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Creeping Around Pitfalls on the Way to Scary Savings? - How to Avoid Horror When Implementing Cost Containment Schemes
Creeping Around Pitfalls on the Way to Scary Savings? - How to Avoid Horror When Implementing Cost Containment Schemes

DON’T MISS OUT! Whether you’re embarking on a new cost containment adventure in-house, or with the help of a vendor, most programs are not simple “plug and play” affairs. Those who head into the dark unprepared will undoubtedly find themselves spooked by what hides around the corner.

Are regulatory nightmares keeping you up at night? Just last week the federal government announced some gory changes to their regulations, sure to have a scary impact on reference based pricing. Nervous the path you’re headed down will lead to certain doom? Many are questioning how far they can go with dialysis carve-outs, without running afoul of the Medicare Secondary Payer Act. Are the tricks piling up, but no treats are in sight? The HHS has announced a scheme to crush skinny plans. If that isn’t enough to scare you straight, someone had better check for a heartbeat!

Now is not the time to explore the regulatory wilderness alone! If you are looking to create some sweet savings, join The Phia Group’s own CEO, Adam Russo, Sr. VP & General Counsel, Ron Peck, and other members of the legal team, as they review the hottest topics and biggest news to impact our industry in the recent weeks.
Don’t be left “holding the bag;” add this free webinar to your calendar; October 30 at 1 PM and fear no more!

Click here for PDF version!

Click here to view webinar


The Phia Group, LLC Comments on Recent Industry Developments
October 22, 2014; Braintree, MA

Friends & Colleagues:

These last few weeks have brought with them a whirlwind of controversy and concern.  The Phia Group, LLC is pleased to announce that it will be addressing three of the hottest topics during its monthly webinar.  If you have not yet signed up for our FREE webinar, to be held on Thursday, October 30th, 2014, from 1:00 – 2:00 PM EST, then you will most certainly be missing out!  Hear our assessment of the following major topics:

The Regulatory FAQ Addressing Reference Based Pricing (“RBP”)

Recently, a regulatory FAQ addressing RBP programs was released, regarding “reasonable” access to providers willing to accept the RBP rate, and RBP’s impact on patient out of pockets; (limited by the Patient Protection and Affordable Care Act [“PPACA”]).  Attendees of our October webinar will hear from our legal team, as we discuss the FAQ, what it means for RBP programs, and the steps we believe you can take to protect yourself and your program.

Recent Concerns with the HHS Minimum Value Calculator

As employers are preparing their plans for the upcoming year, some are looking at other plan options that will meet most of the requirements of the Affordable Care Act (ACA) but will perhaps not meet the minimum value requirement of the Employer Shared Responsibility Mandate (Employer Mandate). However, as some employers have discovered, there appears to be a flaw in the Federal Minimum Value (MV) Calculator, a tool used to determine if a plan meets the minimum value requirement of the Employer Mandate. The MV Calculator is indicating, in some cases, that plans that do not offer basic benefits such as hospitalization coverage still meet the minimum value requirement of the ACA but this calculation contradicts the IRS guidance in IRS Notice 2012-31.

Our legal team will discuss the different types of plan designs that employers are looking at for 2015 (i.e. Preventive Only (“Skinny”) Plans and Minimum Value Plans) as well as our considerations when using the MV Calculator for these types of plans.

Pressing Our Luck When Administering Dialysis Carve-Outs In The Face Of The Medicare Secondary Payer Act (“MSPA”)

Dialysis carve-outs are common, and work very well.  Many benefit plans have taken advantage of this excellent process, and are maximizing benefits while minimizing costs.  Unfortunately, the rate of success has been “all over the map,” largely dependent upon vendors and their clientele ensuring that the applicable plan language matches the process, and doesn’t run afoul of applicable law.  Newly brought to the industry’s attention are theories and procedures, reflected in widely adopted plan language, that may come too close to violating the MSPA.  Our team will discuss what some vendors are promoting, and what concerns many have shared in response.

Join us on October 30th at 1PM to discuss these issues!

SIIA State Legislative/Regulatory Update Report
October 21, 2014 — This is your weekly update of state legislative/regulatory developments affecting companies involved in the self-insurance/alternative risk transfer marketplace. Should you have any questions on information provided in these reports and/or would like to alert SIIA to new state legislative/regulatory activity (health care, workers’ compensation and/or captive insurance matters) we may have missed, please contact Adam Brackemyre, Director of State Government Relations directly at 202/463-8161, or via e-mail at abrackemyre@siia.org.


Colorado- Exchange Assessment Regulations Published
At long last, the Colorado Division of Insurance has published draft regulations addressing outstanding questions about the Colorado exchange’s assessment. The regulations can be viewed here. The link should open the rules in a Word document.

A hearing on the proposed rules has been schedule on November 5th. SIIA will be reviewing the proposed rules to see if it needs to submit comments or questions by this date.

