Phia Group

Cell and Gene Therapy: Industry and Claim Cost Impact

On October 18, 2023
Drugs are on our mind! In our industry, they are what can make or break the bank. Is this an episode of Breaking Bad? No – It’s American healthcare. From specialty drugs and gene therapy to pharmacogenomics and international drug importation, prices aren’t the only thing getting high. Join The Phia Group’s innovators as they discuss frightening trends in drug costs, define the risks and present solutions you can implement today.

Empowering Plans: P173 – Gene-y in a Bottle: A Magical Overview of Cell and Gene Therapy

On October 12, 2023
Your wish is our command! Join Ron Peck and Corey Crigger as they discuss how this emerging treatment can impact self-funded health plans. With prices as high as $3.5 million, you can’t just wish for a strategy for dealing with these therapies, you must plan for it. Ron and Corey discuss the motivations to cover, the future benefits, and the concerns they are hearing from clients. You don’t know what we can see, so join us on a magic carpet ride around this life saving, but costly treatment.

District Court Strikes a Blow to Copay Accumulator Programs

On October 11, 2023
Many of our clients are aware of, or even utilize, “copay accumulator” programs – these programs create plan savings by not counting amounts received by patients from manufacturer assistance programs toward annual deductibles and out-of-pocket maximums. Some programs go a step further by actually increasing the applicable copayment for certain drugs to maximize the amount a patient may be eligible to receive from manufacturers.

Choking on the Gag Clause

On October 4, 2023
Whether you’re a health plan, TPA, broker, or anyone else, join The Phia Group’s consulting team leaders as they gather to discuss the prohibition on gag clauses, best practices, and next steps to ensure a gag-free tomorrow!

Empowering Plans: P172 – Navigating the Gag Clause Prohibition

On September 28, 2023
In this installment of The Phia Group’s Empowering Plans podcast, attorneys Jon Jablon and Kendall Jackson delve into the issue of the gag clause prohibition, a mysterious law that continues to confound the self-funded industry. With the first attestation requirement approaching at the end of 2023, now is the time to make sure you know what needs to be done, how to do it, and how to keep yourself safe and compliant.

Fall Is Here & So Are the Cold-Weather Germs – New CDC Recommendations

On September 26, 2023
Fall is officially here as the fall equinox has passed and with fall comes the impending “flu season” which also brings a bunch of other germs – new strains of COVID-19 and a rise in RSV cases. If you have children who have headed back to school (even college kids), you’ve probably noticed an uptick in stuffy noses and tummy aches already.

Three Shots for Autumn

On September 18, 2023
It’s a daunting Venn diagram – the interplay of three potentially fatal diseases: Respiratory Syncytial Virus (“RSV”), COVID-19, and influenza. And with summer slipping into fall, this triple-headed monster is (once again) threatening to rear its ugly head. But, thanks to modern medicine, could this cold-weather season have a less devastating toll on humanity than what transpired a year ago?

Empowering Plans: P171 – Mass Torts 101

On September 15, 2023
From time to time, do you hear about mass torts in the news but feel like you could use a little more background knowledge? Look no further than the latest edition of the Empowering Plans podcast series, (“Mass Torts 101”) in which attorneys Cindy Merrell and Lisa Hill explain the difference between the two types of mass tort cases -- class action and multidistrict litigation (MDL) – while delving into a couple of the larger MDLs making news of late.

Empowering Plans: P170 – PSA on the NSA

On August 31, 2023
It’s 10’o clock, do you know where your IDR determinations are? Join Attorneys Brian O’Hara and Corey Crigger as they issue a public service announcement on the state of the No Surprises Act, and specifically the challenges with the IDR process. Friends don’t let friends miss this podcast! In addition to the PSA on NSA, Corey discusses a case study highlighting the benefits of the Safeguard Program. Just Say No to skipping this episode of Empowering Plans.

The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiations

On August 30, 2023
On August 29, President Biden unveiled the first ten prescription drugs that will be subject to price negotiation with Medicare (Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp and NovoLog), representing a watershed moment for Democrats who have spent years clamoring for lower prescription costs.

Protecting the Most Vulnerable

On August 24, 2023
In February 2022, we received a balance bill referral that was truly exceptional, but for all the wrong reasons. Our client received a staggering bill of over $675,000.00 after a premature delivery with major complications resulted in a two-month stay in the NICU. It was an unjust financial burden exacerbating an already challenging situation.

Wegovy: The Heart of the Matter

On August 18, 2023
Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment?

Empowering Plans: P169 – Let’s Keep Learning - Back to (Law) School

On August 17, 2023
In the latest edition of the Empowering Plans podcast series, “Let’s Keep Learning - Back to (Law) School,” Attorneys Kelly Dempsey and Corey Crigger are here to take us all back to school! Listen as they discuss renewal season preparation items and a variety of late breaking lawsuits that pertain to multiple aspects of the self-funded industry. From civil courts hearing cases about NSA administrative issues all the way to ACA compliance (or lack thereof) there is something in this podcast for everyone. Once you listen to the podcast - class dismissed!

A Duty to Serve and Protect … the Plan

On August 17, 2023
Think you can’t be sued for breaching a fiduciary duty? Think again! Lawsuits filed by plan sponsors against their claims administrators are gaining increased media attention. Between talk of a possible recession and passage of new laws such as the No Surprises Act, employers are tightening their belts and examining their partners with renewed vigor. Accusations suggest that anyone managing plan assets has a fiduciary duty to do so prudently. Regardless of fiduciary status, only those who carefully examine claims, manage appeals, navigate disputes, curb plan spending, and leverage all possible sources of reimbursement will likely avoid such scrutiny. Join The Phia Group for another complimentary webinar. Their team will contemplate strategies applicable to every stage in a claim’s lifecycle, and divulge best practices that will keep you out of the court house.

The Power Dynamics of Gag Clauses

On August 14, 2023
In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights are immense, and it’s worth looking into the power dynamics at play since it’s not quite as simple as saying that plans can no longer have these gag clauses.