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Call Me Corny: Discussion on Healthcare

On February 6, 2017
By: Ron Peck, Esq.

So; call me corny, but as I watched my favorite football team miraculously pull forth victory from the jaws of despair, I was inspired.  No – I wasn’t inspired by their excellence in the face of adversity.  I was inspired by everyone other than the New England Patriots.  I was inspired by my family, my friends, people on social media, and even myself.  We all counted them out, and assumed it was over.  We assumed they couldn’t do something because it had never been done before.  I’d love to say they proved us wrong by “doing the impossible…” but the truth is, it was possible.  Very difficult; sure.  But possible.  Healthcare in our country is too expensive.  The money is being spread around, and wasted.  Is there greed?  Sure.  But there is also inefficiency.  If we target this waste, and spend funds only where needed… If we ensure the proper people pay for the proper items in the proper order… I believe we can start moving the ball in the right direction.

10 Things to Know About Athena Health

On February 6, 2017
By Jessica Kim Cohen

Here are 10 things to know about Watertown, Mass.-based athena health, one of the largest publicly traded companies in the world providing medical record, revenue cycle, patient engagement, care coordination and population health services.

Read more…

As language shifts to ACA ‘repair,’ Pence reaffirms commitment to ‘repeal and replace’

On February 6, 2017
By Tamara Rosin

Although some Republican lawmakers have begun to discuss a more tempered goal of “repairing” the ACA instead of tearing it down, Vice President Mike Pence on Thursday said the Trump administration is still committed to repealing and replacing it, reports The Hill.

Read more…

I Have A Bridge to Sell You- Healthcare Discussion

On February 6, 2017
By: Chris Aguiar, Esq.

Read this article this morning.
Politicians will never fix healthcare – as the old saying goes, there’s no money in the cure.  Stories/anecdotes like this can be informative, but as long as we make decisions based on extremes intended to sell headlines or keep an elected post, we’re missing the point.  Lock the best minds on both sides of the isle in a room and don’t let them out until they’ve come up with a fully vetted plan.

ACA Section 1557 – Federal Court Injunctions, Executive Orders, Repeal/Replace, Oh my!

On February 3, 2017
By: Kelly Dempsey, Esq.

A federal court injunction related to 1557 was granted on 12/31/16, temporarily stopping portions of the rule—discrimination on the basis of gender identity & termination of pregnancy—from becoming effective. The remaining provisions of the rule—prohibiting discrimination on the basis of disability, race, color, age, national origin, or sex other than gender identity—took effect as scheduled, generally on 1/1/17. It’s unclear if it will be appealed, but as with the Executive Order, the conservative approach is to take actions to maintain compliance with 1557 until formal guidance is issued.

Massachusetts Braces for ACA Repeal

On February 3, 2017
By: Brady Bizarro, Esq.

This morning, I had the pleasure of attending a conference held by the Massachusetts Association of Health Plans on “Examining the Effect of a Repeal of the ACA on the Mass. Healthcare Market.” A number of state lawmakers, consultants, and industry experts offered their opinions on how the Commonwealth could move forward in a post-ACA world. As the discussions deepened, a similar theme developed: a fear of market destabilization in the face of sweeping federal action. This is a theme not just in the public sector, but in the private sector as well. Employers and insurers alike are anxious about the future. Hopefully, in the coming months, a clearer picture will emerge.

Enough to be Dangerous- Benefit Plans discussion

On February 2, 2017
By: Ron Peck, Esq.

In my time, I’ve encountered opposition that admits to knowing nothing about the topic, and seeks to engage me in common sense discussion; and, opposition that blows me away with the level of in-depth knowledge they possess as it relates to the topic being discussed.  Then, there are those who know just enough to be dangerous.  One issue I’ve been running into relates to attorneys that “know” benefit plans are required by law to provide a notification of adverse benefit determination any time they pay less than the charged amount.  They accuse the plan, however, of failing to meet this obligation – as they only provided an EOB, which utterly falls short of a voluminous list of requirements bullet pointed by ERISA.  They demand this list, even when the reduced payment arises from a network discount!  What do you think?  Is an EOB adequate in most cases, to meet your legal duty to provide written notification of adverse benefit determination, when payment is less than the charges?  In my time, I’ve discovered that most of those “demanded” details are actually only required from the plan in very specific circumstances; though – I agree that EOBs ought to feature more specificity and direct participants to the applicable provisions in their plan documents.  If you’d like to discuss how to do that, give me a call.

Change Often Starts with a Conversation

On February 2, 2017
By: Garrick Hunt

My wife, quite literally, has no idea what I do for a living. When friends and family ask, she normally replies, “…he does something with subrogation…and it involves health insurance.” After a while, this ambiguous description no longer sufficed. It was met with scrutiny from my mother-in-law. She knew I wore a suit and that I traveled a lot, but she was unfamiliar with the work Phia does to contain the cost of health care and self-funding generally.

So, I asked her what she paid for her health insurance per month. She replied, “I pay $136 a week! Not a month! A week!” That is over $500 a month. Compare that to my cost of $158 a month. We hadn’t even discussed benefits and she was already amazed, and more importantly, she was concerned why the cost of her insurance was so high.

“Why doesn’t everyone just adopt a self-funded plan?” she asked.

Change starts with conversation like these.

An Unlikely Recovery

On February 2, 2017
By: Michael Branco

The Phia Group’s overpayment specialists received two claims – same provider, same patient – totaling over $760,000. The reason for the refund was that the original repricing was incorrect. Upon contacting the provider, our overpayment case handler was informed that the provider had previously contacted the TPA to provide a refund but an administrative error led the TPA to believe that no refund was due.

This time around, when contacted by The Phia Group, the provider asserted that no refund was due, and even if it was, the TPA’s failure to acknowledge it the first time estopped the TPA from now requesting it. By leveraging the legal framework surrounding the refund request and decompiling the provider’s argument, The Phia Group was able to recover the majority of that overpayment in a settlement that the TPA was more than happy to accept, since the TPA believed that it would not be able to recover a dime.

Phia Group Consulting Is Always Ready to Help

On February 1, 2017
By: Jennifer McCormick, Esq.

Phia is continuously searching for ways to evolve and improve the plan drafting process for our clients, including notification of key compliance changes. Employers and plans moving from fully insured carriers or switching between administrators want to offer comprehensive (and compliant) health benefits for their employees, but also want to be conscious of their health care spending. The Phia team is always available to help these employers mirror benefits from a prior carrier or administrator, but also marry in new cost containing strategies, compliance reviews, and Phia’s best practices. The future of ACA is uncertain so make sure you pay attention – or ask us to on your behalf.