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Keeping the “Benefit” in Benefit Plans
By: Ron E. Peck, Esq.

Once upon a time, employers offered employees “benefit plans,” with an eye toward attracting and retaining a talented workforce.  The word – benefit – literally means something good; positive; of added value.  At some point, though, health insurance became less of a benefit and more of an entitlement.  At first it was an entitlement in theory, only, but more recently it became an entitlement according to law.  Next, between minimum value plans and high deductible plans, these so-called “benefit” plans became a point of contention – bad blood – between employers and employees.  Employers are increasingly frustrated with the rising cost of medical services and medication, as well as their employees’ perceived lack of concern or “skin in the game.”  Employees see co-pays and deductibles rising, and assume that greedy employers and “insurance companies” are looking to give them less, while expecting more from them.  When did we stop thinking of these plans as a “benefit?”  Fortunately, there are a few entities that still believe that “benefit” in “benefit plan,” has meaning, and are offering innovative ways to cut costs without reducing coverage – focusing on needs and avoiding worthless, wasteful endeavors.  From directing participants to use only the best, most cost effective providers, to rewarding them for spotting errors… from providing benefits that people actually need, and carving out high cost rarely needed services… by engaging providers in negotiation and direct contracting rather than blind faith on a third party’s efforts… we are all empowering plans, and returning the “benefit” to benefit plans.

The Big Elephant in the Room….
By: Michael Branco

From day one, over 16 years ago, we have offered overpayment recovery services, but over the last year, I have seen the largest growth in this service. It’s not enough to simply make a call or send a letter, and it’s okay to have that uncomfortable conversation with your client on why an overpayment occurred.  Ignoring the issue is no longer an option.

HIPAA Special Enrollment vs. Section 125 Permitted Election Change – There is a difference!
By: Jennifer McCormick, Esq.

An individual may want to adjust their health plan enrollment. For example, if a plan member’s spouse loses plan coverage due a reduction in hours it will likely trigger a HIPAA special enrollment under the health plan.  However, if that spouse discontinues their plan coverage because premiums increased a HIPAA special enrollment would not be triggered.   A permitted election change is separate, and would be outlined within the Section 125 cafeteria plan, not the health plan. HIPAA special enrollments and Section 125 permitted election changes do not necessarily overlap, and must be reviewed on a case by case basis.

Want to improve health care? Focus on hospitals
By Rich Lesser & Barry Rosenberg

(CNN) As Congress and the Trump administration debate the future of America’s health care system, they should go beyond the issues of access and cost and recognize an equally important priority: that patients come first, so health reform should also focus on quality of care.

Read more…

HHS nominee Dr. Tom Price’s 2nd confirmation hearing: 5 things to know
By Emily Rappleye

Rep. Tom Price, MD, R-Ga., faced another four hours of cross-examination Tuesday, this time with the Senate finance committee.

Grilled by Democrats and lauded by Republicans, Rep. Price’s second hearing comes ahead of a vote that will determine his nomination. The committee recessed and will reconvene to vote “promptly,” according to Sen. Orrin Hatch, R-Utah.

Here are five things to know about the second hearing.

Read more…

Another Successful Balance Billing Negotiation
Phia received a $167,000 claim from a Surgery Center (Spinal Decompression) where a client tried to negotiate it on their own and were unsuccessful. Phia reviewed the claim and engaged the provider for a settlement.  After many exchanges the provider offered to settle at a case rate of 40K (still too high) but when Phia called Provider to discuss they had transferred the claim to an external accounts receivable company.  This company now advised that they would only offer a 30% discount.  Armed with Phia’s industry leading cost-containment Plan Language, the Plan issued a UCR payment to Provider of 10K.  As expected the provider balanced billed the member until Phia’s legal team got involved – the claim was settled a week later for a total of 15K

The Gap Trap
By: Jon Jablon, Esq.

So how ‘bout those stop-loss carriers?! We work closely with some excellent carriers that look for reasons to pay claims and are a pleasure to interact with – but there are also carriers and MGUs out there that will do whatever they can to deny claims. Make sure you and your clients read policy proposals carefully! Don’t fall into the stop-loss “gap trap.”

The ACA, a New Congress, and President Trump – Oh My….
By Tim Callender, Esq.

