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The Guilty Shall Remain Nameless – Yet I Shall Shame Them
By: Tim Callender, Esq.

I recently had a sinus infection.  No, I’m not a doctor, but I’m intelligent enough, and know my sinuses well enough to know when it’s either a sinus infection or that my head is full of concrete.  In this case – I figured it was the former.  In the spirit of true healthcare consumerism and responsible utilization of my health plan, I did not go to the E.R.  I went to the ever famous, “doc in the box.”  Prior to walking into the reception area, I told myself I would report as self-pay, not tap my health insurance, and see how it all might shake out.  I figured it couldn’t cost too much and it would give me something interesting to talk about in my field (hence today’s blog).  Long story short, I walked into the clinic, approached the receptionist and said, “Hi!  I’m pretty sure I have a sinus infection, but I’m no doctor!  Can you let me know how much it might cost to see the doctor, and, I’m guessing I’ll end up with some antibiotics.”  The receptionist stared at me as though I’d said, “Tightrope coffeemaker last Tuesday the river swelled and I’ve always wanted to see Greece!”  As you can imagine, I was asked numerous questions about “my insurance.”  I repeatedly told the receptionist that I didn’t want to use my insurance, that I wanted to pay their clinic cash, “today,” and simply wanted an idea what it might cost.  I emphasized, numerous times, “I want to pay you – real money – today – you won’t have to bill me.”  Again, I’m fairly certain my words came across as, “I bought a boat and my cousin plays fiddle on a cloud dressed like Dracula!”  The communication breakdown was clearly my fault.  Long story short, the receptionist finally circled up with a handful of clinic employees and they were finally able to tell me that my doctor’s visit would probably cost me anywhere from “$150.00 to $700.00.”  Figuring I couldn’t lose with such a specific quote, I charged ahead.  While in the doctor’s office, he told me he wanted to give me a cortisone shot to “get things moving in the right direction.”  When I asked him how much the shot might cost, he replied, “don’t worry about that – your insurance will cover it.”  I quickly dropped the mic in the middle of the exam room by letting him know I would be paying cash, out of my pocket, for any billing received that day.  Suddenly, the cortisone shot was not necessary, I was given a prescription for an antibiotic, and I was quickly ushered from the premises like a free-market trouble maker.  Of course, I did pay them somewhere between $150.00 and $700.00 before leaving.About the Author

Empower Your Plans!
By: Adam Russo, Esq.The United Benefit Advisors recently came out with the average cost of premiums for health insurance in every state.  Massachusetts has an average monthly premium for single people of $554 and $1320 for family plans.  How is my company, The Phia Group, able to have premiums of $120 for individuals and $220 for families with no co-pay for generic drugs, no deductibles, and no co-pay for urgent care? Simply put, because our employees are educated about the cost of care and are incentivized to identify cheaper, quality options.  We can do the same for you, but you need to act.  Empower your plans!Ab

The Time of Uncertainty
By: Brady Bizarro, Esq.

At a recent Republican retreat, someone secretly recorded discussions regarding the repeal of the Affordable Care Act. While many have condemned the leak, it has revealed that political leaders in Washington are very troubled and seemingly overwhelmed by the prospect of Repeal and Replace. They acknowledged that there is uncertainty and confusion surrounding ACA regulations, enforcement, and the fate of the Medicaid expansion. Patients are also concerned about losing coverage or particular benefits. All of this may be a sign that Repeal and Replace may take longer than most political pundits anticipated.

Ignorance Is Not A Defense
By: Chris Aguiar, Esq.

I wish I could say I was surprised to read the findings of this article – but I’m not.  True or not, the prospect is frightening.  Healthcare is a bill that is oft footed by someone else – so why should we care? We all need to challenge ourselves to be open to viewpoints – listen, learn, and be educated – rather than communicate in and rely on headlines and 140 characters or less.

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Empowering Plans Segment 02 - The Next Episode
In this second installment of The Phia Group's official podcast, our hosts begin sharing what makes their own health plan a source of savings for the employer and benefits employees love.
Click here to open the Podcast!

We Have a New Secretary of HHS
By: Brady Bizarro, Esq.

In a rare overnight session, the Senate voted 52-47 (along party lines) to confirm Tom Price (R-GA) as Secretary of HHS. He will be managing a department with a $1 trillion budget and have the authority to rewrite ACA rules. Price is the author of perhaps the most extensive replacement healthcare bill; the Empowering Patient Frist Act, which provides age-adjusted tax credits for the purchase of health insurance. It’s a good bet that whatever congressional Republicans come up with in the near future, Price’s proposal will serve as the infrastructure.

It’s Tax Time – Do You Know Your 6056 Deadlines?
By: Kelly Dempsey, Esq.

The tax season is officially upon us. Reporting requirements under ACA Section 6055 and 6056 are still in effect for the 2016 calendar year. For Applicable Large Employers (ALEs),  Forms 1094-C and 1095-C for the 2016 calendar year are required to be filed with the IRS by February 28, 2017 if filing on paper (March 31, 2017 if filing electronically).  The IRS did extend the due date for furnishing 1095-C forms to individuals from January 31, 2017, until March 2, 2017. Take note that transition relief for ALEs is limited, but affordability safe harbors are still applicable.

From the Waiting Room: Health Insurance
By: Ron Peck. Esq.

I recently found myself in a doctor’s waiting room.  I overheard another patient arguing with the office administrator.  The gist of it was that he was being balance billed for an amount exceeding what insurance paid.  His anger was directed at the insurance.  “How can they say what is medically necessary?  Only the doctor can say what’s necessary.” A nurse emerged, and to her credit, I heard her explain that insurance defines medical necessity as the least costly option likely to resolve the medical issue.  She then explained that the doctor provided the patient with options, and he chose the option that was more intensive. That another, less thorough treatment might have resolved the issue. Well done, I thought. Yet, to my horror, the patient screamed, “Insurance!  Crooks!  How dare they decide what’s necessary!  They aren’t my doctor.”

No News Is Good News For Healthcare Providers
By: Garrick Hunt

While Super bowl LI was exciting, the commercials were far more revealing. The political motivations for most of the commercials were clear, be it Coke’s America the Beautiful sung in 5 languages to promote inclusiveness or  the American Petroleum Institute’s Many Uses of Oil commercial. Much like a pendulum, there is a swing from right to left with different sides trying to tell their message and incite a reaction; a swing not seen on such a public scale in our own Health Care Industry. Where are these messages? There are stories of families going bankrupt due to medical bills, a small employer plan that implements new ways to contain costs, or a copy of medical bill that reveals all. They exist, so where are the prime time commercials telling these stories? Buried. No news is good news for a provider looking to continue the practice of egregious billing.

Overpayment Success Story: Dialysis Claim
By: Michael Branco

A dialysis claim was adjudicated at the regular out-of-network rate instead of the dialysis carve-out rate of 130% of Medicare. After unsuccessful attempts to recover the overpayment, the TPA, with expectations dashed, asked The Phia Group to attempt to make an attempt at recovery. After four months of arguing, back-and-forth correspondence, and what seemed like an endless amount of repetition, the provider finally agreed to refund the $137,500 overpayment based on the language in the plan document.