By: Kevin Brady, Esq.
In May of this year, the Federal Drug Administration (FDA) approved the most expensive drug in the world, Zolgensma. The drug was developed by Swiss drug maker, Novartis, and costs $2.1 million for the one-time single dose. The drug maker will spread the burden of the high cost by allocating payments for the drug over a 5- year plan at $425,000 a year.
Zolgensma is a new gene therapy drug used to treat spinal muscular atrophy (SMA). SMA is a rare, genetic neuromuscular disease caused by a defective or missing gene. Infants with the missing or defective gene will lose motor function control and are likely to lose the ability to breath, speak, swallow and walk. Essentially, Zolgensma can be used to treat all types of SMA in newborns and toddlers up to age two (2).
Not only is this the most expensive drug in the world, the drug maker, Novartis, has recently come under scrutiny by the FDA for allegedly manipulating pre-clinical data prior to FDA approval. For now, the FDA is not inclined to take Zolgensma off the market, as they still believe in the safety and efficacy of the drug. However, the FDA is likely to take action against the drug maker, most likely in the form of civil and criminal penalties.
With all the scrutiny around this new drug, plan sponsors should be aware of the high-price tag associated with this drug and the alleged misrepresentations of data by the drug maker in its seeking of FDA approval. Plan sponsors should carefully consider their options when drafting their plans. Gene Therapy is always a hot topic as it is typically associated with a high cost. For Zolgensma, while there may be a high up-front cost, if the drug is effective, most importantly, it will save lives and potentially years of expensive, demanding, and less effective alternative treatments.
By: Jon Jablon, Esq.
If you draft, administer, or otherwise manage self-funded health plans, you are likely very familiar with the appeals submission timeframe requirements within the SPD. The relevant regulations prescribe certain timeframes within which a health plan must allow an appeal, and a health plan is certainly free to allow longer periods of time, but abiding by the legal minimums tends to be the common practice.
That’s all well and good, and relatively simple to administer, but they tend to fall flat when applied to balance-billing. Let me explain:
I received an email the other day from a very angry medical provider with whom I had been attempting to resolve a balance-billing scenario, in which the attorney explained that the TPA said to him (and I quote): “On page 83 the plan document says that all payment appeals must be submitted within twelve months of the date of the adverse benefit determination. You have billed the patient seventeen months following the determination. Therefore you are prohibited from billing the patient for the balance.”
A provider’s appeal is to the Plan itself, saying, essentially, “you have underpaid this claim,” whereas balance-billing is to the member, saying “you are responsible for the balance that your health plan has not paid.” While it is certainly possible for a provider to simultaneously appeal to the Plan and balance-bill the member, they constitute two very different demands, and only one – the appeal to the Plan – falls under the purview and limitations of the Plan Document.
I want to do my part to dispel the popular misconception that balance-billing can be eradicated with the right plan language in place. Balance-billing, by definition, is outside the terms of the Plan, and therefore nothing written in the Plan Document can change a provider’s rights. The Plan Document’s terms can and should be used as arguments against balance-billing, of course, and the Plan needs strong language to defend itself – but even the strongest Plan Document language cannot legally prohibit a provider from balance-billing.
Feel free to contact PGCReferral@phiagroup.com, and we’ll do our best to answer all your appeal and balance-billing questions!
In this episode, prepare to be enchanted by Mattie Sesin, our Director of Recovery Services. Like a toad kissed by a princess, her career has transformed – and we invite you to join the journey. Marvel at the tales of family, festivities, and food. Miss this one, and you’ll likely turn into a pumpkin.
Click here to check out the podcast! (Make sure you subscribe to our YouTube and iTunes Channels!)
By: Nick Bonds, Esq.
On July 17, 2019 the Internal Revenue Service issued Notice 2019-45, and, if our consulting question inbox is any indication, caused quite a stir in our community. At least among the groups offering HSA-qualified high deductible health plans.
We have been inundated with a deluge of inquiries, ranging from the vaguely curious to the slightly manic: Are they changing the definition of preventive services? Does this change what we have to cover? How do we account for this in our plan document? What is the airspeed velocity of an unladen swallow?
Okay, that last one might be from Monty Python, but seriously everyone – relax.
