenomenal asset to the company, and The Phia Group’s transition into working remotely would not have gone so seamlessly if it weren’t for her.
Congratulations Cindy, and thank you for your many current and future contributions.
Phia News
Celebrating 20 Years of Empowering Plans!
On February 10, 2020, The Phia Group celebrated 20 years of being in business! The Phia Group was founded in Adam Russo’s basement in February of 2000. Since that time the company has grown beyond any dream that Adam could have imagined. It is hard to believe how fast 20 years have passed, but we are looking forward to many more years of success!
The PACE Certification program will educate you using 3 distinct chapters of information:
Chapter One Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.
Chapter Two Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals. Chapter Three Explains what PACE is, what PACE does, and how it's obtained, implemented, and utilized.
The PACE Certification Program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.
Additionally, the PACE Certification program provides education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.
Please see the PACE Certification flyer, as well as this video for more information.
Please contact Michael Vaz (mvaz@phiagroup.com) for more information.
Job Opportunities:
• Plan Drafter
• Case Investigator
• Claim Recovery Specialist III
• Consulting Attorney
• Claim and Case Support Analyst
See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers
Promotions • Zachariah John has been promoted from Manager, Applications Development to Sr. Manager, Applications Development
• Igor Senic has been promoted from Accounting Administrator to Senior Accounting Administrator • Ulyana Bevilacqua has been promoted from Supervisor, PGC to Manager, Drafting Services
• Andrew Fine has been promoted from Intake Specialist to Team Lead, Intake
• Cara Carll has been promoted from Manager of Claim Evaluation to Manager of Claim & Case Support
• Lisa Decristoforo has been promoted from Team Lead of Case Evaluation to Team Lead of Case Evaluation and Customer Service
• Ashley Hoey has been promoted from Team Lead of Customer Service & Claim Analysis to Team Lead of Claim Analysis and Claim & Case Support
• Kelly Dempsey has been promoted from Director, Consulting and ICE Services to Vice President, Consulting
• Kelsey Dillon has been promoted from Claim and Case Support Analyst to Senior Claim & Case Support Analyst
• Ulyana Bevilacqua has been promoted from Supervisor, Drafting Services to Manager, Drafting Services
• Lauren Radley has been promoted from Manager, Drafting Services to Director, Drafting Services
New Hires • Rebekah McGuire-Dye was hired as the VP, Client Solutions and Account Management
• Josh Jones was hired as a Claim Recovery Specialist IV - BI
• Timothy Pope was hired as a Provider Relations Attorney
• Jessica Riley was hired as a Sr. Administrative Assistant
• Hollan Holm was hired as an Attorney I
• Laura Pickett was hired as a Sr. Claims Recovery Specialist
• Julia Goyette was hired as a Legal Intern
• Nick Frederick was hired as a Claim Recovery Specialist IV - BI
• Daniel Scalzi was hired as a Case Investigator I
• Brad Tramontozzi was hired as a Manager of Talent Acquisition
• Kori Watkins was hired as a VP, Project Management Offices (PMO)
• Mitch Hilbert was hired as a Claims Specialist, Provider Relations
• Larry Moffett was hired as a Claims Specialist, Provider Relations
• Jessica Dunn was hired as a Plan Drafter
Superbowl Festivities
The Phia family held its famous Superbowl Sunday pride party the week before Superbowl Sunday, and we had a great turnout this year! With all of the great gear, our Phia family wore this year, we got a great picture that you can check out below. Congratulations to the Kansas City Chiefs on their big win!
Candy Heart Contest
We set up a little contest at the front desk for Valentine's Day and asked everyone to guess how many candy hearts were in the jar! The winner was Samantha Cox with a guess of 258 candy hearts. There were a total of 267 candy hearts in the jar. It’s hard to believe that all of those pieces of candy fit into that tiny jar!
By: Kevin Brady, Esq.
