Stop-loss is vital to the self-funded marketplace, and for good reason – because catastrophic claims can bankrupt an employer in the blink of an eye. Not all is well in the land of stop-loss, however, as forces – both internal and external – conspire against stop-loss carriers. Regulators, fearing the impact self-funded adverse selection may have on PPACA exchanges seek to eliminate self-funding by striking at stop-loss. Meanwhile, many will attest that some stop-loss carriers have taken a more heavy handed approach to cost containment. There are different types of carriers and MGUs in the marketplace, with varying attitudes toward discretion, plan language, bill auditors, caps on payable amounts, and many other aspects of a reinsurance arrangement that can be the difference between being able to comfortably self-fund a health plan and being forced into the fully-insured market.
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.
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In 2015 the self-funded industry evolved like never before. Innovative ideas spread like wildfire, as TPAs, stop-loss carriers, employers and brokers all over the country implemented new techniques to contain costs and secure the best results. Yet, the path to savings hasn’t been an easy one to travel.
All along, The Phia Group has worked with you to resolve thousands of issues – and by far, the most misunderstood, repeated, passion-inspiring issue has been reference-based pricing, balance billing, and the role of a fiduciary when handling such an arrangement.
Thank you for joining The Phia Group’s legal team on December 15th as they discussed reference-based pricing and balance-billing from the ground up and debunked common myths associated with it. This webinar will ended the year with a comprehensive primer on reference-based pricing and balance-billing, the rights of all parties involved, and what you can do to be proactive and successfully administer a reference-based pricing program.
The self-funding industry is experiencing great opportunity and growth. In the past two years, millions of lives have transitioned away from the fully-insured health plan model in favor of the self-insured model – and despite the rise of exchanges, many employers are steering away from them for various reasons. These encouraging facts are tempered by the increased burdens facing both new and existing employer sponsors, third party administrators, industry brokers, and even stop-loss carriers and MGUs.
Fiduciary responsibilities have grown, liability shifting is now a common theme in a standard RFI, and lawsuits over claims and appeals decisions are becoming more prevalent.
Thanks for joining The Phia Group’s legal team on November 30th as we explored the numbers behind our industry’s growth and provided real-world discussion on the topic, while we explored real solutions to the issues presented.
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All too often, we find ourselves comfortably observing change from a distance, allowing others to dictate our destinies. Today, various litigious matters are being presented to courts of law, regulators are issuing new rules, law makers are drafting statutes, and insurance commissioners are releasing bulletins that impact how we operate. Elsewhere, stop loss carriers, TPAs, plan sponsors, networks, and other entities that should be working in concert are instead working against each other.
Thanks for joining The Phia Group’s legal team on October 14th as we discussed many such ongoing instances, and shared with you opportunities to take an active role in the preservation of our industry.
We’ve got the stories that will enable us all to learn from others’ mistakes, and see that “what we have here…is a failure to communicate.”
As employers look to self-fund with increasing frequency, expectations that brokers, vendors, and third party administrators will take on more binding authority are trending as well. Cases where an entity is held liable for failing to uphold a responsibility it didn’t intend to adopt are consequently on the rise as well. These recent cases impact how you are (or at least should be) handling claims.
Are you living up to expectations? Gaps in coverage and a lack of clarity expose you all to punishment and regulation.
Thanks for joining The Phia Group’s legal team on September 17th, at 1:00 PM EST, as they analyzed recent cases featuring communication breakdowns, regulation popping up in its wake, and best practices to make sure you know your role and do your job.
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Join The Phia Group on Wednesday, May 20th, from 1 to 2 PM EST, as its attorneys discuss their experiences providing plan administrators with guidance as it relates to difficult claim processing decisions, conflict resolution, and bill negotiation… as well as dissect the small factual differences between otherwise similar scenarios that made all the difference.
These are our Stories from the Front Lines.
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Join The Phia Group on April 23, from 1 to 2 PM EST, as they discuss best practices and new methodologies TPAs are considering, in their quest to remain relevant in a modern healthcare arena. Covered topics will include innovative services, products, and processes being used today, and developed for tomorrow. The Phia Group will identify both the issues and solutions that seem to be spreading, and how proactive administrators are addressing both.
Join The Phia Group’s legal team as they discuss the best practices for TPA’s and how this can help you!
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Being a fiduciary is serious business. Determining whether you are one can also be very complicated. Case law increasingly establishes that being a fiduciary has more to do with the action one takes, than the contract one signs. Entities working on behalf of self-funded benefit plans may be unknowingly taking on fiduciary status. Are you a fiduciary? What are the advantages and disadvantages of taking on that burden? What can you do to protect yourself?
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Pushback & Counter-Attack – How attorneys, providers, and the government are combating your efforts to contain costs… and what you should be doing about it!!!!
ERISA has been a target of scrutiny since its passage. Rights to subrogation, coordination of benefits, audit claims and enforce plan provisions – though pillars of cost containment – are constantly attacked. Attempts to prudently manage plan assets, though required by federal law, are met with pushback at every level. Now, with the passage of PPACA, old and new methods to maximize plan benefits and minimize costs are challenged. Join The Phia Group’s team of attorneys on Thursday, February 12th at 1PM as they discuss the hurdles we face, both old and new; and what we can do to not only survive, but thrive in the face of such adversity.
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IMPLANT WARS: How monitoring provider self-referrals, & negotiating based on actual costs can result in major plan savings!
Those who fail to identify ways to separate themselves from the pack through new, innovative cost containment processes will be left behind. Yet, even the most diligent administrator feels powerless in the face of excessive costs, finding it nearly impossible to negotiate claims with providers, or apply reasonable and appropriate pricing. Thriving requires tackling you plans’ biggest cost drivers; but how can you carve out, monitor, and negotiate “the big claims?” Kick-off the new year by joining The Phia Group’s CEO, Adam V. Russo and his legal team, as they discuss this important topic and introduce you to their newest offering; Implant Cost Pro! This is a webinar not to be missed.
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