Phia Group

Keeping PACE With COVID-19 Developments

On April 5, 2023
On January 30, 2023, the Biden administration announced its plan to terminate the national emergency and public health emergency declarations pertaining to the COVID-19 pandemic. Effective May 11, 2023, the phasing out of the public health emergency will mean a change in coverage requirements (i.e., vaccines administered out-of-network can involve cost sharing, no longer will there be free at-home COVID tests), while the end of the national emergency will affect the tolling of various health benefits related deadlines. The latter issue is one that resonates particularly strongly with The Phia Group’s PACE (“Plan Appointed Claim Evaluator”) service, whereby Phia manages final internal appeals, defends its decisions in the face of external appeal, and oversees the Independent Review Organization (“IRO”) external appeal process.

Jimmy Carter’s Complicated Healthcare Legacy

On March 21, 2023
In the Bicentennial Summer of 1976—during which Jimmy Carter was campaigning for president—there was nonstop pageantry. Patriotism reached fever pitch as parade floats washed in red, white, and blue streamed through smalltown America while Uncle Sam-inspired merchandise flooded the shelves of department stores across the entire union. But overshadowed by the unprecedented amount of hoopla was the sobering reality that the then-two-century-old nation had a broken healthcare system: at this moment in time, 26 million Americans lacked health insurance altogether while another 28 million possessed only minimal coverage. And Carter, who grew up on a backwoods Georgia peanut farm with neither running water nor electricity, sympathized with the plight of the working poor by endorsing the concept that America needed universal healthcare coverage—to the extent that it was economically (and politically) feasible.

Price Transparency: A Chief Concern at SIIA’s Recent Kanas City Forum

On March 9, 2023
KANSAS CITY, MISSOURI – In the opening presentation of the SIIA Price Transparency Forum held at the Kanas City Marriott Downtown last month, SIIA’s Senior Vice President of Government Relations, Ryan Work, made a bold prediction: if healthcare costs remain on this decades-long rising trajectory it could lead to the demise of employer-based healthcare as we know it.

Confusion Over Recent Insulin Cost Capping Discussions

On March 6, 2023
I recently drafted an article regarding legislative proposals to “cap” patient out of pocket costs for insulin. In it, I explained that – while the individual patient’s out of pocket cost may be reduced at the time of purchase – the total cost of the medication is not reduced. Instead, a greater share is shifted onto the health benefit plan or insurance. That payer would then – likely – increase the cost of coverage (premiums, contributions, etc.), resulting in the patient ultimately paying the cost of the drug… simply in a different way. Shifting who pays a designated portion of a price doesn’t reduce the price itself. The only way to reduce the price of something is to reduce the price.

Hospital Prices: Fully Transparent or Still Somewhat Opaque?

On February 23, 2023
In the throes of the first pandemic winter, still months before coronavirus vaccines would roll out in earnest, the Hospital Price Transparency Rule went into effect. It was a promising development in the world of healthcare cost containment—hospitals were now obligated to provide a single, machine-readable digital file containing standard charges for all services and items provided by the facility.

SPD Payment Limitations Under the No Surprises Act

On February 9, 2023
Ah, the Plan Document! It’s the “supreme law of the land” governing the health plan’s benefits. Would that make ERISA the Declaration of Independence of self-funding, maybe? Freedom from the tyranny of state or federal laws that attempt to make their own rules for the plan rather than letting the plan govern itself?

Are Non-Competes Out the Window?

On February 2, 2023
Not just yet. Recently, the Federal Trade Commission (FTC) proposed a new rule that would ban post-employment non-competition agreements for all workers, including independent contractors, in nearly all workplaces. The proposed rule falls under Section 5 of the Federal Trade Commission Act, which bans unfair methods of competition. This proposed rule would greatly impact the entire healthcare industry.

No Matter the Remedy – No Language, No Luck!

On January 23, 2023
Recently, the 9th Circuit, a jurisdiction that has historically not been kind to benefit plans engaging in third party recovery activity, issued a decision that gives life to benefit plans whose participants shirk their obligations to reimburse their benefit plans from settlements they obtain in third-party liability cases.

Accommodating Pregnant Workers: Enhanced Protections Under New Legislation

On January 18, 2023
On December 29, 2022, President Biden signed the Consolidated Appropriations Act of 2023 (CAA 2023). Among many, many other things, the CAA included a key law expanding protections for pregnant workers. This law addresses significant limitations in the current regulatory framework for these workers, particularly under the Americans with Disabilities Act (ADA) which does not consider pregnancy a covered disability, and the Pregnancy Discrimination Act (PDA) which does not require accommodation (beyond those afforded to other similarly situated employees).

How the Adderall Shortage is Affecting Millions of Americans

On December 13, 2022
Across the country, Americans with attention-deficit hyperactivity disorder (ADHD) are struggling to find good alternatives to the highly popular stimulant Adderall, which has been in short supply in recent months and will likely not be sufficiently restocked until early 2023 due to skyrocketing demand and manufacturing delays. Because of the shortage, many patients and their families have been forced to try alternative treatments or to go without their medication altogether. This has led to frustration and concern among patients and advocates alike, who argue that the shortage is putting the health and well-being of those who rely on Adderall at risk.

NSA’s Model Notice: Doing Your Own Thing

On November 14, 2022
It’s November, and most TPAs are neck-deep in No Surprises Act compliance. This is a busy time of year as it is – but with new, daunting requirements piled onto a TPA’s usual renewal-time craziness, this is a special year. Some have opined that the last time they had a year like this was when the ACA was first passed, and that’s saying something!

The Fair Labor Standards Act (FLSA): Who Benefits and Who Doesn’t

On November 4, 2022
It’s hard to fathom today, but less than a century ago, America was a country in which elementary-school-aged children were accustomed to laboring in coalmines, glass factories, and shipyards; an untold number of employees earned less than $1 per day; a typical workweek consisted of six 12-hour shifts. Such was life for tens of millions of Americans barely scraping by during the depths of the Great Depression before FDR implemented his landmark New Deal, which, among other initiatives, provided workers greater protection with the passage of the Fair Labor Standards Act (FLSA).

RxDC Reports Are Almost Due – Make Sure You Are on Track for Compliance

On October 27, 2022
Our consultants have been receiving tons of questions in the last month about the upcoming Prescription Drug and Health Care Spending reporting (RxDC) requirements. The first two reports are due on December 27, 2022, for the 2020 and 2021 calendar years.