The Book of Russo:

I love April. Between the New England winter finally loosening its grip, my birthday, Easter (including hiding easter eggs around my yard at 4 a.m. when it’s 35 degrees outside), and yes…OPENING DAY FOR THE CLEVELAND GUARDIANS (and some other teams, I guess) – in my opinion, you can’t beat this month! It’s also the beginning of conference season. In fact, I just got back from SIIA’s event in Orlando, where we saw not only the largest crowd since the pandemic began – but perhaps the best attendance I can remember, period. The industry is changing for the better, as TPAs realize that certain technology and member communication are the keys to ensure the self-insured industry enjoys growth and expansion, now – and in the future.

I have never seen such proactive measures and such an upbeat attitude about our work, and what our future can bring. There are, however, risks all around us. Whether it’s a random gap between plan coverage and the applicable stop-loss policy, groups forcing products or vendors upon administrators that can’t coordinate with them, services being advertised to witless employers one way whilst the reality is far different, rigid contracts and processes eliminating customization, and beyond… there are pitfalls around every corner. This is a major reason why The Phia Group is here for the industry. We love looking at new technologies and offerings that promise to reduce overall cost and increase quality outcomes, while remaining wary of cracks in the armor; ensuring a seamless implementation process that’s is never as easy as it seems. As always, we celebrate what is great about this industry, but continue to be on the lookout for threats. With that in mind, I hope you enjoy this newsletter, and the great insight from our staff.

– Happy reading!

Service Focuses of the Quarter: Subrogation & Phia Unwrapped 

Subrogation  

At The Phia Group, we recognize that being prudent with plan assets entails recovering them whenever possible. Thus, we offer comprehensive subrogation recovery services that help our clients maximize recoveries, protect their plans’ best interests, and, most importantly, keep costs down. Our team of specialized recovery professionals, including attorneys, is widely considered to be the most experienced in the self-funded industry. Having vast industry experience even outside of subrogation and expertly crafted plan language that reflects the current state of the law and this ever-changing industry allows us to review existing plans and customize subrogation rights and other language to fit our clients' needs. 

Our subrogation services involve ordinary third-party accident cases (such as car accidents, slip and falls, etc.) and mass tort cases (such as products liability, toxic torts, etc.), and we place all high-dollar cases in our attorneys’ hands for optimal settlements. Our state-of-the-art analytics and advanced algorithms ensure robust case identification, and our case management process promotes efficiency. We also provide specialized reporting so our clients can manage their business. We understand what a comprehensive, optimally performing subrogation service is because we've built one. Let us help you maximize your recoveries and protect your plan's best interests.

Phia Unwrapped  

Wrap, extender, and other leased networks offer small discounts and audit restrictions, affording providers nearly unlimited rights. With Phia Unwrapped, we replace wrap network access and modify non-network payment methodologies, securing payable amounts based upon fair market parameters that are unbeatably low.

Phia Unwrapped places no minimum threshold on claims to be repriced or potential balance billing to be negotiated, and The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full. 

Phia Unwrapped implementation entails setting up an EDI feed with the claims administrator, so claims are flagged, transferred, and repriced automatically. Phia Unwrapped is billed based on a percentage of actual savings, leading to fair rates and no excessive costs for unprecedented savings – and if there’s pushback or balance-billing, our Provider Relations team will handle it. 

Out-of-network claims that run through Phia Unwrapped yield a whopping average savings of 74% off billed charges (three times the average wrap discount). On average, The Phia Group sees roughly 2% of claims result in balance-billing; these results are similar throughout different plan types and locations, proving that this program and these results can be replicated nationwide. 

Per our data, Phia Unwrapped has yielded significantly better savings than wrap networks. Can you and your clients afford to maintain the status quo given such results? 

Contact Garrick Hunt, at GHunt@phiagroup.com to learn more about The Phia Group’s Subrogation and Phia Unwrapped services. 

