The Phia Group Appoints Tim Callender, Esq. as Vice President of Sales & Marketing

Braintree, MA – The Phia Group, LLC is pleased to announce the appointment of Attorney Tim Callender to the role of Vice President of Sales & Marketing.

The Phia Group benefits from its reputation as a forward thinking advocate for the employer based and self-funded health plan industry. In this newly established role, Tim will provide customer guidance, brand development, and lead The Phia Group in its offerings to the industry. Sales Executive, Garrick Hunt, will continue to serve in his vital role and benefit from Tim’s leadership and industry expertise.

Tim brings with him over 10 years of legal and business experience, ranging from private legal practice, to various industry association board memberships and his time as general counsel for a large TPA.

Commenting on his new role, Tim stated, “This new role is a natural progression and a perfect fit. I’m very fortunate that my career has allowed me to learn the ropes of the self-funded industry first from the TPA perspective and then grow that knowledge from within The Phia Group’s industry-wide footprint. With my legal background, I know that I am uniquely positioned to understand the nuances and legal difficulties presented to those within our industry and then work to apply solutions best suited to fit those needs.”

The Phia Group’s CEO, Adam V. Russo, remarked, “Tim is an attorney who has walked in the shoes of our clients, and spent the majority of his career defending them. As the VP of Sales and Marketing, Tim will once again be called upon to improve the standing of our industry – by sharing opportunities to work with The Phia Group and benefit from our efforts, products, services, and ideas. His legal acumen, ability to communicate in any forum, and overall leadership qualities make him a perfect fit for this new role.”

For more information regarding Tim’s new role and The Phia Group’s many services, please contact Attorney Callender by email at tcallender@phiagroup.com or by phone at 781-535-5631.

About Timothy Callender, Esq.

Tim was raised in the pinnacle business environment – a successful, family-run cattle operation in central Idaho. Tim began practicing law in Boise in the early 2000s before transitioning to the role of in-house legal counsel for a third party administrator where he learned the ins and outs of the TPA world and the self-funded industry as a whole. Tim has spoken on a variety of industry topics at respected venues such as the Society of Professional Benefit Administrators (“SPBA”) and the Health Care Administrator’s Association (“HCAA”). Tim currently sits on the Board of Directors for the HCAA as well. In the past year, Tim has held a leadership role within The Phia Group, directly related to Phia’s Plan Appointed Claim Evaluator (“PACE”) service as well as Phia’s Independent Consultation and Evaluation (“ICE”) service. Tim works out of The Phia Group’s Boise, Idaho office.

By J.B. Silvers

There’s a joke among insurers that there are two things that health insurance companies hate to do — take risks and pay claims. But, of course, these are the essence of their business!

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By popular demand, The Phia Group has published a list of common or helpful industry acronyms. This list has historically been used this as a training tool for The Phia Group's own employees, but it is being provided here in the hopes that it is found informative.

Click here for the list.

The Phia Group thanks you for sharing its common goal of reducing health care costs and helping the self-funded industry grow.

2016 has been another huge year for self-funding, and a year of significant change for healthcare in general – and with the results of the recent presidential election, 2017 is slated to be an exciting year as well. 2016 has played host to all sorts of new federal regulations, state laws, market trends, and cost-containment options, and we expect 2017 to be even more unpredictable…but still great for self-funding.

Thank you for joining The Phia Group’s legal team on December 13, 2016, for the 2017 Phia Forecast.

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The Phia Group, LLC Officially Announces the Release of its New “Independent Consultation & Evaluation” (ICE) Service

Braintree, MA – The Phia Group has for more than a decade been a source of document review, claim analysis, and regulatory compliance consultation for the health benefits industry. Today, statutory changes are occurring with greater frequency, and the industry needs objective analysis and expert consultation now more than ever before.

Unfortunately, hourly billing (the method by which most legal consultants charge clients) tends to be difficult to budget, predict, and afford. Rather than force clients to choose between dealing with open ended invoices and addressing difficult situations without assistance, The Phia Group now offers a consultation service featuring a per-employee per-month subscription fee.

“From business development and third party contract review to the application of ambiguous plan exclusions in unusual circumstances, you need legal consultation. To address regulatory compliance concerns, claim processing queries, and to collaborate on difficult administrative tasks, having an experienced team of attorneys and industry experts on call is a must have,” remarked The Phia Group’s CEO, Adam V. Russo, “The Phia Group understands, however, that the cost can be prohibitive – until now.”

The Phia Group’s Senior Vice President and General Counsel, Ron E. Peck, remarked, “We believe that we are all ethically obligated to seek out objective, professional feedback in response to difficult situations. When the cost of such aid increases as the time spent on the matter extends, those who bill by the hour are rewarded for delays, and clients are punished for seeking out thorough review. The Phia Group opposes that inherent conflict of interest.”

With an ICE subscription fee, clients can preemptively budget for and share the cost of this invaluable resource – allowing The Phia Group and their clients to focus on what is really important – results.

For more information regarding ICE and The Phia Group’s many other services, please contact The Phia Group’s Sales Executive, Garrick Hunt, by email at ghunt@phiagroup.com or by phone at 781-535-5644.

The election is behind us, and no matter who you supported, it was one of the most divisive in recent history. Regarding the contentious topic of healthcare, President-elect Donald Trump has promised to repeal the Affordable Care Act and replace it with a better, more efficient system. The future of our industry is sure to change.

