What a spring we have had here at The Phia Group. From travelling across the country speaking at various venues, hosting our own Phia Forum a few weeks ago, to our new service offerings; we have been extremely busy here at the home office. Now that the summer is here, you would expect that things would slow down but that’s not the case at all. As the temperature rises, so does our work load, as the number of issues facing the self insured industry continues to grow. Who said that health insurance is boring!?!?!?
As plan sponsors and administrators examine their benefit plans in light of recent legal upheaval, now is our chance to implement important cost containment mechanisms. While only some changes are “mandatory,” while the “hood is open,” why not look around and make some other improvements? First and foremost, but often forgotten, is coordination of benefits, third party liability and subrogation. ”Subro” is one item that must be set forth in writing, and flow cohesively between the plan, stop-loss, network, and administrative service agreement. How recovery efforts are handled, who gets what (and when), and other subro-related issues can tie the elements of a strong plan together, or create gaping chasms between partners.
While it is true that some network contracts restrict a benefit plan’s ability to audit claims – or as is more often the case, simply prohibits the benefit plan from doing anything with the information so identified; some contracts apply unrealistic deadlines and still others contractually compel payment of claims otherwise excluded by the plan document… There are key provisions plan administrators can use to limit or eliminate the negative impact of such provisions.
Whether you are a plan administrator or claims processor trying to determine eligibility of a claim, or a stop-loss carrier trying to determine whether a submission is reimbursable, how applicable provisions apply to specific facts make all the difference. From exclusions to definitions… from discretionary authority to applicable law… not only understanding what a great document says – but understanding those documents “mean” – is the difference between overpayments and financial stability. Join The Phia Group’s innovative leaders as they discuss the best and worst language, how it impacted real plans when theory met reality, and when we were forced to ask, “to pay, or not to pay?”
2014 is now upon us and I can’t imagine it being any crazier, both personally and professionally, than 2013; of course, I’ll probably say the same thing next year! Thanks to your concerns and needs, we have many exciting new opportunities coming your way this year. 2014 will be the year of self funding where we see the industry grow to heights never seen before. With growth comes many potential pit falls, as always, we are here to get you through them. It will be interesting to see how Obamacare fares in 2014 and what it does to the employer based healthcare system. I am optimistic that things will work out for us in the end and that we will be stronger for it. Just remember that through all the chaos, The Phia Group will be your one stop for all of your cost containment and consulting needs. 2013 was great – the prospects are even brighter for this year!!!! Happy reading!