Phia Case Study: Gag Clause Attestations

The Consolidated Appropriations Act made many changes for health plans, including prohibiting so-called gag clauses, which are contractual provisions prohibiting a plan from disclosing information involving cost of healthcare services or availability of lower-cost alternatives. This prohibition is intended to increase healthcare transparency and empower patients to make more informed decisions – but, ironically, the law applies to health plans. In other words, while providers suggest gag clauses, health plans are prohibited from agreeing to them, resulting in a strange contractual dynamic. 

A TPA utilizing Phia’s ICE service approached the consulting team hoping to receive an affirmation of its current process regarding the relatively new requirement for health plans to submit “gag clause” attestations. Specifically, although the requirement applies to the plan itself, the TPA tried to make things easier for its plans and offered to submit gag clause attestations for its clients for a nominal fee. When we asked how the TPA verifies the lack of gag clauses, we were told that they do not, and affirmations are submitted on a given plan’s request, even without asking the plan to prove or even verify it! 

;We immediately cautioned against that practice, because although the TPA’s ASA had a broad indemnification provision, we know from experience that when a regulatory body finds fault with a particular plan’s operations, it also often takes a deep dive into the TPA’s operations on a larger scale as well, under the theory that the TPA’s actions often facilitate or promote the plan’s actions. We’ve seen this lately, particularly regarding mental health parity. If a TPA submits a gag clause attestation on behalf of a health plan and that attestation is ultimately imperfect, the TPA may be indemnified by the plan, but it’s a better idea for the TPA to at least confirm that the attestation is correct prior to submitting it. Furthermore, an audit of the TPA’s processes is burdensome. 

Proactively verifying accuracy of a gag clause attestation may be slightly more work, but anecdotally, protecting yourself is worth it! (Of course, Phia can help review contracts if necessary.)

Fiduciary Burden of the Quarter: Mental Health Parity – Past and Future

It’s old news that health plans subject to Mental Health Parity and Addiction Equity Act must perform a nonquantitative treatment limitations analysis, intended to document a plan’s compliance with the law’s parity aspects. This has become an important plan function, and plan administrators must disclose the report per normal plan disclosures. 

There are many nuances involved in performing an NQTL analysis, which many readers may have experienced; for example, while plans are struggling to comply with mental health parity, they are updating documents and processes in the normal course of business and in response to unearthed parity concerns – but to perform a given analysis, the plan must travel back in time and report on what was the case, rather than what is now the case. 

The result? Many health plans want to have their NQTL analyses performed after they have updated their SPDs to change or remove noncompliant provisions. The logic makes sense: once a compliance issue was discovered and fixed, why would the plan want to perform an analysis of a version that is now old and defunct?! After all, plans understandably want to do whatever possible to get a “passing” grade on the analysis report.

Unfortunately, though, that’s not what regulators look for, and not what health plans have been directed to do. An analysis is specifically designed to review the plan’s historical compliance, which is bolstered by the idea that analysis must also include data regarding the plan’s operational compliance. Updating SPDs is always good, but an NQTL analysis can’t scrutinize a new plan document that didn’t exist during the testing period, just as the analysis can’t inspect future operational data, since by definition it doesn’t exist at any given time either. When an SPD is updated, it’s updated for the future, not for the past, so the NQTL analysis needs to rely on the SPD that was in place in the past. The report can certainly document what changes were made after the testing period, which goes a long way if there’s an audit, but the report must nonetheless discuss the past.

Webinars:

• On February 15, 2023, The Phia Group presented “Love is in the (Health)Care!,” in which we discussed important issues, best practices, and case studies. From disputes with providers, to subrogation, to regulatory updates, and beyond. 

• On January 19, 2023, The Phia Group presented “An Omnibus Edition to Kick Off 2023,” in which we discussed The Consolidated Appropriations Act of 2023, its inclusion of protections for pregnant and nursing mothers, regulatory updates regarding the No Surprises Act, and manufacturer assistance programs.

Be sure to check out all of our past webinars!

