Phia Group

The Double-Edged Sword of Discretion: How Even Great Plan Document Language Can Cause Gaps in Coverage

On April 27, 2017
Nearly all Plan Documents have some mention of discretionary authority. The ability to interpret the terms of the plan is necessary to receive deference from the courts, and is needed since not every conceivable scenario can be planned for within the plan document.

Medical Bill Blues: Pre-Payment Contracting and Negotiation, Pricing Alternatives, and Post-Payment Recovery of Overpayments

On March 23, 2017
It’s common knowledge that not every network contract adds real value, nor can medical providers always be relied upon to bill responsibly. As the fiduciary duty to be prudent with plan assets becomes increasingly relevant, it's important that self-funded health plans, and those who service them, not fall behind.

Top Miscues Employers Make When It Comes To Their Health Plans ... And What We All Can Do To Become Health Plan Heroes

On February 15, 2017
Employers who self-fund their health plan act as a traditional employer, a plan sponsor, and a plan administrator. Juggling this many roles, conflicts and contradictions are bound to happen. For instance, an employee handbook’s handling of disability leave may conflict with the health plan document as it relates to employment and plan coverage.

Back to The Self-Funding Future – Which Echoes of 2016 Will Continue to Impact Self-Funding in 2017

On January 19, 2017
The past decade has ushered in both outrage and opportunity for self-funded plans, and 2016 was no different. The characteristics of self-funded plans continued to alter in concert with new laws and regulations. While these bureaucratic efforts often hindered our ability to self-fund, for those daring enough to change with the times, we saw increased growth and prosperity. We will no doubt see these issues and opportunities continue to evolve in 2017, and only those that prepare will thrive.

2017 Phia Forecast

On December 13, 2016
2016 has been another huge year for self-funding, and a year of significant change for healthcare in general – and with the results of the recent presidential election, 2017 is slated to be an exciting year as well. 2016 has played host to all sorts of new federal regulations, state laws, market trends, and cost-containment options, and we expect 2017 to be even more unpredictable…but still great for self-funding.

The First 100 Days: President-elect Donald Trump, Healthcare, and Self-Funding

On November 21, 2016
The election is behind us, and no matter who you supported, it was one of the most divisive in recent history. Regarding the contentious topic of healthcare, President-elect Donald Trump has promised to repeal the Affordable Care Act and replace it with a better, more efficient system. The future of our industry is sure to change.

The Good, The Bad, and The Ugly – Ethics: Simple Mistakes vs. Breach

On November 15, 2016
As the Department of Labor hones in on what is ethical (or unethical) and what constitutes fiduciary liability, plan administrators, third party administrators, brokers, and various advisors who service self-funded plans must make a renewed effort to ensure that their actions are in compliance with current legal and ethical standards. All self-funded entities must take steps to avoid actions that may be deemed unethical or in violation of their considerable responsibilities - and even when exercising good faith, it is still possible to act unethically.

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.

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.

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.

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.

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.

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.

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.