Phia Group Media


Phia Group Media

Enough to be Dangerous- Benefit Plans discussion
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
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
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
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.

Relationships Matter in Resolving Claims Disputes
Phia received a $60K claim caused by a serious fall while the member was hiking. The member was taken to the nearest hospital which was out of network, and where the client had a history of 20% discounts.  Phia had previously developed a good relationship with this California Hospital and was able to settle the claim for 13K (200% Medicare).  Cost-containment is often claim expertise and legal strength, but relationships always count as well; Phia balances all these considerations in our dealings.

For Some, the Affordable Care Act Is a Lifesaver. For Others, a Burden.

After President Trump and the Republican-controlled Congress vowed to repeal and replace the Affordable Care Act, millions of Americans have been left wondering about the future of their health care. We asked readers to tell us how they would be affected if the law were repealed. These are some of their stories, condensed and edited for clarity.

Read more…

Diabetes patients sue 3 drug companies over alleged fraudulent insulin pricing
By Kelly Gooch

Eleven diabetes patients are suing several drug companies for alleged collusion on insulin pricing, reports The Washington Post.

The lawsuit was filed Monday in U.S. District Court in Massachusetts against Indianapolis-based Eli Lilly, French pharmaceutical company Sanofi and Danish drugmaker Novo Nordisk. The suit claims the companies systematically increased insulin list prices for years in an alleged fraudulent-pricing scheme that left patients with “crushing out-of-pocket expenses,” according to the article. The companies, the lawsuit says, increased the insulin list prices to expand their discounts without lowering the overall price tag, according to the report.

Read more…

Empowering Plans Segment 01 - The Maiden Voyage
Welcome to the maiden voyage of "Empowering Plans," a new Podcast by The Phia Group where our hosts will review the purpose of this new series of Podcasts, reveal what the next few episodes will be about, and open the forum to our partners for comments and ideas.

Industry Trends & Demands- Alaska to Maine
By: Tim Callender, Esq.

It’s about this time each year that travel really starts to kick in to high gear for numerous Phians.  From Adam, to Ron, to Mike, to Garrick, to me…. Planes, trains and automobiles!  I for one view this as an opportunity take our passion for this industry and our passion for cost-containment and unique solutions all across the nation.  This week I will be lucky enough to be a speaker at the Alaska Association of Health Underwriters Annual Expo in Anchorage, Alaska.  It will be my privilege to spend time with this great group and focus on innovating in the self-funded space.  I will be talking about cutting edge solutions that can help self-funded plan sponsors, TPAs, consultants, and other industry stakeholders keep health plan costs down while reducing the legal risks associated with self-funding.  Specifically we will be focusing on third-party fiduciary transfer opportunities to minimize legal liability; subrogation and recovery opportunities to maximize dollars returned to a plan’s pocket; and out-of-network solutions that can be utilized to keep out-of-control provider billing down while providing clear resolution on seemingly open-ended claims.  In addition, I look forward to some great discussion on plan documents and how the proper utilization of cutting-edge language is key to support all of these solutions.

Billing Itemization Required?
By: Jon Jablon, Esq.

Question: is a medical provider required to give an itemization as part of the billing? Answer: Generally no. Texas and Florida have passed legislation requiring them in certain instances, but often TPAs and plans must make the arguments that (1) the bill is not complete or “clean” without an itemization, and (2) the itemization is part of the medical record, which the patient is entitled to pursuant to HIPAA.