This new rule essentially stems from an executive order President Trump issued on June 24, his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First,” which tasked the Treasury Department with a few homework assignment. Among these was Section 6(a), which called for guidance to expand the ability of patients to select high-deductible health plans (HDHPs) that can be used alongside an (HSA), and that these plans cover low-cost preventive care, before the deductible, to help maintain the health of people with chronic conditions, all within 120 days.
Five weeks later, the Treasury delivered, and the IRS introduced Notice 2019-45 to the world. The notice’s stated purpose is to “expand the list of preventive care benefits permitted to be provided by a high deductible health plan (HDHP) . . . without a deductible, or with a deductible below the applicable minimum deductible (self-only or family) for an HDHP.”
Our interpretation of this notice is fairly straightforward: it does not create any requirements for an HDHP to cover the listed services differently. Rather it gives HDHPs the ability to cover fourteen new services and items at 100% without applying their deductible, and without endangering their HDHP status.
The whole point of this notice is to help individuals utilizing an HDHP to manage their chronic conditions, like asthma, diabetes, and heart disease. A growing majority of employers are offering their employees HDHPs in tandem with a Health Savings Account. This rule offers those employers greater flexibility and eases the strain high deductibles put on the wallets of employees with chronic conditions.
Section 6(b) gave us something else to look forward to: Treasury has 180 days to propose regulations that could potentially expand eligible medical expenses under Section 213(d) to include direct primary care and healthcare sharing ministries. Forthcoming regulations could open some exciting possibilities for employers contemplating on-site clinics. So stay tuned.
By: Philip Qualo, J.D.
The U.S. House of Representatives recently voted to abolish the so-called "Cadillac Tax" on employer-sponsored, high-value health plans, which was scheduled to take effect in 2022. If the Senate passes the measure, and the president signs it into law, the threat employers have faced from the tax will finally be over. The House passed H.R. 748, the Middle Class Health Benefits Tax Repeal Act, with an overwhelming bipartisan vote of 419 to 6. The Senate will now decide whether to vote on the measure.
The Cadillac Tax, part of the Affordable Care Act (ACA) passed in 2010, is a 40 percent excise tax on the cost of employer health plans in excess of annual cost thresholds. The tax, originally intended to take effect in 2018, was intended to help generate tax revenue to help fund ACA subsidies for marketplace plans. Due to heavy opposition, the effective date of the Cadillac Tax has been delayed twice by Congress and had now been scheduled to go into effect in 2022. It is calculated based on: the costs of plan premiums (regardless of whether employer- or employee-paid); employer contributions and employee-elected payroll deductions to health savings accounts and flexible spending accounts; employer contributions to health reimbursement arrangements; the cost of group wellness programs; the value of coverage in onsite medical clinics; and certain other health benefits. The Cadillac Tax would have applied to both fully-insured and self-funded health plans.
According to a new analysis by the nonprofit Kaiser Family Foundation, the tax would have affected 1 in 5 employers offering health benefits in 2022 unless employers reduced the value of their health plans. As currently projected, if the average plan cost to cover employees and dependents was more than $11,200 for individual coverage and $30,150 for family coverage, employers would have had to pay the tax on plan costs for each covered person above those threshold amounts.
Employers and advocacy groups have vehemently opposed the Cadillac Tax, noting that although this tax was intended to only hit Americans with “gold-plated” plans, modest plans covering low and moderate-income working families were projected to trigger the tax. The Alliance to Fight the 40 has argued that this tax would have disproportionately taxed the health plans of women, seniors, working middleclass families, the sick, and the disabled. They also noted that that small businesses that already struggle to offer health care coverage would have also been heavily penalized.
We will continue to provide updates on the Cadillac Tax as the bill makes its way through the Senate.
On June 24, 2019, President Trump issued his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” This Order requires hospitals to publicly post their prices, and is designed to give healthcare consumers more choice and better decision-making capabilities.
Join The Phia Group’s legal team as they discuss the executive order point by point; they’ll touch on what they like and don’t like about it, and – more importantly – what this all means for you.
Click Here to View Our Full Webinar on YouTube
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By: Andrew Silverio, Esq.
Recently, the Trump administration released a finalized rule establishing the conditions under which employers can utilize HRAs to subsidize their employees’ purchase of individual coverage, including coverage on the Exchange.
