The Book of Russo:

It's conference season yet again, and like Johnny Cash, I’ve been everywhere – Arizona, California, Florida, Oklahoma City, the Caribbean, and every place in-between … and in all places, I am spreading the message to the masses. Your message, my message, Phia’s message. A message of optimism and hope. A belief that together we can improve the quality of healthcare, reduce the costs we pay for it, improve access, and put the “benefit” back in “benefit plan.” I am honored to be educating brokers and employers on better ways to fund their health plans, and am witnessing a new level of interest from those entities unlike any I’ve seen before.

I am explaining to technologists and software developers the various compliance rules and regs, and all the other “tough stuff” that we must deal with every day in the self funded industry. The audience has grown – in size and composition. It is a great time to be on the road! Yet, I see those familiar faces in the crowd as well. I love getting to see old friends and meet new ones, but it’s not all positive. The horrible part of hitting the road is saying goodbye each week to my family. You know the feeling… but I know the cause is worth it. I humble myself, knowing that it could be a lot worse. I could be in the military overseas, fighting for our freedom, not seeing my family for months or even years. I could be any one of our plan participants, in-patient at a hospital for weeks or months… missing my family just as much, but gazing at my own mortality instead of your shining faces. Yeah – I think about those who have got it worse, and it gives me the jolt I need to work even harder, on their behalf. 

As you know, at The Phia Group our mission is to ensure that every American has access to high-quality, low cost care. It's a tough battle, but I know we are winning. The tools we have rolled out, and those that we are developing now, will make the difference. Whether it's our Ignite software, our A/I powered compliance and appeals software, or the vast algorithms we have created to identify recovery trends and ways for you to lower your costs, the best will keep getting better. Yet, the challenges aren’t getting any simpler either. There is no better example right now than what is happening with the No Surprises Act (“NSA”). I urge all of you to read the article provided here, about the Brookings Institute findings. Let this one example show you just how much you and your plans are overpaying for these out-of-network facilities. We know that with the right processes, the right education, and the right compliance team, you can cut those NSA expenses by almost 50%. You owe it to your clients to take a look at your current process… and we can help. 

 Additionally, on a personal note, this May will mark 11 years since one of my best friends was killed by cancer. Robert "Staga" Pokorski was not only like a brother to me, he was also a loving husband and father to two beautiful young children. Then, a few years later, I lost my father-in-law to cancer. Jack Sheehan was a legend, and so many of my stories feature this larger-than-life character. I know I am not alone. For too many of us, it’s not a matter of “if” but “when” cancer will impact you or someone you love. Only by investing in research can we reduce the chances that cancer will win. At the same time, more effective, efficient diagnoses and treatments reduce the cost we pay to fight cancer. It’s a win-win. Join me as I fight alongside my friend and Phia Group CLO – Ron E. Peck – in our fundraising effort, on behalf of the renowned Leukemia and Lymphoma Society (“LLS”). Take a minute to click this link, https://pages.lls.org/voy/ma/ma24/arusso or use the QR code below, and donate. Every dollar counts, and every donor has my eternal gratitude. I don’t want to lose another person I love to cancer, and I don’t want you to lose someone you love either. 

Thank you for believing in The Phia Group and happy reading.

Service Focus of the Quarter: No Surprises Act & IDR Support 

As you probably know, the No Surprises Act has created what seems like a never-ending set of hoops for health plans to jump through. In the course of providing our Phia Unwrapped and Independent Dispute Resolution (IDR) support services, we have discovered that not only are there more and more hoops all the time, but that the hoops actually seem to be getting smaller and smaller. 

According to a recent Brookings study (https://www.brookings.edu/articles/a-first-look-at-outcomes-under-the-no-surprises-act-arbitration-process), the mean IDR decision is actually 50% higher than the mean in-network commercial payer’s cost, coming in around 370% of Medicare (including an average of 401% of Medicare for emergency claims and a whopping 511% of Medicare for neonatal/pediatric care). Somewhat ironically, that pricing is far higher than what CMS seems to have expected, and is actually closer to historical non-network prices, likely frustrating the very purpose of the IDR process in many cases. Though the NSA was created specifically to increase the burden on health plans, we’re not confident that the regulators intended the added burden to be quite this large. 

