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Phia Group Media


How Low Can You Go? Managing Specialty Drugs, Reducing Overall Pharmacy Spend, and Unraveling the Mystery Behind PBMs

On October 27, 2016
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.

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Independent Consultation & Evaluation: ICE, ICE, Baby!

On September 22, 2016
Our industry is plagued by issues related to compliance, contracts, and cost-containment – and a myriad of other legal issues as well. Engaging an expert for a second set of eyes is a chore in itself, requiring approval from management or an individual group as well as a cost-benefit analysis of the expert’s fees – sometimes resulting in the decision not to consult a neutral third-party at all.

The Phia Group has been providing consulting services since its inception seventeen years ago. We have seen thousands of problems that could have been mitigated or avoided entirely by consulting an expert. As a result, we have created the ICE service – short for Independent Consultation and Evaluation.

Thank you for joining The Phia Group’s legal team on September 22, 2016 at 1:00pm (EST) as they discussed some of the problems facing the self-funded industry today, provided examples of situations where being proactive rather than reactive would have been beneficial, and presented the value that ICE can hold for TPAs and health plans.

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Unwrapping Your Wraps

On August 23, 2016
Wrap networks provide plans with discounts off billed charges for claims that don’t fall within the plan’s primary network. But do these wraps really add value? With skyrocketing provider charges and static discounts off of those charges, the modern-day wrap network doesn’t seem to provide much help when it comes to claims costs.

Thank you for joining The Phia Group’s legal team on August 23rd, as we analyzed provisions of wrap network agreements, with a focus on what plans can or can’t do to cut costs. We proposed some innovative ways for your plans to save additional money above and beyond wrap networks, generating unprecedented value for your plans.

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Back to Basics: Plan Documents 101 (Part 2)

On July 13, 2016
When we think of hot topics in the self-funded industry, plan document drafting is hardly the first thing that come to mind. Instead, issues such as fiduciary duties, reference-based pricing, transgender coverage, employee incentives, and provider abuse are on the tip of everybody's tongues. All these topics, however, share a common feature: they're all reflected, in some way or another, within the plan document. Without compliant and effective plan document language, a plan can't offer robust benefit programs while containing costs.
 
Thank you for joining The Phia Group's legal team (including Jen McCormick) on Wednesday, July 13th, 2016, at 1:00pm (EST), as we presented Part 2 of our "Back to Basics: Plan Documents 101" presentation. We discussed some more of the best and worst practices for plan drafting, to help you make the most of every page of your plan document.

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Back to Basics: Plan Language 101

On June 15, 2016
Most situations that involve self-funded benefit plans revolve around language within the plan document. Whether deciding if a service is experimental, or figuring out whether a dependent is actually covered, or deciding whether a leave of absence will extend coverage, the plan document controls in just about all situations. For that reason, it's all the more disastrous when poor plan language handicaps plans and TPAs. Like we always say, your rights are only as good as your language.

Back by popular demand, The Phia Group's very own Jen McCormick was the star of this webinar, since nobody knows plan documents like Jen.

Thank you for joining The Phia Group's legal team - and Jen McCormick - for an hour on Wednesday, June 15th, 2016, at 1:00pm (EST), as we went "back to basics" and discussed some best and worst practices for plan drafting, to help make sure your plans don't lose their rights by failing to claim them in the first place.

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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.

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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.

Thanks for joining us as The Phia Group's legal team and special guest Tim Martin of Payer Compass helped unravel the mystery of the DOL's latest FAQ - and what it means for you and your plans.

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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.

Thank you for joining The Phia Group's legal team as they described recent goings-on within the legal and regulatory framework in which we all operate. Being aware of changes within the industry can be important to take the necessary action as well as to be able to predict and prepare for what might be on the horizon.

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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!

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

On January 19, 2016

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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