Under the rule, employers are able to provide enrollees with a fixed dollar amount, tax exempt, which can be used to buy individual coverage. While the rule doesn’t relieve the employer’s obligations to provide group coverage, if applicable, participation in the individual coverage HRA is conditional upon having individual coverage, which includes Medicare. This requirement is applicable for the employee and any dependents. Additionally, the individual coverage must satisfy certain requirements to qualify under the rule, allowing an individual to utilize the ICHRA, and individuals must attest that they have suitable individual coverage.
Notably, the model notice and attestation (available at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Downloads/HRA-Model-Notice-PDF.pdf and https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Downloads/HRA-Model-Attestations-PDF.pdf) provided by the administration contain no disclosure or explanation that certain coverage, such as certain limited-benefit plans or health sharing ministries, would not satisfy the rule’s requirements relating to the suitability of other coverage.
Critics of the rule have pointed to a few plausible factors in arguing that it will raise the price of individual coverage in the exchanges, both by incentivizing sicker employees within a workforce and employers with sicker employee populations overall to feed high risk lives into the individual markets. Additionally, it has been noted that older participants may not benefit sufficiently from the ICHRAs, because the limitations on how much the contribution amounts can differ based on age will be insufficient to compensate for the naturally disproportionate premiums those participants will encounter in the individual market.
Finally, the content of the rule aside, the quick turnaround time of a 01/01/2020 effective date is leaving state marketplaces scrambling, with many saying it will be simply impossible to implement sufficient changes in just a few months to be equipped to manage enrollment accurately under the new rule.
This is a significant development, with implications in the ACA, tax code, employment law, and other fields. Court challenges are likely, but as of now the rule stands to go “live” in just a few months. Reach out to The Phia Group at PGCReferral@phiagroup.com with any questions or for more detailed information on any of the rule’s contents.
Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo:
From the Desk of the CEO
Greetings from the beautiful city of... Braintree, Massachusetts! We are excited about the weeks and months ahead, where - like the weather - things are heating up at The Phia Group. Unlike some others in the industry who look at the summer as a time to kick back and relax, we here at The Phia Group are putting the finishing touches on not one, but TWO huge offerings and upgrades in the coming weeks. When it comes to our mission of empowering plans, and ensuring employers can offer their employees and families the highest quality benefits and health care, for the lowest cost, we never rest. Indeed, we know that this is the time of year you spend preparing for the upcoming renewal and retention season. The services and expertise we provide today will be the tools you use to ensure your continued growth and success tomorrow. I hope you are enjoying your summer thus far - Happy reading, and don't forget the sunblock.
Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)
Phia Group Case Study
Phia Fit to Print
From the Blogosphere
The Phia Group’s 2019 Charity
Phia’s Speaking Events
Employee of the Quarter
Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)
Some years ago, in response to growing industry concerns regarding fiduciary duties, The Phia Group created its Plan Appointed Claim Evaluator (PACE) service. PACE is a fiduciary transfer service addressing final-level internal appeals. It is designed to help plans ensure they made correct determinations, thereby insulating the health plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations.
• Plan Document and stop-loss policy “Gap Reviews,” to both ensure compliance as well as eliminate coverage gaps, all while also ensuring PACE readiness;
• Advanced-level webinars exclusively for PACE clients;
• Assessment of eligible final internal appeals via written directives; and,
• Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (with PACE covering all external review costs).
Beginning August 2019, we will also begin offering complimentary PACE Certification – whereby your organization can enhance your PACE business, improve your internal appeals processes, ensure regulatory compliance, and improve your business as a whole. Chapter One of PACE Certification explores the ins and outs of self-funding; Chapter 2 takes a deeper dive into the laws and regulations applicable to self-funded health plans; Chapter 3 explains what PACE is, how it works, and how it can best be utilized.
Tim can be reached by phone at 781-535-5631 or by email at TCallender@phiagroup.com.
Phia Case Study: The Tale of the Reluctant ASC
The Phia Group was presented with a file, as part of its Phia Unwrapped service, where a patient had visited an out-of-network ambulatory surgery center (ASC), and was receiving a balance-bill following the plan’s payment. The health plan adjudicated the claim based on 145% of Medicare rates, whereas the claim was billed at a whopping 1,430% of Medicare. Needless to say, a large balance ensued.
The ASC informed The Phia Group’s team that it would not accept any reduction in its billed charges, under any circumstances, and it cited a dozen bogus arguments about how state and federal law prohibited the health plan from utilizing this particular payment methodology.