In response, Phia’s services have evolved as well, with an increased focus on a multi-benchmark system to develop settlement offers that are reasonable not only to providers, but (far more importantly, in our view) for health plans as well. Our relationships are becoming deeper and our cadence is quickening, leading to increased efficiency and unprecedented settlement leverage. In our experience, quick response times and bona fide settlement efforts prior to IDR will almost always be more favorable to a health plan, which is where Phia really shines. The benefit of accessing Phia’s NSA-related services is attaining favorable settlements with a focus on avoiding IDR whenever possible, since IDR is unpredictable and more often than not lands in favor of higher payments. Even if a claim progresses to IDR, however, Phia has an arsenal of data and logic to promote more favorable outcomes. 

To learn more, contact sales@phiagroup.com.

Enhancement of the Quarter: NQTL Report Cards  

Users of Phia’s Independent Consultation and Evaluation (ICE) service will now have access to a benefit specifically geared toward the federal Mental Health Parity law! For groups that aren’t sure what MHP is all about, or that are hesitant to do a full non-quantitative treatment limitations (NQTL) analysis until the Department of Labor gives more guidance, or who want to know how their plan language stacks up compliance-wise, our team of experts can now provide a “report card” of parity-related information from a given SPD. 

Whether it is a group’s finalized plan document or a template, our team will review the provisions and provide a high-level summary of MHP-related compliance issues. This is included within the ICE service, so your groups can rest assured knowing that we’ve got their backs. 

Federal law still requires health plans to generate full NQTL comparative analyses, but this is a way to find out where the health plan is bleeding, and bandage up the wounds, as soon as possible. 

Phia Case Study: The Unusually Narrow Hazardous Activities Exclusion  

A TPA recently presented Phia’s consulting team with a stop-loss denial and asked if we could help opine on the merits of the denial. Specifically, the claim involved a bull-riding accident; the health plan excluded hazardous activities, but only in connection with professional or semi-professional sporting activities, which – the plan determined – did not apply here; and so, the plan paid this claim. The claims exceeded the plan’s specific deductible, and thus were submitted to stop-loss for reimbursement. The carrier subsequently denied the claim for reimbursement, citing the SPD’s hazardous activities exclusion, though it’s not clear whether the carrier misinterpreted the exclusion or simply saw the word “hazardous” and decided that it applied. 

Phia analyzed the claim and language and provided a thorough written analysis, concluding that not only did the plan’s hazardous activities exclusion not apply here, since this had nothing to do with semi-professional or professional sporting activities, but the No Surprises Act in fact wouldn’t even allow this exclusion to be used in this case since it is a “general plan exclusion” that has been rendered inapplicable to emergency claims pursuant to federal guidance. 

Since the stop-loss policy did not contain its own hazardous activities exclusion but rather the carrier relied on the plan’s exclusion, and since the plan did not need to exercise any discretion to allow this claim, Phia’s review also concluded that the carrier’s denial did not appear to be substantiated by any limitation found within the policy. 

The TPA went back to the carrier, armed with Phia’s review, and we were thrilled when three weeks later the TPA updated us to let us know that the carrier reversed its denial and paid the claim. 

Fiduciary Burden of the Quarter: Considering All the Evidence

As you probably know, the law allows health plans a great deal of discretion in interpreting facts and plan document provisions and administering benefits based on those interpretations. But what happens when the facts underlying a claim aren’t clear, or when there is conflicting information in the record? 

With some exceptions, judicial review of benefit determinations will defer to the plan administrator’s interpretations of facts and the SPD unless they are deemed “arbitrary and capricious”. To illustrate that and differentiate between the two terms, picture flipping a coin. An example of a decision that is arbitrary would be flipping the coin, and making the decision based on however the coin landed. In contrast, a decision that is capricious would be flipping the coin, checking the result, and then deciding on a whim that you want to choose the other one instead. Benefit interpretations are rarely that simple, of course, but it’s important to realize that while arbitrariness involves a degree of randomness, capriciousness involves applying inconsistent logic rather than choosing randomly – and it’s not always so obvious when a decision rises to the level of capriciousness. 

