In this episode, learn more about the life and background of Andrew Fine, Phia’s Lead Intake Specialist. Listen in as Andrew discusses his family, the fan club behind him, compliance being the number one priority for plans, and the bittersweet nature of the Celtics. Listen in closely, as the former sports analyst might give you some insider tips!
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By: Kevin Brady, Esq.
In May of this year, the Federal Drug Administration (FDA) approved the most expensive drug in the world, Zolgensma. The drug was developed by Swiss drug maker, Novartis, and costs $2.1 million for the one-time single dose. The drug maker will spread the burden of the high cost by allocating payments for the drug over a 5- year plan at $425,000 a year.
Zolgensma is a new gene therapy drug used to treat spinal muscular atrophy (SMA). SMA is a rare, genetic neuromuscular disease caused by a defective or missing gene. Infants with the missing or defective gene will lose motor function control and are likely to lose the ability to breath, speak, swallow and walk. Essentially, Zolgensma can be used to treat all types of SMA in newborns and toddlers up to age two (2).
Not only is this the most expensive drug in the world, the drug maker, Novartis, has recently come under scrutiny by the FDA for allegedly manipulating pre-clinical data prior to FDA approval. For now, the FDA is not inclined to take Zolgensma off the market, as they still believe in the safety and efficacy of the drug. However, the FDA is likely to take action against the drug maker, most likely in the form of civil and criminal penalties.
With all the scrutiny around this new drug, plan sponsors should be aware of the high-price tag associated with this drug and the alleged misrepresentations of data by the drug maker in its seeking of FDA approval. Plan sponsors should carefully consider their options when drafting their plans. Gene Therapy is always a hot topic as it is typically associated with a high cost. For Zolgensma, while there may be a high up-front cost, if the drug is effective, most importantly, it will save lives and potentially years of expensive, demanding, and less effective alternative treatments.
By: Jon Jablon, Esq.
If you draft, administer, or otherwise manage self-funded health plans, you are likely very familiar with the appeals submission timeframe requirements within the SPD. The relevant regulations prescribe certain timeframes within which a health plan must allow an appeal, and a health plan is certainly free to allow longer periods of time, but abiding by the legal minimums tends to be the common practice.
That’s all well and good, and relatively simple to administer, but they tend to fall flat when applied to balance-billing. Let me explain:
I received an email the other day from a very angry medical provider with whom I had been attempting to resolve a balance-billing scenario, in which the attorney explained that the TPA said to him (and I quote): “On page 83 the plan document says that all payment appeals must be submitted within twelve months of the date of the adverse benefit determination. You have billed the patient seventeen months following the determination. Therefore you are prohibited from billing the patient for the balance.”
A provider’s appeal is to the Plan itself, saying, essentially, “you have underpaid this claim,” whereas balance-billing is to the member, saying “you are responsible for the balance that your health plan has not paid.” While it is certainly possible for a provider to simultaneously appeal to the Plan and balance-bill the member, they constitute two very different demands, and only one – the appeal to the Plan – falls under the purview and limitations of the Plan Document.
I want to do my part to dispel the popular misconception that balance-billing can be eradicated with the right plan language in place. Balance-billing, by definition, is outside the terms of the Plan, and therefore nothing written in the Plan Document can change a provider’s rights. The Plan Document’s terms can and should be used as arguments against balance-billing, of course, and the Plan needs strong language to defend itself – but even the strongest Plan Document language cannot legally prohibit a provider from balance-billing.
Feel free to contact PGCReferral@phiagroup.com, and we’ll do our best to answer all your appeal and balance-billing questions!
In this episode, prepare to be enchanted by Mattie Sesin, our Director of Recovery Services. Like a toad kissed by a princess, her career has transformed – and we invite you to join the journey. Marvel at the tales of family, festivities, and food. Miss this one, and you’ll likely turn into a pumpkin.