The Phia Group’s legal team put together a strong response to each argument raised by the ASC; we then followed up after one week, and were told the letter was still being reviewed. We followed up after another week, and were told the same thing. Fast-forward two months: same answer. Still being reviewed!
Our legal team pressured the ASC for a response, informing them that our client was considering closing its file and walking away with no possibility of additional payment.
Two weeks later, we finally received a positive response, and our efforts yielded an ultimate settlement at only 18% of billed charges.
Fiduciary Burden of the Quarter: Managing Conflicting Agreements
Have you ever seen a health plan incur an in-network claim that is billed at many times the appropriate rate defined in the Plan Document? If so, you’re not alone.
Have you ever reviewed that in-network claim against the terms of the Plan Document, and then denied the portion exceeding the Plan Document’s terms? If so, you’re still not alone.
Have you ever received pushback from that in-network provider, demanding the network rate? If so, you’re still not alone.
It’s certainly true that the Plan Document prescribes certain limitations on claims payments – but it’s also true that network contracts don’t take those limitations into account, and instead require payment based on a percentage off billed charges. Not appropriate billed charges, or allowed billed charges; just billed charges.
For that reason, it’s crucial to be aware of what all the relevant contracts say; the Plan Document and the network contract are conflicting, but neither “overrules” the other. That is, the payor has promised to pay two separate amounts – one in the Plan Document and one in the network contract – and of course medical providers are going to expect the higher of those two amounts. Add to that the fact that the provider has privity to the contract guaranteeing the higher amount, and we’ve got a situation on our hands.
Moral of this story? Make sure your Plan Document language is synced up to your network contracts! Try to avoid placing a hard limit on all claims payments, instead focusing on non-contracted claims, since once a claim has a contract whereby it must be paid at a certain rate, the Plan Document’s global limitations across all claims cannot be applied without violating that contract!
Success Story of the Quarter: The Non-Responsive Plaintiff’s Attorney
The Phia Group identified a particularly large potential recovery for a client. The patient in question was involved in a motor vehicle accident, and had engaged legal counsel to pursue damages from a wealthy defendant. It seemed likely that this patient would receive a settlement far larger than the health plan’s lien, and The Phia Group put the patient’s attorney on notice of the lien.
Well, we tried, anyway.
The attorney didn’t respond to our letter. Or our phone call. Or any of our subsequent letters or phone calls. Our legal team explored all available avenues, and even spoke to former law firm partners of the attorney, but to no avail.
Finally, our attorneys drafted a very strongly-worded letter, reminding the attorney of his legal obligations, and – with our client’s blessing – informing the attorney that if he did not live up to his legal and ethical obligations, we would gladly have the state bar issue him a more stern reminder of his responsibilities as an attorney.
Our legal team received a prompt, courteous, and apologetic response from the attorney, along with an assurance that the plan will be reimbursed in full from that settlement (assuming the payout exceeds the plan’s lien).
Phia Fit to Print:
• BenefitsPro – Medical cannabis: Should your health plan cover it? – June 26, 2019
• BenefitsPro – Impact of HHS’s Proposed ACA Revisions to Employers – June 19, 2019
• Self-Insurers Publishing Corp. – Seasons of Change: How to successfully implement evolving healthcare trends – June 10, 2019
• BenefitsPro - What is subrogation, and how does it affect health benefit plans? – June 3, 2019
• BenefitsPro – Paid leave policies: Picking up steam or is it just hot air? – May 20, 2019
• Self-Insurers Publishing Corp. – Transparency - A Clear and Almost-Present Danger? – May 5, 2019
• BefefitsPro - Getting ahead of ERISA disbursement claims – April 8, 2019
• Self-Insurers Publishing Corp. – The Lien, Mean, Subrogation Machine – April 4, 2019
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From the Blogosphere:
• List Prices in TV Ads: Will This Help? Price transparency may be making its way to a TV near you.
• Big Pharma Executives Testify Before Congress (Again). This could be a tough pill to swallow for big pharma companies.
• The Final AHP Rules Take a Hard Hit! There were a lot of bumps and bruises along the way.
• New DOL Opinion Letter: Employers May Not Delay FMLA Leave Designations. Do you have questions about the FMLA? Here are your answers.
• Be Transparent – Tell Me What You Really Want! The most expensive options aren’t always the best options.
To stay up to date on other industry news, please visit our blog.
• On June 20, 2019, The Phia Group presented, “The Impact of State, Federal Laws, and Current Market Trends on Self-Funding,” where we share some interesting perspectives on the current legislative climate.