The national shift to social distancing has effectively changed the way almost all of us go to work. For some, rather than physically report to an office, we simply wake up (hopefully followed by some coffee), and get the day going. The daily “Good Morning” from a coworker is sent over skype, the “Boomers” are now masterful “Zoomers”, and many talented folks juggle the full-time job of parenting while somehow managing their full-time work responsibilities each day. For some (very brave) others, such as nurses and grocery store employees, the way they report to work may not have necessarily changed, but the workplace they go to has taken on an entirely new light.
While it has been a significant shift, those who are able to work remotely are certainly lucky to have the opportunity to do so. Shelter-in-place orders, albeit an absolutely necessary measure to flatten the curve of COVID-19, have had a significant impact on how people work and has unfortunately resulted in a lack of “work” for many.
In an effort to protect employees during these difficult economic times, The Families First Coronavirus Response Act (FFCRA) was signed into law. The new law provides new paid leave entitlements intended to protect employees who are directly impacted by COVID-19. The Emergency Paid Sick Leave Act for example, requires employers to provide up to 80 hours of paid leave when employees go on leave due to certain qualifying circumstances, such as experiencing symptoms of COVID-19 or being advised by a healthcare provider to self-quarantine, among others. One particular circumstance, which has caused a rash of confusion between employers and employees alike, relates to shelter-in-place orders. Under the EPSLA, employees who are unable to work as a result of a federal, state, or local quarantine order are entitled to emergency paid sick leave.
As Congress expedited the drafting, and passing, of the FFCRA, some of its provisions were quite confusing and required further clarification to comprehend the intent behind the language. Luckily, the U.S. Department of Labor (DOL) has issued guidance to help clarify some of the confusion surrounding the EPSLA in particular. The guidance provides that individuals unable to work as a result of a shelter-in-place order are only entitled to leave if they are 1) actually unable to work or telework (meaning they cannot leave their homes to travel to the workplace and cannot telework because of the nature of the position or the required access to technology) and 2) that the employer actually has work for that individual to do (the business operations have continued and the employer has work to be done by the employee). While this application of the law may seem obvious, it is actually quite nuanced and difficult to determine whether an employee is actually eligible for paid leave, and possible even more difficult to determine what their rate of pay should be during said leave. For more information on these nuanced questions, see the DOL’s FAQ page.
As the COVID-19 situation continues to develop, we anticipate that further guidance on how these entitlements are meant to apply will be issued; the DOL has already updated the FAQ portion of their website several times since the FFCRA’s enactment. Given that the situation is fluid and that it is unclear what, if any, steps will be taken next to protect the economy and the workforce, we are interested to see how leave entitlements under the FFCRA will be applied in practice.
Join Attorneys Brady Bizarro and Jennifer McCormick as they discuss some of the latest studies on the potential cost of COVID-19 treatment for self-funded plans, the projected impact on employer-sponsored insurance, and how they think this pandemic could change the industry.
Click here to check out the podcast! (Make sure you subscribe to our YouTube and iTunes Channels!)
By: Jen McCormick, Esq.
COVID-19 has impacted most aspects of our lives, and the lives of our families. From a healthcare perspective, we want to do all we can to protect our families from the virus. In most cases this means that households where both parents work outside the home and children attend school or daycare are now all confined to their homes… every day. We do this in hopes of keeping the children and ourselves safe. Being confined to our homes, however, can be challenging in many ways.
For families where being home is the exception over the rule this has been an adjustment. We are forced to redefine our roles as co-workers, parents, and spouses to find the perfect work-home balance, all while at home. Dealing with this new normal is hard, and certainly pays a toll on our mental health. Mindful of this extra stress for many, plans and employers should consider additional ways to help.
Consider ways the parent can use their health plan, for example, does the employer health plan cover telehealth? Is this available for mental health as well? The option to contact a doctor over the phone would make receiving care easier for many. A waiver of the copay or deductible would make this even more attractive, and likely provide many benefits for the individual, their family, and work productivity.
