To build on last month’s webinar (Part 1), join The Phia Group’s legal team for an hour on December 12, 2018, as they present the second part of this two-part series on What to Expect in 2019. Touching on topics such as appeals, stop-loss trends, reference-based pricing, and much more, this webinar will highlight current industry happenings and our predictions to help you look forward to the coming year. Just like last month: miss this one, and you’ll be left behind.
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The future is here! As we’re about to enter 2019, the undercurrents of the self-funded industry are as exciting as they are dynamic, and changes are happening at an unbelievable pace. Join The Phia Group’s legal team as they present Part 1 of this two-part series on What to Expect in 2019, which will highlight current industry happenings and our predictions to help you look forward to the coming year. Miss this one, and you’ll be left behind.
No matter what corner of the industry you’re in, you know that health plans have had a constant need to contain costs as a result of skyrocketing medical bills. The rising cost of Rx drugs has certainly been an issue as well – and specialty drugs are a hot-button issue as health plans struggle to find ways to manage them.
Join The Phia Group’s legal team for an hour as they discuss the latest trends and issues relating to specialty drugs – including plan design, international sourcing, copay programs, and more.
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In the self-funded industry, being diligent with respect to employer groups, vendors, and contracts is always important – but sometimes knowing what to put on a checklist in the first place is more difficult than checking off the items. Renewal time means it’s time to impress prospective clients, keep existing clients happy, and make sure the vendors and contracts being utilized are the best possible fit for your groups.
Join The Phia Group’s legal team for an hour as they outline a laundry list of what employers, TPAs, brokers, and stop-loss carriers should look for this time of the year – and provide some guidance on how the industry’s players can stay ahead of the curve.
From drafting the plan document all the way to recovering subrogation claims, health plans (and the TPAs, brokers, stop-loss carriers, and other vendors that service them) need to be creative, diligent, and vigilant. Network contracts, stop-loss claims, and intricate medical claim determinations are just a few of the complications that self-funded health plans and their partners need to be able to successfully navigate. Join The Phia Group’s legal team for an hour as they discuss some common snafus that health plans and TPAs face, and propose some creative solutions for managing them.
Check out these highlight snippets from our August 14 Webinar:
July 2018 PGC FAQs (11 minutes into Webinar)
Jennifer McCormick: Continuation of coverage versus a leave of absence are completely different concepts. ADA leave, specifically, is granted to an individual as a reasonable accommodation. Employers began adding these provisions to their plans due to the UPS case in which there was an individual who was pregnant and unable to continue delivering packages for UPS and there was no other function that she could perform. Thus, the reasonable accommodation for her was a leave of absence under the ADA. This is separate from short-term disability or long-term disability in that the leave under the ADA is an accommodation, as opposed to a designated leave granted through a specific employer policy.
Network Contracts (28 minutes into Webinar)
Jon Jablon: First, plans can terminate network contracts. Obviously, you should not do this before notifying the parties involved. However, in terminating the contracts, there are many reference-based pricing (RBP) vendors out there that can help you achieve your payment goals. Every RBP vendor has their own style and techniques, so we recommend you vet each one prior to making a decision. RBP also includes carve-out options, and some popular ones associated with high-dollar claims are dialysis carve-outs and air ambulance carve-outs. If are seeing claims that you can carve out of your plan, chances are there is some way to address it. It is also possible to carve out all out-of-network claims – so not just dialysis or air ambulance. This would be anything not covered by the preferred provider organization (PPO) contract.
Brady Bizarro: We have seen a lot more new disputes lately. Many have to do with soft gaps, which may not catch your eye if you are reviewing a stop-loss policy on its own. For example, there may only be four exclusions and it may say that it otherwise mirrors the plan document, but you may not always be good to go. First, the treatment of Pharmacy Benefit Manager (PBM) rebates, which can be an issue if you have a high volume of drug claims. A plan, in theory, gets rebates from drug manufacturers, but in reality, it is the PBM who is getting those rebates. One plan’s stop-loss carrier somehow found out about these rebates through an audit and was then reducing the reimbursement amounts by the rebate figures, even if it was the PBM and not the plan getting money. The key was interpreting the wording, as some carriers may use “refund” instead of “rebate”. Another issue relates to billing protocols, as some stop-loss policies will reimburse claims in accordance with “standardized billing protocols”. Some carriers even cite Centers for Medicare & Medicaid Services (CMS) billing protocols even though CMS is not the payer and this is a private payer. Medicare reimbursement rates are not the issue here, it is the way Medicare itself pays claims.
The industry is ablaze! From specialty drugs, to association health plans, to the “right to try” law, we’re all feeling the heat. The Phia Group’s leadership team attempts to address these scorching issues and perhaps cool some nerves in the process.
On Tuesday, June 19th, the Department of Labor issued a final rule on Association Health Plans. Supporters claim the rule will allow millions of Americans to access more affordable coverage options. Critics contend that it will reduce patient access and weaken the insurance markets, leading to increased costs for all. Join The Phia Group's legal team in this special edition webinar in which they will break down the final rule and explain the significant impact it is expected to have on the self-funded industry.
In a financial climate where saving money has to be made a top priority, so many entities within the insurance industry have fallen victim to someone trying to shift blame onto them. Regardless of fault, it’s in everyone’s best interests to work together to overcome issues rather than point fingers – but it’s not always that simple.
Join The Phia Group’s legal team as they discuss some situations where fingers have been pointed, how those situations were resolved, and how you can help insulate yourself from similar circumstances.
At long last, after a lengthy investigation, we are ready to present the allegations of collusion. It is alleged that powerful forces have been working together in a complex scheme to mislead us. To be clear, we are talking about Big Pharma and certain PBMs. A new class action lawsuit has been filed against CVS Health alleging that it knowingly colluded with PBMs to raise generic drug prices. The claim is that health plans and consumers alike have been overpaying for drugs. We have seen this playbook before. This time, however, there is potential for TPAs and their groups to join the lawsuit to recoup funds allegedly overpaid to CVS. Join The Phia Group’s Special Counsels for an hour as they share reports on this alleged fraudulent scheme and discuss the ways in which our industry can fight back and tackle the underlying problem of specialty drug prices.
Nostradamus? Miss Cleo? The Phia Group? In a psychic feat of foresight, The Phia Group’s team has gazed into their crystal ball and identified four issues that may not presently be keeping you up at night, but will certainly be disturbing your slumber very soon. From being forced to pay for surrogate pregnancy and births, to the IRS actively issuing letters notifying employers of 2015 tax year penalties; from a new wave of fraud, errors, and abuse leading to heretofore unseen overpayments, to case law addressing the rights of plans to utilize reference based pricing – you’ve been warned! We predict this complimentary webinar will open your eyes. Miss this webinar at your own peril… You’ve been warned!