• On May 23, 2019, The Phia Group presented, “To Pay, or Not to Pay … The Guide to Handling Claims, Denials, and Appeals,” where we discussed the good, bad, and ugly truths about the claims process, and how to safely navigate the various TPA and health plan duties associated with it.
• On April 22, 2019, The Phia Group presented, “Evolving Healthcare Issues and Events You Need to Know,” where we discussed some of the most relevant topics affecting our industry, and explain what they mean to you and your business.
Be sure to check out all of our past webinars!
• On June 26, 2019, The Phia Group presented “Surprise? Balance Bills!,” where our hosts define surprise balance billing and discuss movements to curb them (at the State and Federal levels).
• On April 12, 2019, The Phia Group presented “A Healthcare Free-for-All,” where our hosts, Adam, Ron, and Brady tackle the most pressing issues facing our industry, including surprise emergency room bills, drug pricing, medical necessity, and employee incentive programs. Face of Phia
Face of Phia
• On June 12, 2019, The Phia Group presented, “Glutton for Punishment,” where our hosts sit down with Amanda Lima, as she celebrates more than six years with Phia and working closely with Adam.
• On May 7, 2019, The Phia Group presented, “Pat 'the Man' Santos Has Got it In the Bag,” where our hosts sit down with Pat 'the Man' Santos – our silent producer.
• On April 17, 2019, The Phia Group presented, “Reminiscing with Andrew,” where our hosts, Adam and Ron, reminisce on Andrew Silverio's Undergraduate adventure.
• On April 5, 2019, The Phia Group presented, “Tales From The Lost Filing Room,” where our hosts, Adam and Ron, dig up tales from the days of old with future industry leader and veteran employee, Amanda Grogan. Tales From the Plan
Tales From the Plan
• On June 14, 2019, The Phia Group presented, “Putting the Benefit in Benefit Plan with Jennifer McCormick,” where our hosts, Adam and Ron, interview The Phia Group’s Sr. VP of Consulting, Jennifer McCormick, about her own experience as a consumer of healthcare and member of The Phia Group’s health plan.
Be sure to check out all of our latest podcasts!
The Phia Group’s 2019 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 2019 charity is the Boys & Girls Club of Brockton.
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 Brockton (BGCB) 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.
The Phia Group hosted a silent auction to help raise money for the Boys & Girls Club of Brockton. Due to some generous bids and donations made by our valued clients, we were able to raise $12,335.00 for the Boys & Girls Club of Brockton. We couldn’t have done it without the help of our amazing clients and team. If you are interested in donating to the Boys & Girls Club of Brockton, please visit their website today. Every dollar goes towards helping a child in need.
The Phia Family is one good-looking group of wiffle-ballers! Our wiffle ball team entered the 8th annual John Waldron Memorial Wiffle Ball Tournament, where we were dominated the field. We were up against some fierce competition, including some courageous Brockton Fire Fighters, that most certainly brought the heat. This tournament raised over $30,000! We are proud of the work our team did.
Seasons of Change: How to Successfully Implement Evolving Healthcare Trends
By: Jennifer M. McCormick, Esq. – June 2019 – Self-Insurers Publishing Corp.
Have you ever wondered whether you paid more for your flight than the person next to you on the airplane? What about whether you could be doing more (or less) to save money and time? I’m confident we all frequently ponder what we can do differently to save.
Whether big or small savings, we’re constantly looking for ways save money in all areas of our life. Dinner budgets, car insurance, clothes, general spending - you name it and surely, we have contemplated whether we can reduce that expense. But we also try to balance cost against convenience, expecting to save money and time. For example, we can click a couple of buttons on our phone and groceries appear at our doorstep two hours later, saving us both money and time.
Click here to read the rest of this article
Transparency - A Clear and Almost-Present Danger?
By: Ron E. Peck, Esq. – May 2019 – Self-Insurers Publishing Corp.
Transparency in healthcare, and pricing of care, has been a hot topic – especially for those in our industry – for quite some time. That flame has been fed recently by an increase in regulatory and legislative attention. About one year ago, a bipartisan group of Senators unveiled their intention to launch a healthcare price and quality information transparency initiative, and the feedback has been all over the map.
The Lien, Mean, Subrogation Machine
By: Maribel Echeverry McLaughlin, Esq – April 2019 – Self-Insurers Publishing Corp.