Podcasts:

• On March 31, 2023, The Phia Group presented “Putting the Patient First: Challenges to Common TPA Operations,” in which our hosts, Katie Malkin and Jon Jablon, discussed three aspects of TPA operations designed to try to make the TPA's job more manageable. 

• On March 17, 2023, The Phia Group presented “Seek and Ye Shall Find,” in which our hosts, Chris Aguiar and Cindy Merrell, discussed how, particularly regarding auto accidents involving participants with substandard coverage, there is greater need to capitalize on opportunities for plans to recover funds. 

• On March 3, 2023, The Phia Group presented “New TPA Liabilities – Section 1557,” in which our hosts, Brady Bizarro and Andrew Silverio, discussed a recent federal court case whereby a TPA was found liable for violations of ACA’s Section 1557. 

• On February 16, 2023, The Phia Group presented “Accommodating Reasonably: Navigating the ADA and PWFA in 2023,” in which our hosts, Kelly Dempsey and Kevin Brady, discussed the reasonable accommodation process under ADA and PWFA. 

• On February 10, 2023, The Phia Group presented “The State of the Union 2023: Phia’s Take,” in which our hosts, Ron Peck and Brady Bizarro, discussed the president’s speech, providing you with their reaction and analysis, and explained what you should be watching this year. 

• On February 3, 2023, The Phia Group presented “No Ordinary Time in Healthcare,” in which our hosts, Corey Crigger and Nick Bonds, discussed the ever-changing world of healthcare. 

• On January 20, 2023, The Phia Group presented “Living Up To Expectations,” in which our hosts, Jen McCormick and Jon Jablon, discussed past predictions, their predictions for 2023, and what the best health plans need to do to stay ahead of the game this year! 

• On January 5, 2023, The Phia Group presented “The Contemporary Fiduciary: Emerging Law on an Old Topic,” in which our hosts, Katie MacLeod and Jon Jablon, discussed fiduciary status, both traditionally and in the new age of self-funding.

Be sure to check out all of our latest podcasts!

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Phia Fit to Print:

• BenefitsPro – The relevance of network reimbursement rates to mental health parity compliance – March 22, 2023 

• Self-Insurers’ Publishing Corp. – Extended Telehealth Relief For HSA Plans – February 5, 2023 

• BenefitsPro – Health care 2022: Challenges and opportunities in the years ahead – January 11, 2023

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From the Blogoshpere:
 

• Price Transparency: A Chief Concern at SIIA’s Recent Kanas City Forum. A look into SIIA’s Price Transparency Forum. 

• The State of Paid FMLA: Thirteen States and Counting. Thirteen states and the District of Columbia have enacted paid family leave. 

• No Matter the Remedy – No Language, No Luck! If your language is lacking, so too will your remedies. 

• Accommodating Pregnant Workers: Enhanced Protections Under New Legislation. How much do you know about the Consolidated Appropriations Act of 2023? 

• New Year, New Rules – But Don’t Forget About the Old Ones. Go into the new year knowledgeable about new rules.

To stay up to date on other industry news, please visit our blog.

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The Stacks:

Extended Telehealth Relief for HSA Plans

By: Andrew Silverio, Esq. – February 2023 – Self-Insurers Publishing Corp. 

The COVID-19 pandemic has led to many practical and regulatory challenges for self-funded plans and those serving them. Most of these regulatory changes create important protections for plan participants but create significant burdens and potential exposure for plans – including significant expansions to COBRA rights under the American Rescue Plan Act of 2021, vaccine and testing mandates under the FFCRA and CARES Act, and extension of plan deadlines relating to claim submission, appeals, enrollment, and COBRA.  

Click here to read the rest of this article

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The Phia Group's 2023 Charity

At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.

The Phia Group's 2023 charity is the Boys & Girls Club of Metro South.

The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.

The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.

Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. 