On Friday January 20th, President Donald Trump signed his first executive order, directing agencies to give more leeway to the states in the way that states implement (“carry out”) the Affordable Care Act.  It appears that this executive order is primarily a precursor of things to come and is an attempt to set general expectations as to healthcare policy under the Trump Administration.  At its core, the order provides a sweeping mandate, directed at the heads of agencies that administer the ACA, to find ways to ease the financial burden of the ACA.  Specifically, the order does mention the Department of Health and Human Services, soon to be headed up by Representative Tom Price.  As all of us in the industry know, HHS might be the federal agency most impacted by the ACA.  HHS’s actions, or inactions, under this order will likely guide the IRS and the DOL, the other two federal agencies primarily guiding the day-to-day execution of the ACA.


Many pundits have already spoken up, concerned, or pleased, that this marks the end of the individual marketplace (aka The Exchanges).  Truth be told, whether a support of the ACA and its marketplaces, or not, it seems that all would agree the marketplaces have seen significant troubles and the sustainability of the model has been in question for some time.  Is this the piece that truly spells the end of the ACA marketplaces?  Perhaps it is.

But, as in all things coming from Washington D.C., we will have to wait to see the true, logistical impact of this broad, executive order.

In addition, GOP Senators Bill Cassidy (R-LA) and Susan Collins (R-ME) recently released one Republican-led proposal that may be introduced as a replacement to the ACA.  Among the highlights of the plan are measures allowing states to continue with the ACA, should they “like it” – whatever that means.  Additionally, the proposal appears to urge pricing transparency on medical procedures, while also allowing for the existing subsidies and tax credits provided in the 2010 law to remain intact.  This proposal seems to be a mid-ground departure from many other GOP plans, in that it seems to allow for many aspects of the ACA to remain in place.

The most interesting aspect of the Cassidy-Collins proposal is an item that would appear to push all uninsured residents into a federally subsidized catastrophic plan, through auto-enrollment.  Good idea or bad idea – I don’t know.  But, it feels like an interesting departure from the typical, market-driven, free-choice arguments that conservative lawmakers usually provide when discussing healthcare.  Then again, perhaps the focus on a catastrophic plan narrows the concern that this “forced” auto-enrollment would be replacing market-driven free-choice in that a catastrophic plan would not cover many of the day-to-day health needs that a plan member might want, thus pushing him or her to explore additional, private options for their routine coverage.  Perhaps the genius of this “forced” catastrophic move is that it takes a good deal of the risk off of the primary insurer thus causing those costs to decline?

It all remains to be seen.  Stay tuned as we watch, digest, and continue to comment on the upcoming changes affecting our industry.

Attack on ERISA Preemption Continues…
By: Chris Aguiar, Esq.

ERISA preemption seems like such a simple concept; further proof that reasonable minds can disagree.  In just the past 10 days we have received mixed messages from some of the highest courts in the country.  First it was the 8th Circuit’s unanimous pro-preemption decision, and then it was the Supreme Court’s refusal to hear a case to overturn the 6th Circuit’s anti-preemption decision regarding the HICA tax.  All of this while the ACA is in danger under the Trump Administration, and states continue to attack a key component of self-funding; stop loss (with New Jersey being the most recent culprit).  I am interested to see how the ACA repeal will develop and whether the anti-preemption momentum brought on by the states in their attempt to thwart employers from providing cost effective benefits in an effort to bolster the exchanges will slow down.

For a bit more history and background visit http://issuu.com/sipconline/docs/self-insurer_jan2015?e=8828922/10737445.

Welcome to our New Blog!
By: Adam Russo, Esq.

Welcome to the newly updated passionforsubro blog.  Starting today, you all will get daily updates, comments, tidbits, opinions, and fun facts from the many outstanding team members here at The Phia Group.  We couldn’t have thought of a better time to start this than the first week of the Trump Administration.  We have no idea where Trump will take us within the world of healthcare but we do know that it will be an interesting and wild ride.  We always welcome your feedback and opinions so let the free thoughts flow as we enter a new world in the health insurance space.   Here is what I can tell you for now – self funding is hot and continues to grow.  More and more employers want the ability to cater to the needs of their workforce and identify ways to rein in costs.  We are here to help these employee benefit plans identify creative ways to do just that.  Happy reading!