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Phia Group Media


Issue of the Year: Reference-Based Pricing and Balance-Billing
Issue of the Year: Reference-Based Pricing and Balance-Billing

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.

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Court Nixes Health Plan’s Subrogation Claim
Posted December 22, 2015, 3:11 P.M. ET
By Carmen Castro-Pagan
A health plan isn’t entitled to reimbursement of $48,000 in medical expenses it paid on behalf of a minor beneficiary who was injured in an all-terrain vehicle accident, the U.S. District Court for the District of Arizona ruled.


In granting the beneficiary’s motion to dismiss, Judge Diane J. Humetewa ruled Dec. 17 that the plan’s reimbursement clause was unenforceable because it wasn’t included in the formal plan document, but instead was part of the summary plan description. The court further held that in light of the conflict between the plan and the SPD, the terms of the master plan controlled.
The case is Apollo Educ. Grp. Inc. v. Henry, 2015 BL 419831, D. Ariz., No. 2:15-cv-00143-DJH, 12/17/15

Less Takes More - The Phia Group Addresses the Summary of Benefits & Coverage Requirement

Benjamin Franklin, Blaise Pascal, and Mark Twain are all credited with having said, “I would have written a shorter letter, if I’d had the time.” Unfortunately, efforts to simplify complex matters often constitute the greatest challenge. This fact of life is certainly proven by the Affordable Care Act and its requirement that health plans provide consumers with a concise document detailing, in plain language, information about plan benefits and coverage. This summary of benefits and coverage document ( or “SBC”) is meant to help consumers better understand the coverage available to them, and allow them to easily compare options by summarizing key features such as the covered benefits, cost-sharing provisions, coverage limitations and exceptions.

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Keeping PACE With The Trends
Keeping PACE With The Trends

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.

Download Webinar (Slides with Audio) Here

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The Supreme Court Seeks Solutions to the Latest Challenges to Subrogation Rights in Montanile Case
By Catherine Dowie

The facts of the latest healthcare subrogation challenge on the SupremeCourt’s docket (Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan) will be familiar to many. As you may recall from the June 2015 article,“TheRoad to Recovery: Subrogation Gets Its Day in Court… Again,” following a motor vehicle accident, Robert Montanile’s health plan paid over $120,000 on his behalf, subject to all plan terms, including a subrogation and reimbursement provision.
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