If you have any questions or would like the proposed rule emailed to you, please contact Adam Brackemyre, SIIA’s Director of State Government Relations at abrackemyre@siia.org.

DC- Stop-Loss Legislation
On Friday, October 10th, the Business, Consumer and Regulatory Affairs (BCRA) Committee passed the DC stop loss language contained in B20-0797 to the full DC Council without any changes.

As previously reported, SIIA and other stakeholders testified at a public hearing and met with Department of Insurance Securities and Banking (DISB) staff responsible for writing the legislation and submitted amended language and justifications for those amendments, per DISB staff request. SIIA also worked with other industry lobbyists to request that members of the BCRA committee introduce the amendments, too.

There are still opportunities to seek amendments from the full DC Council. SIIA will continue to work with stakeholders to improve the legislation, which contains a minimum $40,000 individual attachment point and effective prohibition on employers of 50 and fewer from purchasing stop loss.

Illinois- Legislation Repealing Captive Tax Increase Introduced
Since the last SIIA state update, House Bill (HB) 6302, legislation repealing the recent Illinois captive tax increase, has been introduced.

There are two short legislative periods between now and the end of the year and nobody really knows how much will be accomplished because, as one Illinois insider told SIIA, legislative matters are taking a back seat to the close gubernatorial race.

Viewing this realistically, the best chance of repealing the tax will rest with a new legislature and new governor. There are two major barriers for HB 6302 in the lame duck period. First, the legislation is co-sponsored by members of the minority political party. Second, if HB 6302 were to be passed during the lame duck session, the governor would probably veto it, as he recently referred to the tax increase as “closing a loophole” during a recent debate.

In the meantime, SIIA will continue to work with the business community, support the repeal efforts and prepare to work with elected leaders next year who may be more favorable to the business community.

New York State- Advocacy Day in Albany
SIIA has tentatively planned an advocacy day in Albany next February in support of legislation that would protect small business access to stop loss insurance.

While SIIA has professional lobbyist resources in place, we need SIIA members who are New York State residents and business owners to attend. You are the best messenger to discuss how your clients, the legislators’ constituents, would be impacted if businesses with 51-100 covered lives would lose access their current health plan. If you could take one day to travel to Albany and educate legislators, it would be an invaluable service to your clients and your industry.

More information will be coming as the event details are finalized.

Supreme Court of California Case Notification for Children’s Hospital Central California v. Blue Cross of California
In an important legal development in the healthcare cost debate, the California Supreme Court has denied a petition for review of the recent decision in Children’s Hospital of Central California v. Blue Cross of California, 226 Cal. App.4th 1260 (2014). You’ll recall that a few months ago, a California appellate court reversed a decision by the trial court holding Blue Cross responsible for the full billed charges because the jury found that an implied-in-fact contract existed between the Hospital and Blue Cross. In so doing, the jury awarded the hospital $6.6 million in addition to the $4.2 million Blue Cross had already paid, totaling a payment of $10.8 million. This decision set up a potential showdown in the California Supreme Court; but the showdown is not to be. As a result benefit plans get important legal support for the proposition that a hospital cannot be paid an amount simply because they charge for it.

See the full appellate decision here.

Stay tuned as the the California courts try to determine on remand what should be considered when determining the “reasonable and customary” value of services rendered.

Final Part of Self-Funded White Paper Series Released
American Association of Payers, Administrators & Networks

This is the third and final installment of a three-part series examining the self-funded insurance market. Part one took a look at the benefits of self-funding, the significant role the self-funded market plays in the healthcare arena, and current statistics, including the substantial increase in self-funding since the enactment of the Affordable Care Act. Part two outlined the important role the TPA provides in administrating self-funded plans. Part three outlines the business practices of the stop-loss carrier in providing coverage for self-funded plans. The white paper in its’ entirety is attached or you may access it here.

3rd Quarter Newsletter 2014

Well, the fall is definitely upon us! Over in Boston, leaves are falling, changing to majestic landscapes, and the nights are getting cold; but The Phia Group is just heating up. We have so much information to share with you this newsletter from new service offerings to case law to regulatory changes. One of the things I wanted to share with you is the amazing conference I had the privilege to speak at this past weekend in Oklahoma City; the First Free Market Medical (FMMA) Association conference. It is rare that I am overwhelmed with new information, but this forum did the trick. The goal of the Free Market Medical Association is to bring together physicians, surgeons, providers, facilities, and support businesses to provide necessary resources to promote a successful industry. Its focus is to defend the practice of free market medicine without the intervention of government or other third parties.

Read More


3rd Quarter Newsletter – Phia News
Phia Gives Back – 2014 Charity

As is our tradition for the past several years, The Phia Group partners with a local charity where we invest our time, money and support to ensure a successful program. We not only make monetary donations, but also collect needed items and have a company-wide day off so that our employees can volunteer their time and efforts to the cause. This year we have chosen to work with Jewish Family Service of Metro-west (JFS).