Another consideration would be how employers are actively trying to stay engaged by using video chat features, hosting virtual happy hours, or playing virtual games. By setting up meetups it’s a way to remain connected while still maintaining distance. No effort is unnoticed in this particularly challenging time and even a ‘how are you doing’ could make a big difference for a struggling parent.
By: Jon Jablon, Esq.
The CARES Act is brand new, obviously, but its treatment of the relationship between medical providers and health plans is anything but. As with just about all legislation to date on the topic of payor-provider relations, the legislature has not hesitated to essentially give all the power to the providers. The bill includes the following provisions:
SEC. 3202. PRICING OF DIAGNOSTIC TESTING.
(a) Reimbursement Rates.—A group health plan or a health insurance issuer providing coverage of items and services described in section 6001(a) of division F of the Families First Coronavirus Response Act (Public Law 116–127) with respect to an enrollee shall reimburse the provider of the diagnostic testing as follows:
(1) If the health plan or issuer has a negotiated rate with such provider in effect before the public health emergency declared under section 319 of the Public Health Service Act (42 U.S.C. 247d), such negotiated rate shall apply throughout the period of such declaration.
(2) If the health plan or issuer does not have a negotiated rate with such provider, such plan or issuer shall reimburse the provider in an amount that equals the cash price for such service as listed by the provider on a public internet website, or such plan or issuer may negotiate a rate with such provider for less than such cash price.
If there is a negotiated rate between the payor and provider, then the payor must pay that rate. If, however, there is no previously-negotiated rate, then the payor and provider can either elect to negotiate a rate (on a case-by-case basis, or globally – same as any other payment contract), or, if negotiation is not possible or not successful, the plan is required to simply pay the provider whatever price the provider has identified on its website. In other words, the plan must pay a negotiated rate, if there is one, but if not, the plan must pay whatever the provider demands.
Even in this time of near-universal employer financial hardship, the legislature has been very careful to not give a damn about the costs incurred by health plans – including self-funded employer-sponsored plans, many of which are struggling small businesses. It will never cease to amaze me.
Interestingly, the section of the bill immediately following the one quoted above reads:
(b) Requirement To Publicize Cash Price For Diagnostic Testing For COVID–19.—
(1) IN GENERAL.—During the emergency period declared under section 319 of the Public Health Service Act (42 U.S.C. 247d), each provider of a diagnostic test for COVID–19 shall make public the cash price for such test on a public internet website of such provider.
(2) CIVIL MONETARY PENALTIES.—The Secretary of Health and Human Services may impose a civil monetary penalty on any provider of a diagnostic test for COVID–19 that is not in compliance with paragraph (1) and has not completed a corrective action plan to comply with the requirements of such paragraph, in an amount not to exceed $300 per day that the violation is ongoing.
So, the law requires payment of either a negotiated rate or the provider’s published rate – and the same law requires the provider to publish its rate. But what if it doesn’t, or what if the particular provider doesn’t maintain a website at all, as many smaller offices don’t? Health plans should be wary about what happens in the event the provider fails to “make public the cash price for such test on a public internet website.” It’s tempting to take the “you didn’t comply, so if you don’t negotiate a reasonable rate, we’ll report you” approach – but some consider that at least extortion-adjacent. Instead, a good practice may be to simply inform the provider – if it hasn’t posted a price – that there is no option but to negotiate, and make sure you’re armed with reasoning for what you should reasonably be paying.
One thing is clear, though: RBP plans will need to be careful here, since the legislature’s primary aim seems to be that patients do not get balance-billed for COVID-19 testing. The traditional RBP approach, then – where the Plan determines its pricing and then pays its minimum to the provider – is not going to be a viable option under the current state of the CARES Act. If there’s no pre-negotiated rate with the provider, the Plan must pay the provider’s published rate, or negotiate on the spot – but we strongly caution all health plans against creating a situation in which balance-billing is even a possibility.
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