The Leukemia and Lymphoma Society

The Phia Group’s Louisville-based employees, Rebekah McGuire-Dye, Cindy Merrell, and Corey Crigger, and their wonderful relatives, represented our company with style at The Leukemia and Lymphoma Society (LLS)’s Student Visionaries of the Year Grand Finale Celebration, held at the Kentucky Derby Museum. The Phia Group is heavily invested in LLS and looks forward to continue supporting the noble organization by participating in the upcoming “Big Climb” event and fundraiser (May 13 at 1 Beacon St., Boston). Please see the following link to learn more about how LLS performs lifesaving blood cancer research for patients worldwide.

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Phia News: Get to Know Our Employee of the Quarter:
Emily Rodriguez

Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. 

The Phia Explore team has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Emily Rodriguez as The Phia Group’s 2023 Q1 Employee of the Quarter! 

Here is one person’s comments about Emily: “Above and beyond is the first thing that comes to mind when I think of Emily's work ethic. She will always put the success of the company over anything else - she has met with clients off-business hours, accepts every role and request thrown in the direction of PGC, and all the while acts as a mentor for her team. No matter what happens, she will always be understanding of every situation. She will always bring a friendly "can-do" attitude and swiftly assess how to solve any matter at hand. As she is the point of contact for many clients under PGC, I can think of nobody more suited to act as the face of Phia.”

Congratulations Emily, and thank you for your many current and future contributions.

Valentine’s Day at Phia

The Phia Family celebrated Valentine’s Day by hosting a contest to see who could guess how many candy hearts were in the jar below; one person submitted a very close guess. The jar had 737 candy hearts, and Irene Yalch guessed 732 candy hearts.

Saint Patrick’s Day at Phia

The Phia Family celebrated Saint Patrick’s Day by hosting a contest to see who had the best luck of the Irish! Employees guessed how many M&M’s were in the jar below, and one lucky person submitted a guess that was one off. The jar had 947 M&M’s, and Matthew Painten guessed 946 M&M’s.

Job Opportunities:

• Claim and Case Support Analyst 

• Human Resources Generalist 

• Customer Service Representative 

• EDI Data Engineer

See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers

• Lisa Hill has been promoted from Senior Subrogation Attorney to Managing Attorney, Subrogation Services. 

• Kaycee O’Toole has been promoted from Case Investigator to Claim Recovery Specialist IV. 

• Elizabeth Pels has been promoted from Subrogation Implementation Specialist, Recovery Services to Manager, Recovery Service Onboard & Support. 

• Olesya Avramenko has been promoted from Health Benefit Plan Consultant II to Health Benefit Plan Consultant III. 

• Corrie Cripps has been promoted from Health Benefit Plan Consultant II to Health Benefit Plan Consultant III. 

• Ulyana Bevilacqua has been promoted from Manager, Drafting Services to Senior Manager, Drafting Services. 

• Sarah Ingle has been promoted from Claim Recovery Specialist IV to Sr. Claim Recovery Specialist. 

• Skyla Mrosk has been promoted from Claim Analyst to Senior Claim Analyst. 

• Emily King has been promoted from Customer Care Representative to Claim Analyst.

New Hires

• Ania Russo was hired as Specialist Projects Coordinator. 

• Joanie Verinder was hired as Director, Service Strategist. 

• Denise Aubrey was hired as Director, Subrogation Implementation. 

• Ernestine Cherubin was hired as Accounting Temp. 

• Harman Singh was hired as Sr. Software Engineer. 

• Joanna Marden was hired as Customer Service Rep. 

• Richard Harrison was hired as Sr. Accountant. 

• Saheed Yussuff was hired as Accounting Administrator. 

• Deonte Small was hired as Accounting Assistant. 

• Bharat Bogelli was hired as Business Analyst. 

• Kendall Jackson was hired as Health Benefit Plan Consulting Attorney. 

• Nicholas Walsh was hired as Case Investigator.

Phia Attending the SIIA National Conference

Several of Phia’s industry experts will attend SIIA’s National Conference in Phoenix, Arizona, from October 8th – 10th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: https://siiaconferences.org/nationalconference/2023/index.cfm. 

The Phia Group Reaffirms Commitment to Diversity & Inclusion

At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.

We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.

The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.

We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.

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