JFS provides vital social, health, and community services to alleviate suffering, enhance lives, and support people in need. The program that The Phia Group is involved with is the Reducing Achievement Gaps program (RAG). RAG is a comprehensive system of interventions to address the academic and social needs of poor children of immigrant families in Framingham, Massachusetts, located 30 miles from our office in Braintree.

RAG is based at the 550 student Woodrow Wilson Elementary School, located in Framingham’s poorest and highest-crime neighborhood. RAG gives Framingham’s most economically and educationally challenged school age children and their families the help and resources they need to succeed in school and in life. Please click on the link to this video to learn more:  https://www.youtube.com/watch?v=p4eowvE4kLw  

Summer Event:  In July, The Phia Group spent a day at Woodrow Wilson Elementary School for our annual volunteer day. We spent the day helping the school with various tasks such as: planting and expanding the school vegetable garden, fixing the concrete school yard by repainting lines, a US map, and other recess games, enhancing the playground by purchasing and installing additional equipment, and interior painting of classrooms and the gym.

We would love to be able to provide the students of Woodrow Wilson Elementary School with everything they need, and would greatly appreciate any donation from you. If you would like to make a donation you may do so by visiting: http://www.jfsmw.org /JFS_giving.html?action_donateReport=1&partner=networkforgood&ein=04-2730898, or by mailing a check made payable to JFS of Metrowest to The Law Offices of Russo & Minchoff, 123 Boston St., 1st Floor, Boston, MA 02125

Phia in the Industry

In Case You Missed It …

7/30 – EBMS – Employer’s View:  Cost Containment

8/28 – Sun Life – Self Funding … The Future

9/10 – Connecticut – Pequot – “Curiosity Saved the Healthcare Budget”

9/16 – Sun Life – Self funding … The Future

9/17 – Sun Life – Self Funding … The Future

9/25 – CDB – “Affordable Care Act: What’s in the cards?”

9/26 – Kempton – Oklahoma City – The Perfect Self Funded Plan

Coming to a Conference Hall Near You!

10/6 – SIIA – Best Practices & Cautionary Tales of Referene Based Pricing for TPA & Employers

10/15 – SPBA -Controlling the Hidden High Costs of Drugs Through Your Plan Design

10/23 – HealthFirst – The Perfect Self-Funded Plan

10/28 – Delaware Captive Insurance Association – “Best In Class Self-Insured Group Health Plans – What Captive Insurance Professionals Needs to Know!

11/11 – NASP – Reform & Recovery – Not the Type of R&R You Needed!

New Faces at Phia

Angela Grande – Legal

Lisa Tamulynas  – Recovery

Talise Rivers – Case Support

Joseph Huddleston – Case Support

Moving on Up !!!

Jason Kemp advanced to a CRS IV (specializing in WC)

Amanda Grogan transitioned from CE to CI

Leiana Turner transitioned from CI to a CRS Assistant

Naviana to CS Auditor & Trainer

Kathy Gatanti to Team Leader

Shannon Burns – Info Tier to Case Tier

Derriek Mish – Info Tier to Case Tier

Lyneka Hubbert – CSR to Info Tier

Jessica Goscik – Promoted to Customer Services Department

Additions to the Phamily … Mattie Sesin welcomed a new addition to her family … Say Hello to  …

Kaitlyn Francis Sesin

The Phia Group, LLC Announces The Release of its New “Phia Document Management” (PDM) Software
October 1, 2014; Braintree, MAA first of its kind plan document drafting solution, Phia Document Management (PDM) was created to satisfy the needs of the entire health plan industry. PDM allows for instant population of an online template featuring The Phia Group’s critically acclaimed plan language, while still ensuring customization to meet each client’s unique needs.For years, The Phia Group’s clients have asked them to not only draft plan documents, but also review and revise documents prepared by others; including vendors’ online templates and in-house efforts. The intent of such secondary review has always been to ensure that these plan documents are not only compliant, but forward thinking in areas of cost containment and the defense of plan rights.“Missing from the market was software that encompasses the three C’s: Compliance, Cost Containment and Customization,” said The Phia Group’s CEO, Adam V. Russo, “Our goal was to deliver a powerful and intuitive solution for plan document creation and management.” “Options presently available to the health plan industry either promote a detail oriented customized approach, or a quick and easy mass production approach…” remarked Jennifer McCormick, Vice President of Consulting, “… but until now, nothing offered a balance of the two.”“Phia Document Management is a SaaS (Software as a Service) product,” Michael Branco, The Phia Group’s co-founder and Principal said, “as a SaaS commodity, no additional hardware is necessary to access PDM; all you need is the internet.”For more information regarding PDM and The Phia Group’s other innovative offerings, please contact the PDM Project Manager, Toussaint Anderson III, by email at tanderson@phiagroup.com or by phone at 781-535-5662.About The Phia Group:The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.