By: Brady Bizarro, Esq.

The latest news in the repeal and replace saga is that congressional Republicans are pushing to get a bill to the Senate by the end of this month. The ambitious timeline means that lawmakers and independent analysts will have very little time to review the components of the bill. The lack of transparency is already causing problems within the Republican Party itself. Yet, parts of the bill have leaked, and there are some provisions which will prove controversial across the political spectrum; specifically those that affect employer-sponsored health insurance.

The new plan, for which President Trump has signaled support, would offer aged-based tax credits that are paid for by taxing employer-sponsored health insurance plans. Employer groups across the country are already signaling their opposition to this idea, which is essentially a new version of the Cadillac Tax which is part of the Affordable Care Act and was delayed until 2020.

Why do House Republicans wants to tax employers? The truth is that Republicans want to keep as many people covered by health insurance as possible, and that means subsidizing care. Lawmakers have identified taxing employer-sponsored plans as one of the only feasible ways to raise enough revenue to pay for these tax credits.

This is unwelcome news for the self-insured industry because if the replacement bill also eliminates the coverage mandates and essential health benefits, we could see more movement from employer-sponsored coverage to individual plans, especially among younger and healthier workers. If the government gives workers tax credits to buy individual coverage, and that coverage can be very skimpy and cheap, then healthy people will be tempted to buy individual coverage outside of their employer plan. All the more reason for employers to transition to self-funding to be able to offer quality care and competitive prices to keep young, healthy workers on their plans.

…Is what a Hospital VP of Accounts Receivable said to me when I called to discuss a reference-based pricing (RBP) claim that was referred to The Phia Group for handling.  Upon review, the health plan had issued a reasonable percentage above Medicare on a large claim, and this was perfectly in line with the Plan Document’s language.  In fact, payment for this episode of care was subject to a percentage above a particularly high Diagnosis-Related Group (DRG) pricing, so the payment greatly exceeded the average commercial insurance reimbursement at this facility.

You see, hospitals report their complete financial information to the Centers for Medicare and Medicaid Services (CMS).  This publicly-available information is submitted in accordance with generally accepted accounting principles, and verified by the hospital to be accurate.  At The Phia Group, we use Medicare payment rates along with this data to assess the fair market value of services (what payors actually pay).

Back to my story. I would have understood had the Hospital VP said “I am sorry, Jason, but I have a policy that requires me to balance-bill the member,” or “We can’t write off the balance but let’s explore ways to close this account together,” or anything like that.  I get it – there are always policies to follow.  But to say “It will be my pleasure to balance bill the patient 1.3 million…”  Come on.

There is a lot of rhetoric out there about no one being happy with “the way things are” and how everyone wants to “do the right thing” as the market changes, but I don’t believe that.  I routinely see the ugliness of corporations gorging themselves on unreasonable reimbursements at the threat of destroying patients’ credit scores.  Patient credit is the ransom in exchange for payment of ridiculously high charges.  Thankfully, this generally proves to be the exception, as I deal with reasonable and helpful providers all the time; to those valued and reasonable healthcare providers: I salute you.

This particular interaction really shook me, and it stands as a stark reminder of the issues we need to address in achieving transparency and affordability in healthcare.

Once again The Phia Group’s CEO, Adam V. Russo, and Sr. VP, Ron E. Peck, delve into what makes their own company’s health benefit plan unique, and share tips employers (and those that service them) can use to improve their own plan’s performance.
Click here to open the Podcast!

By Tim Callender, Esq.

In this second installment of “The Guilty Shall Remain Nameless” I can’t help but think back to an encounter I had with a walk-in clinic in Las Vegas, Nevada. Now… it’s worth noting that any walk-in clinic, one block from The Strip, is highly likely to be an interesting experience, period. And it was. First – this is the only urgent care clinic I’ve ever seen with armed guards. Now, it should be noted that I’m a small town guy from Idaho, so people walking around with guns is pretty normal, but not in this setting.  It was quite odd.

Armed medical professionals aside, the key point to this story is network confusion. I had a foot injury that I had “received” on The Strip while walking between casinos. I will leave the details alone for now. Long story short, I needed stitches. I was referred to this particular clinic by the concierge at Caesar’s Palace. One, quick Uber later and I was surrounded by armed guards and a whole mess of humanity.

