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!
As has seemingly been the case for almost every year in the last half-decade, 2013 – like its predecessors – was a busy year for those of us involved with health benefit plans. The continued (bumpy) rollout of PPACA and efforts made by legislators, regulators, and attorneys – both at the State and Federal levels – handicapped us as we attempted to adjust our plans to meet the requirements of law, while maintaining cost effectiveness. Now 2014 promises to be as eventful, if not more so. Join The Phia Group as we review the biggest issues dealt with in 2013, the lessons learned, and what we expect to be dealing with in the year to come.
MyHealthGuide Source: Adam V. Russo, CEO, The Phia Group, 2/6/2012
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