Phia Group

The Tangled Web of Contracts

On May 12, 2016
The self-funded industry is made up of a complex system of contracts, and navigation across them is anything but simple. Network contracts supersede plan documents; Administrative Services Agreements “add” plan provisions, stop-loss policies embrace carve-outs but networks prohibit them, employee handbooks promise benefits not provided by the SPD…and those are just a few examples of areas of confusion. Thank you for joining The Phia Group on May 12th, 2016 as its legal team gave a crash course in contracts. Cost-containment can be impacted by the contracts you sign, and there are often exceptions and restrictions buried deep down, or potential issues not considered beforehand. In this webinar, The Phia Group explained some of the contracting pitfalls experienced on a daily basis within the self-funded industry.

Unraveling FAQ Part 31

On May 4, 2016
Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now; in its latest FAQ, published just last week (FAQs about Affordable Care Act Implementation, Part 31), the regulators reiterate concerns regarding network adequacy and how it relates to - and regulates - reference-based pricing arrangements.

Reference-Based Pricing Webinar: Unraveling FAQ #31

On April 28, 2016
Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now

Why Plan Sponsors should be Upfront with Workers about Self-funding

On April 26, 2016
Self-funded health plans don’t have health insurers, only health plan administrators. Learn more about why plan sponsors should be upfront with workers about self-funding.

A Changing Industry: Navigating the current (Events)

On April 14, 2016
The self-funded industry changes rapidly and without notice. In recent memory, the biggest culprit has been the ACA - and in its aftermath, there have been numerous regulatory guidelines and court cases that have helped interpret the ACA's provisions. Still, though, there are many other changes occurring at any given time. Examples include assignments of benefits, discrimination, preemption, bankruptcy, subrogation, stop-loss, and more.

The Replacements

On April 8, 2016
As the self-funded industry evolves, benefit plans are forced to evolve with it or get left in the dust. Employees need quality coverage – but providing robust yet affordable programs has proven difficult for many self-funders. This conundrum can be addressed by changing inefficient or archaic processes; in response to contractual handcuffs limiting your ability to target cost drivers, too many health plans and TPAs overreact, thinking that the solution is to trash their plan entirely, and to try something new and untested – trading security for savings. When it comes to benefits, don’t remove, don’t reduce... replace! Avoid the extreme sides of the spectrum, achieve balance, and ensure your own viability with “The Replacements.” Thank you for joining The Phia Group on Tuesday, February 16th, as we identified the trouble spots found in all benefit plans, and helped develop strategies to carve them out and replace faulty portions with new alternatives – without harming the rest of the plan!

Sky-Rage: Bills, Debt, Lawsuits Follow Helicopter Medevac Trips

On March 18, 2016
The helicopter ambulance that rushed Shauna Laswell to a Las Vegas hospital after a heart attack may have saved her life. Read More.

TPA of Self-Insured Health Plan Not Subject to Texas Prompt-Pay Law

On February 24, 2016
The Fifth Circuit has ruled that a third-party administrator (TPA) of employer-sponsored self-insured health plans is not an insurer subject to the Texas Prompt Payment Act.

The Top 10 Lessons of a Reference Based Pricer

On February 16, 2016
Where to gather to discuss reference based pricing (RBP), you will have three opinions.

Montanile Changes Subrogation – How Will You Respond?

On January 27, 2016
On January 20, 2016, The Supreme Court of the United States decided in favor of the plan participant in the case of Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan

ERISA Plan Cannot Recover Settlement Funds That Have Been Spent

On January 25, 2016
The U.S. Supreme Court has narrowed, ever so slightly, the ever-changing definition of “appropriate equitable relief” under ERISA Section 502(a)(3).

How to Proactively Manage Self-Funded Employer Health Plans Recommendations by a Hospital Legal Advisor

On January 25, 2016
As more patients join self-funded plans, hospitals face new challenges regarding billing and collection. The increase in self-funded employer health plans has triggered an unintended consequence for hospitals with respect to payment for services.

Saving Stop-Loss - Protecting a Key Self-Funding Ingredient in a Hostile World

On January 19, 2016
Thank you for joining The Phia Group’s legal team on Tuesday, January 19, 2016, as they provided first-hand insight into the self-funded market’s reliance on stop-loss and threats to that industry, including what TPAs and brokers should look for – and look out for – when advising health plan sponsors regarding stop-loss options.

Secrets to Making Reference-based Pricing Work

On January 18, 2016
Employers, administrators, brokers and courts have begun to realize that determining the value of a health care service must involve something more than considering only a provider’s billed charges.

Anti-Assignment Clauses Bar Provider’s ERISA Claims

On January 7, 2016
An out-of-network health-care provider can’t continue with her claims under the Employee Retirement Income Security Act for unpaid benefits, fiduciary breach and failure to disclose documents against four health benefit plans, the U.S. Court of Appeals for the Eleventh Circuit ruled.