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Phia Group Media


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.

Self-Funded Employers Beware the Network!
By: Jennifer McCormick, Esq.

Self-funded employers should be careful when selecting networks. In some cases,  low discounts, anti-audit clauses, unseen provider agreements, and upside-down DRGs can cause more problems than the network access is worth. That’s especially true with wrap networks!

The Details of Your Coverage Plan Matter
By: Brady Bizarro, Esq.

Employers face many, many regulatory burdens. There is an ever-increasing number of federal regulations to abide by (although that might change), and each state maintains its own set of regulations. This can get very complicated. The family and medical leave laws are a prime example of this. In Oregon, for example, an employee can be eligible for up to 36 weeks of leave under certain specific conditions. It is essential that employers understand the eligibility criteria involved to avoid coverage gaps with a stop-loss carrier.

A Canadian Pays Cash for Care – Part One
I have personally experimented with paying cash for healthcare. I had sustained a rather nasty cyst/lesion on my chin (basketball accident – I named it Jermaine for the guy that accidently hit me) and I was on the waiting list in Canada to see a plastic surgeon (I am Canadian BTW, if you did not already know, and coverage does not equate access). I had already waited two uncomfortable months when I decided to take matters into my own hands and wallet. As I was speaking at a conference nearby, I called Surgery Center of Oklahoma (SCO), which had recently made the national news for shunning networks and offering transparent pricing, which they post online (what a concept). I will admit that I was a little nervous about the price because I had a claim on my desk from New York City for a similar procedure and it was billed at $24,000. I did some research and estimated that the average charges for my procedure would be about $8,000. Finally, I spoke with SCO, and my cash price was $800. I paid for the procedure, had no claim to worry about, and the care was excellent.  BTW – 1 year later I am still on the waiting list…

Mental Health Parity and Claim Negotiation
By: Jon Jablon, Esq.

When choosing claims to have negotiated, don’t worry about mental health parity. While it’s an important set of laws, it primarily protects patients from having higher responsibility; as long as the SPD is compliant with the Mental Health Parity and Addiction Equity Act, negotiating claims will not cause a violation, since the patient’s liability won’t decrease.

Call Me Corny: Discussion on Healthcare
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
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.

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

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I Have A Bridge to Sell You- Healthcare Discussion
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!
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.