A great example that happens somewhat often is when a health plan receives conflicting information regarding, say, the medical necessity of a given claim. If a plan is in receipt of two conflicting medical reviews – one confirming medical necessity and the other denying it – courts in many jurisdictions would consider it capricious for the plan to simply choose the review most favorable to itself, unless the plan can articulate a reasoned basis for valuing one medical opinion over the other. In many cases, seeking a neutral third opinion to resolve the discrepancy can be a prudent strategy to sidestep that capriciousness – but in the absence of that third opinion, when faced with a “he said, she said” scenario, opting for the review that benefits the plan without a compelling and articulable rationale may well be considered capricious, potentially compromising the plan’s decision-making authority.

Webinars:

• On February 21, 2024, The Phia Group presented “The Skinny on Weight Loss Drugs,” in which we discussed off-label drug usage, international drug importation, defining medical necessity, plan drafting and exclusions. 

• On January 16, 2024, The Phia Group presented “Navigating 2024: The Latest, Most Innovative Plan Design Features & Stop-Loss Policy Updates,” in which we discussed a rundown of 2024’s biggest plan document and stop-loss updates, including matters about which our team has been asked the most.

Be sure to check out all of our past webinars!

Podcasts:

• On March 29, 2024, The Phia Group presented “Xenotransplantation: A Potential Game Changer for Self-Funded Plans” in which our hosts, Nick Bonds and Jen McCormick, discussed the groundbreaking development of the world's first successful genetically engineered pig kidney transplant at MGH in Boston. 

• On March 14, 2024, The Phia Group presented “Weighing the Options” in which our hosts, Ron Peck and Corey Crigger, discussed the impact the surge in demand for weight loss drugs has had on health plans and consumers. 

• On March 8, 2024, The Phia Group presented “State of the Union, 2024” in which our hosts, Brady Bizarro and Nick Bonds, discussed some key healthcare initiatives that we’ll be keeping a close eye on in the coming months. 

• On February 29, 2024, The Phia Group presented “The Therapeutic Equivalence Approach: A New “Pill”ar of Contraceptive Coverage,” in which our hosts, Kendall Jackson and Jon Jablon, discussed the “therapeutic equivalence” approach to compliance, what it means for consumers, and what it means for health plans. 

• On February 15, 2024, The Phia Group presented “Navigating Post-Settlement Fund Pursuits,” in which our hosts, Andrew Silverio and Cindy Merrell, discussed a newly decided case which provides a roadmap for pursuing settlement funds after disbursement. 

• On February 1, 2024, The Phia Group presented “Chevron Deference in Peril – What It Could Mean for Healthcare Regulations,” in which our hosts, Brady Bizarro and Brian O’Hara, discussed the legal doctrine involved in two cases now before the Supreme Court – Chevron deference. 

• On January 18, 2024, The Phia Group presented “The Continuing Evolution of MHPAEA,” in which our hosts, Jennifer McCormick and Kelly Dempsey, discussed the ever-shifting landscape of the Mental Health Parity and Addiction Equity Act (MHPAEA). 

• On January 4, 2024, The Phia Group presented “Higher Healthcare Prices (Made From Concentrate),” in which our hosts, Ron Peck and Nick Bonds, discussed how the trend of provider consolidation is primed to pick up pace in 2024.

Be sure to check out all of our latest podcasts!

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Phia Fit to Print:

• BenefitsPro – Self-funding plan preparation for 2024 – January, 2024 

• BenefitsPro – Self-funding plan preparation for 2024 – March, 2024

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From the Blogoshpere:

• How the Recent Industry Cyberattack Impacts You. As this horrific situation has been playing out across pharmacies throughout our country, physicians in both massive hospital networks and small clinics are struggling to obtain prior authorization for exams, medications, and procedures. 