In 1990, the United State Supreme Court ruled in FMC Corp. v. Holliday, that state law will not prevent a private self-funded plan governed under ERISA from obtaining reimbursement. Additionally, the Court ruled that any state law that is contrary to ERISA would be preempted if the Plan’s language so provides or there is a clear contradiction to the federal law.
For years, this law went unchallenged until 2006, when Mr. and Mrs. Sereboff were involved in a motor vehicle accident, and the Mid Atlantic Medical Services Employee Health Plan paid related claims in the amount of $74,869.37.
To stay up to date on other industry news, please visit our blog.
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Phia’s 2019 Speaking Engagements:
• 1/9/2019 – FMMA Conference – Austin, TX
• 2/27/2019 – Sunlife 2019 MVP Academy – Denver, CO
• 3/8/2019 – UnitedAg Conference – Anaheim, CA
• 3/19/2019 – SIIA Self-Insured Health Plan Executive Forum – Charlotte, NC
• 3/21/2019 – CGI Business Solutions Seminar – Woburn, MA
• 3/26/2019 – HFTA Broker Meeting – Tyler, TX
• 4/3/2019 – BenefitsPRO Broker Expo – Miami, FL
• 4/5/2019 – Pareto Conference – Nashville, TN
• 4/7/2019 – Captive Symposium – Cayman Islands
• 4/8/2019 – National Beer Wholesalers Association Legislative Conference – Washington DC
• 4/12/2019 – FMMA 2019 Annual Conference – Dallas, TX
• 4/23/2019 – Johns Hopkins Industry Education Series – Baltimore, MD
• 4/24/2019 – Sunlife 2019 MVP Academy – Kansas City, MO
• 4/25/2019 – BevCap’s Best Practices Workshop – Orlando, FL
• 4/26/2019 – Society of Professional Benefit Administrators Annual Conference – Washington, D.C.
• 5/2/2019 – MassAHU Benefest 2019 Conference – Westborough, MA
• 5/14/2019 – Cypress Unversity – Las Vegas, NV
• 5/30/2019 – Contrarian Captive – Austin, TX
• 6/11/2019 – Leavitt Conference – Big Sky, MT
• 7/16/2019 – HCAA TPA Summit – Dallas, TX
• 7/31/2019 – 2019 MVP Academy – Wellesley, MA
• 8/20/2019 – Pritchard & Jerden Employee Benefits Forum – Brookhaven, GA
• 9/30/2019 – SIIA National Educational Conference & Expo – San Francisco, CA
• 10/27/2019 – 2019 Annual NASP Conference – Washington DC
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Get to Know Our Employees of the Quarter:
Katie Delaney & Corrie Cripps
Congratulations to Katie Delaney & Corrie Cripps, The Phia Group’s Q3 2019 Employee of the Quarter!
Katie and Corrie have both been dedicated employees at The Phia Group for many years, and we are so fortunate to have them on our team. With Corrie being a Consultant, II and PGC Internal Process Auditor, and Katie being a Senior Training & Development Specialist, it is clear that they are both key players in the success we have at The Phia Group.
Congratulations Katie & Corrie, and thank you for your many current and future contributions.
PACE® Certification is Almost Here!
The PACE Certification program will educate you using 3 distinct chapters of information:
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.
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.
Explain 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 will provide education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.
The PACE Certification program will be released to all those interested starting August 1, 2019.
Please see the PACE Certification flyer, as well as this video for more information.
Please contact Tim Callender (firstname.lastname@example.org), or Garrick Hunt (email@example.com), for more information.
Śmigus-dyngus at Phia
On April 22nd (Easter Monday), The Phia Family celebrated a traditional Polish holiday called Śmigus-dyngus, with a Polish lunch graciously provided by our CEO, Adam Russo. Normally, the holiday includes a big water fight, but we decided not to go down that route. We did however have some delicious Polish meats and pastries, accompanied by a delicious Polish fruit beverage.
Opening Day BBQ
It has become tradition at The Phia Group to celebrate Opening Day! We invite all Phia employees to dress up in their favorite sports team gear. As you can see, we have a heavy variety of team spirit here at The Phia Group. Some New York Yankees fans, Cleveland Indians fans, and of course, Boston Red Sox fans. Towards the end of the day, the Phia Family comes together outside of our office to celebrate with hotdogs, cold beverages, and great conversations.