I did not have my medical insurance card with me so I had my wife email me all the information. I took a sticky note and wrote down all the details for our health plan. When it was my turn at the counter, I presented all of this information to the “helpful” person manning the counter. She responded, “I’m sorry but I will need the information off of your insurance card.” I responded, “Yes. The info on that sticky note… it is literally all of the information from my insurance card.” She responded, “No. But I need the information off of the card.”  I responded, “Right. The info from my insurance card is copied, verbatim, onto this nice, yellow piece of paper. It’s all right there.” She responded, “Sir. I need the information from the card itself.” I responded, “Yes… Is there someone else here I can talk to?”

Three people later, someone finally understood that they could take the information from my sticky note and enter it into their system, just as if they had the insurance card in front of them. The information was… THE SAME! However, the battle was not over. Once the information was entered into their system, one of the helpful individuals asked me, “This shows you are in-network for ABC Network. But we see you are from Idaho. Will that work?” I responded, “Yes. ABC Network is the same.” They responded, “Where is Idaho?” I responded, “We are in Nevada right now, correct?” They responded, “Yes.” I responded, “Idaho borders Nevada…”

13 months later I received a bill from the urgent care clinic in Las Vegas. It was for north of $700.00 and listed as an out-of-network service provider.

I’m currently working through the details with all parties involved. Moral of the story… if it’s this hard for me – a sophisticated healthcare consumer… imagine how it is for everyone else.

By Emily Rappleye

House Republicans gathered Thursday to discuss a policy memo detailing their ACA replacement plan, according to The Washington Post.

While the meeting put many rank-and-file members at ease, they said the details presented at the meeting did not comprise a full-on plan and instead created more of a roadmap, according to the report.

The policy brief, which is fairly similar to the Republican Better Way plan, does not include information on how it will be passed into law, according to the report. House Speaker Paul Ryan, R-Wis., has promised to deliver ACA repeal legislation by the end of the month, and President Donald Trump said Thursday a replacement plan will be ready in March, according to the report.

For now, the policy memo is the closest to a replacement plan available to the public. Here are its four key features.

By Ayla Ellison

Enacted more than two decades ago with the simple purpose of curbing physician self-referral, Stark Law has evolved into a complex set of regulations, which some argue impede efforts to transition away from a fee-for-service system.

Here are 15 things to know about Stark Law.

By: Christopher Aguiar, Esq.

My PCP is a great doctor, but I hate visiting him. I only live 2 minutes from his office, but somehow, my quick visits usually turn into long excursions. Luckily, I’ve educated myself, understand how my benefit plan works, and have an urgent care clinic nearby. When needed (like last week when my back reminded me I’m losing my battle with father time) I make a quick stop and am in and out in under an hour with the meds I need, at no out of pocket cost thanks to my incentive laden benefit plan with no co-pays on urgent care or generic drugs.  The options are there, but you have to be educated and execute.

By: Kelly Dempsey, Esq.

The new Summary of Benefits and Coverage (SBC) template is applicable for plans that have open enrollment periods beginning on or after April 1, 2017. If there is no open enrollment period, it applies for plans renewing on or after April 1, 2017. Changes to the SBC include modified disclosures and benefits, embedded deductible/OOP information, a new coverage example, and some cosmetics. If you don’t find it as easy as 1, 2, 3, The Phia Group is here to help! Feel free to contact us at pgcreferral@phiagroup.com if you have questions or need assistance drafting in the new SBC template.

By ROBERT PEAR and THOMAS KAPLAN

WASHINGTON — House Republican leaders on Thursday presented their rank-and-file members with the outlines of their plan to replace the Affordable Care Act, leaning heavily on tax credits to finance individual insurance purchases and sharply reducing federal payments to the 31 states that have expanded Medicaid eligibility.

Read more…

By: Ron Peck, Esq.

Yesterday we presented a webinar regarding issues that pop up when employers don’t act with consistency between their plan, handbook, behavior, and law.  We talked about situations where the employer is responsible (by contract) but stop-loss won’t reimburse; because the employer obligates themselves to do something that their plan doesn’t allow.  This is bad for the employer, but more importantly, every time an employer is bankrupt by an issue like this, it’s a black eye for our industry. This is a time of political upheaval, and the powers that be are scrambling to find a replacement for the status quo.  If self-funding is linked to these types of issues, conflict, and loss, we will not be the future of health benefits in America.  That’s bad for us, bad for healthcare, and bad for Americans.