Thank you for joining The Phia Group as we shared our predictions in a special-edition webinar. It’s going to be an interesting year…

Click here to download the slides.
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As the Department of Labor hones in on what is ethical (or unethical) and what constitutes fiduciary liability, plan administrators, third party administrators, brokers, and various advisors who service self-funded plans must make a renewed effort to ensure that their actions are in compliance with current legal and ethical standards. All self-funded entities must take steps to avoid actions that may be deemed unethical or in violation of their considerable responsibilities - and even when exercising good faith, it is still possible to act unethically.

“Every day, millions of dollars are responsibly handled by HCAA members on behalf of self-funded health plans. Unfortunately, we all know of cases where our fellow administrators have made errors or acted unethically,” said HCAA’s CEO, Carol Berry. “The Phia Group’s attorneys are experts in the fields of ethics and fiduciary liability, and we thought it timely to partner with them in presenting an informational webinar to our industry.”

Thank you for joining The Phia Group’s CEO, Adam V. Russo, Esq., and Sr. Vice President and General Counsel, Ron E. Peck, Esq. on November 15, 2016. In this presentation, they delved into the intricacies of the law surrounding self-funded ethics and examine recent case law involving entities that have toed the line of unethical behavior, sometimes finding themselves on the wrong side of this quagmire.

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Pharmacy Benefit Managers, or PBMs, are an important factor in the cost and value of self-funding - yet many TPAs, brokers, and plan sponsors feel it is impractical to even look into changing the status quo. Self-funded plans and those who service them, however, should be constantly on the lookout for effective alternatives to their current procedures - especially in this aggressive economic and legal climate.

Thank you for joining The Phia Group's legal team on October 27, 2016 as they analyzed some of the processes and agreement terms offered by PBMs, to help you make the decision regarding whether or not your current PBM is the best choice for you, your employees, and your clients.

Click here to download the slides.
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By Morgan Haefner 

Health insurer Aetna will subsidize Apple Watches for select large employers and individual policyholders during November’s open enrollment as a healthy living initiative.

The Hartford, Conn.-based insurer said it is the first major healthcare company to subsidize the Apple Watch. Aetna will also freely offer the watch to 50,000 of its employees who participate in the company’s wellness reimbursement program.

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By Andrew Silverio

When a self funded employee benefit plan, or indeed any payer of health benefits, overpays a benefit claim to a medical provider, it is often a tall task to later secure refunds.  This is especially true when the payment, even if clearly an “overpayment” pursuant to the terms of the plan document or policy, is still less than the amount of the provider’s billed charges.  From the provider’s prospective, they have received less than the amount of their bill, and from the payer’s perspective, the beneficiary and/or provider have been paid more in benefits than they are entitled to.  It is no surprise, then, that payers have developed various methods to facilitate overpayment recoveries beyond simply asking for refunds.  One of the most common such methods is “offsetting”, reducing the amount of future benefit claims to “cancel out” a previous overpayment.


The practice of offsetting claims as a method of overpayment recovery has been the subject of much conflict, and more than handful of lawsuits in the past months and years, and the practice does indeed appear more objectionable the farther removed the claims being offset are from the original overpayment.  For example, reducing a later benefit claim from the same plan participant for treatment at the same facility may seem perfectly reasonable.  However, reducing a benefit claim from another, unrelated participant may seem unjust, as the plan participant whose benefit payments are being reduced will be subject to additional exposure from the provider, despite having no connection to the original overpayment.

A major step beyond this practice of cross-participant offset is the primary conduct in question in Red oak Hospital, LLC v. AT&T Inc., AT&T Savings and Security Plan, and Larry Ruzicka, case 4:16-cv-01542 (S.Dist. TX, June 01, 2016).  In this case, it is alleged that United HealthCare, acting as claims administrator for AT&T’s self funded benefit plan under an ASO arrangement, violated ERISA by recouping claims overpaid by the plan from future claims submitted to a different payer, even, as is alleged, a fully-insured plan insured by United.  If true, this would mean that self-funded plan assets are essentially being converted into United HealthCare assets under the guise of overpayment recoupment. The Plaintiff’s complaint goes so far as to describe the practice as:

. . . an elaborate scheme to abstract, withhold, embezzle and convert self-insured Plan Assets that were approved and allegedly paid to Plaintiff for Plaintiff’s claim, to purportedly, but impermissibly, satisfy a falsely alleged ‘overpayment’ for another stranger claim, especially when the stranger is a plan beneficiary of a fully-insured plan that is insured by the Plan’s co-fiduciary, United Healthcare . . . Defendants knew or should have known . . . that converting the Plan Assets by a fiduciary or co-fiduciary of the Plan, in this case United, to the use of another and ultimately its own use, to pay to its own account is absolutely prohibited under ERISA statutes.

The complaint continues:

Defendants and United continued to conceal this kind of unlawful embezzlement and conversion of Plan Assets, camouflaged as overpayment recoupment or offset, even after becoming fully aware of   this self-dealing and embezzlement through investigation by the Department of Labor and repeated appeals, notices, and alerts from Plaintiff.  Defendants failed to remedy the verified embezzlement even after investigation by the Department of Labor and at least three (3) levels of administrative appeals, notices, and alerts by Plaintiff.

This complaint is not the first against UnitedHealth, and similar complaints have been filed against other large carriers acting as ASO claim administrators in the self-funded realm, such as Cigna. Interestingly, United HealthCare, the alleged perpetrator of the conduct in question, is not a party to the action.  The benefit plan itself, AT&T (as Plan Sponsor), and the plan’s individual Plan Administrator are collectively named as Defendants.  Employers and advocates of self funding everywhere should be cognizant of this fact – as plan fiduciaries, any of these parties can be found liable, and there is no better reason to seek out trustworthy and transparent partners.