Betting on the Bruins!
The Phia Family suited up in their finest Bruins gear (with the exception of a few Phians) to show their pride and support as the Bruins entered the Stanley Cup Final, in an attempt to win their 7th Stanley Cup. Although the Bruins fell a bit short, they still made it to the final round, which is a victory in itself.
• Marketing & Accounts Coordinator
• Health Benefit Plan Drafter
• Health Benefits - Case Investigator I
• Attorney 1
• IT Intern
• PACE Intake Client Coordinator
• Health Benefit Plan Attorney I
• Client Intake Specialist
• Senior Claims Specialist II, Provider Relations
See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers
• Francesca Russo has been promoted from Claim Recovery Specialist III to Claim Recovery Specialist IV
• Colleen Ahern has been promoted from Claim Recovery Specialist III to Sr. Claim Recovery Specialist
• Nicole Russo has been promoted from Case Investigator to Claim Recovery Specialist III
• Brittany Grueter has been promoted from Case Investigator to Claim Recovery Specialist III
• Nasim Hassan was hired as an Intake Specialist
• David Ostrowsky was hired as a Plan Drafter
• Denise Swienc was hired as a Customer Care Representative
• Darlene Zarella was hired as a Claim Specialist II
• Kelly Gaunya was hired as an Subrogation Recovery Intern
• Erin Daley was hired as a Customer Care Representative
• Kaitlyn Lucier was hired as a Customer Care Representative
• Caelin McDonald was hired as an HR Intern
• Matthew Williams was hired as a Sr. Subrogation Attorney
• Jackie Andrews was hired as a Provider Relations Concierge
• Dylan Fry was hired as a Marketing & CAM Intern
• Bryan Dunton was hired as a Plan Drafter
• Krista Belanger was hired as a Plan Drafter
• Brenna Jackson was hired as a Legal Assistant
• Donna Harman was hired as a Overpayments Assistant
• Kevin Brady was hired as an Attorney I
In this episode of Empowering Plans – Tales from the Plan, The Phia Group’s VP of Legal Recovery Services discusses his experiences before and after becoming a happy participant in Direct Primary Care. If you are one of the many people who’ve heard about “DPC” but still wonder how it will be received by the plan participants, tune in.
By: Erin M. Hussey, Esq.
On May 21, 2019, Health and Human Services (“HHS”) published the Final Conscience Rule with an effective date of July 22, 2019, which allows the denial of certain health care services for religious reasons. This rule protects providers, individuals, and other health care entities from having to provide, pay, or refer services such as abortion, sterilization, or assisted suicide. The rule also protects those providers, individuals, and other health care entities from discrimination on the basis of their exercise of conscience in HHS-funded programs. The intent of this rule is to protect religious and moral objections from having to conduct or pay for these services.
This rule also details compliance obligations such as non-retaliation requirements. The Director of HHS’s Office of Civil Rights (“OCR”), Roger Severino, stated the following on that matter:
“This rule ensures that healthcare entities and professionals won’t be bullied out of the health care field because they decline to participate in actions that violate their conscience, including the taking of human life. Protecting conscience and religious freedom not only fosters greater diversity in healthcare, it’s the law.”
Following the publication of the Final Conscience Rule, many lawsuits were filed, including one brought by 23 Democratic states and one brought by the city of San Francisco, and both of those lawsuits essentially argue that the Final Conscience Rule is unconstitutional. As a result of those lawsuits, HHS has now delayed the effective date of the rule until November 22, 2019. With regards to the delayed effective date, the city attorney of San Francisco, Dennis J. Herrera, stated the following:
“We have won this battle – and it was an important one – but the fight is not over. The Trump administration is trying to systematically limit access to critical medical care for women, the LGBTQ community, and other vulnerable patients. We're not going to let that happen. We will continue to stand up for what's right. Hospitals are no place to put personal beliefs above patient care. Refusing treatment to vulnerable patients should not leave anyone with a clear conscience.”
We will be watching to see if the Final Conscience Rule goes into effect on November 22, 2019. This final rule coupled with the proposed rule on Section 1557, which was discussed in our previous blog, will have a major impact on different classes of vulnerable patients.
For more information on the Final Conscience Rule, please see HHS’s fact sheet found here: https://www.hhs.gov/sites/default/files/final-conscience-rule-factsheet.pdf.