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Empowering Plans Segment 03 - The Journey Continues
Once again The Phia Group’s CEO, Adam V. Russo, and Sr. VP, Ron E. Peck, delve into what makes their own company’s health benefit plan unique, and share tips employers (and those that service them) can use to improve their own plan’s performance.
Click here to open the Podcast!


The Guilty Shall Remain Nameless – Yet I shall Shame Them… Again
By Tim Callender, Esq.

In this second installment of “The Guilty Shall Remain Nameless” I can’t help but think back to an encounter I had with a walk-in clinic in Las Vegas, Nevada. Now… it’s worth noting that any walk-in clinic, one block from The Strip, is highly likely to be an interesting experience, period. And it was. First – this is the only urgent care clinic I’ve ever seen with armed guards. Now, it should be noted that I’m a small town guy from Idaho, so people walking around with guns is pretty normal, but not in this setting.  It was quite odd.

Armed medical professionals aside, the key point to this story is network confusion. I had a foot injury that I had “received” on The Strip while walking between casinos. I will leave the details alone for now. Long story short, I needed stitches. I was referred to this particular clinic by the concierge at Caesar’s Palace. One, quick Uber later and I was surrounded by armed guards and a whole mess of humanity.

I did not have my medical insurance card with me so I had my wife email me all the information. I took a sticky note and wrote down all the details for our health plan. When it was my turn at the counter, I presented all of this information to the “helpful” person manning the counter. She responded, “I’m sorry but I will need the information off of your insurance card.” I responded, “Yes. The info on that sticky note… it is literally all of the information from my insurance card.” She responded, “No. But I need the information off of the card.”  I responded, “Right. The info from my insurance card is copied, verbatim, onto this nice, yellow piece of paper. It’s all right there.” She responded, “Sir. I need the information from the card itself.” I responded, “Yes… Is there someone else here I can talk to?”

Three people later, someone finally understood that they could take the information from my sticky note and enter it into their system, just as if they had the insurance card in front of them. The information was… THE SAME! However, the battle was not over. Once the information was entered into their system, one of the helpful individuals asked me, “This shows you are in-network for ABC Network. But we see you are from Idaho. Will that work?” I responded, “Yes. ABC Network is the same.” They responded, “Where is Idaho?” I responded, “We are in Nevada right now, correct?” They responded, “Yes.” I responded, “Idaho borders Nevada…”

13 months later I received a bill from the urgent care clinic in Las Vegas. It was for north of $700.00 and listed as an out-of-network service provider.

I’m currently working through the details with all parties involved. Moral of the story… if it’s this hard for me – a sophisticated healthcare consumer… imagine how it is for everyone else.

4 main tenets of the GOP’s ACA replacement plan
By Emily Rappleye

House Republicans gathered Thursday to discuss a policy memo detailing their ACA replacement plan, according to The Washington Post.

While the meeting put many rank-and-file members at ease, they said the details presented at the meeting did not comprise a full-on plan and instead created more of a roadmap, according to the report.

The policy brief, which is fairly similar to the Republican Better Way plan, does not include information on how it will be passed into law, according to the report. House Speaker Paul Ryan, R-Wis., has promised to deliver ACA repeal legislation by the end of the month, and President Donald Trump said Thursday a replacement plan will be ready in March, according to the report.

For now, the policy memo is the closest to a replacement plan available to the public. Here are its four key features.

15 Things to Know About Stark Law
By Ayla Ellison

Enacted more than two decades ago with the simple purpose of curbing physician self-referral, Stark Law has evolved into a complex set of regulations, which some argue impede efforts to transition away from a fee-for-service system.

Here are 15 things to know about Stark Law.

Healthcare Need Not Be a Headache
By: Christopher Aguiar, Esq.

My PCP is a great doctor, but I hate visiting him. I only live 2 minutes from his office, but somehow, my quick visits usually turn into long excursions. Luckily, I’ve educated myself, understand how my benefit plan works, and have an urgent care clinic nearby. When needed (like last week when my back reminded me I’m losing my battle with father time) I make a quick stop and am in and out in under an hour with the meds I need, at no out of pocket cost thanks to my incentive laden benefit plan with no co-pays on urgent care or generic drugs.  The options are there, but you have to be educated and execute.

Summary of Benefits and Coverage- NEW Template
By: Kelly Dempsey, Esq.

The new Summary of Benefits and Coverage (SBC) template is applicable for plans that have open enrollment periods beginning on or after April 1, 2017. If there is no open enrollment period, it applies for plans renewing on or after April 1, 2017. Changes to the SBC include modified disclosures and benefits, embedded deductible/OOP information, a new coverage example, and some cosmetics. If you don’t find it as easy as 1, 2, 3, The Phia Group is here to help! Feel free to contact us at pgcreferral@phiagroup.com if you have questions or need assistance drafting in the new SBC template.

House G.O.P. Leaders Outline Plan to Replace Obama Health Care Act
By ROBERT PEAR and THOMAS KAPLAN

WASHINGTON — House Republican leaders on Thursday presented their rank-and-file members with the outlines of their plan to replace the Affordable Care Act, leaning heavily on tax credits to finance individual insurance purchases and sharply reducing federal payments to the 31 states that have expanded Medicaid eligibility.

Read more…

In the Spotlight… Or the Crosshairs? Healthcare Discussion.
By: Ron Peck, Esq.

Yesterday we presented a webinar regarding issues that pop up when employers don’t act with consistency between their plan, handbook, behavior, and law.  We talked about situations where the employer is responsible (by contract) but stop-loss won’t reimburse; because the employer obligates themselves to do something that their plan doesn’t allow.  This is bad for the employer, but more importantly, every time an employer is bankrupt by an issue like this, it’s a black eye for our industry. This is a time of political upheaval, and the powers that be are scrambling to find a replacement for the status quo.  If self-funding is linked to these types of issues, conflict, and loss, we will not be the future of health benefits in America.  That’s bad for us, bad for healthcare, and bad for Americans.

How expensive are knee replacements in the 20 largest US cities?
By Laura Dyrda

Total knee replacement surgery price varies by geographic region.

The total price includes hospital services, physician services and anesthesia, according to Healthcare Blue Book. The hospital services assume a four day admission and the physician fee is for the procedure and routine postoperative care. The anesthesia price assumes average surgery time of 2 1/2 hours.

Here are the prices for the 20 largest cities based on population from the 2010 U.S. Census.

CMS projects next decade of health expenditures: 5 takeaways
By Ayla Ellison

National health spending is expected to grow at an average annual rate of 5.6 percent from 2016 through 2025, with expenditures projected to hit $5.5 trillion in 2025, according to new estimates from CMS’ Office of the Actuary published Wednesday in Health Affairs.

Although congressional Republicans are working on a plan to repeal and replace the ACA, it isn’t possible to determine the impact of potential policy changes on health spending and health insurance at this time. Therefore, the national health expenditure projections are constructed using current law and do not assume potential legislative changes over the projection period.

Here are five takeaways from the CMS report.