• Millions Saying Good-Bye to Medicaid. That millions of Americans have been losing Medicaid coverage over the past year may be unsurprising, but it doesn’t make it any less heartbreaking. 

• Welcome to the Subrogation Sphere. The subrogation sphere can have a substantial impact on many people. 

 • Are Measles Making a Comeback? Will we start seeing more and more of these outbreaks? 

• A New Year Brings New (Higher) Prescription Drug Prices. Pharmaceutical companies are hiking prices on their drugs

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

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The Phia Group's 2024 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 2024 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. 

Annie: The Play

The Phia Group invited 30 children from The Boys & Girls Clubs of Metro South to watch Annie at the Inly School. They were accompanied by a large number of Phia employees and had a blast watching Adam and the cast put on a phenomenal show!

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Phia News: Candy Heart Contest

As is tradition, Phia held its annual Candy Heart Contest. The Phia Family made some great guesses, but there was one person who came particularly close to guessing the exact number. Congratulations to Regina Cattel on guessing 1076 pieces of candy corn. This was a very close guess, as we had 1089 pieces of candy hearts in the jar!

Get to Know Our Employee of the Quarter: Adam Doherty & Elizabeth Galewski

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 unanimously agrees that there are no individuals more deserving than Adam Doherty and Elizabeth Galewski to be recognized as The Phia Group’s Employee of the Quarter for Q1 of 2024.

Congratulations, Adam and Elizabeth, and thank you for your ongoing and future contributions.

Phia Attending the SIIA National Conference

Several of Phia’s industry experts will attend SIIA’s 2024 National Conference in Phoenix, Arizona, from September 22nd – 24th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: 

Get more details: https://siiaconferences.org/nationalconference/2024/Index.cfm

Job Opportunities:

• Case Investigator 

• Claim and Case Support Analyst 

• Director, IT Infrastructure 

• Case Analyst

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

Promotions

• Jackie Andrews has been promoted from Sr. Director, Provider Relations to Vice President, Provider Relations. 

• Alex Houle has been promoted from Director, Provider Relations to Sr. Director, Provider Relations. 

• Brady Bizarro has been promoted from Sr. Director, PGC to Vice President, PGC. 

• Andrew Silverio has been promoted from Compliance and Oversight Counsel to Director, PGC. 

• Daiana Williams has been promoted from Director, Recovery Services to Senior Director, Recovery Services. 

• Ekta Gupta has been promoted from Manager Data Services Group to Director Data Services Group. 

• Zach John has been promoted from Sr. Manager, Applications Development to Director, Applications Development. 

• Andrew Mead has been promoted from IT Helpdesk Coordinator to Systems Administrator. 

• Sneh Gaonshindhe has been promoted from Sr. Software Developer to Manager, Applications Development. 

• Angela Grande has been promoted from Team Lead to Manager, Provider Relations. 

• David Ostrowsky has been promoted from Content Specialist to Manager, Corporate Communications. 

• Trina Garcia has been promoted from PACE Specialist II to Health Benefit Plan Consultant III. 

• Michelle Rowland has been promoted from Health Benefit Plan Consultant to Health Benefit Plan Consultant III. 

• Tara Otoka has been promoted from Health Benefit Plan Consultant to Health Benefit Plan Consultant III. 

• Diana Newburg has been promoted from PACE Specialist II to Health Benefit Plan Consultant III. 

• Maghen Keefe has been promoted from PACE Specialist I to Health Benefit Plan Consultant II. 

• LaTrisha Keierleber has been promoted from PACE Specialist I to Health Benefit Plan Consultant II. 

• Michelle Haga has been promoted from PACE Specialist I to Health Benefit Plan Consultant II. 

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

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

• Emily Rodriguez has been promoted from NQTL Consultant I to Consultant I, MHPAEA. 

• Bryan Dunton has been promoted from Consulting Attorney I to Consulting Attorney II. 

• Nick Bonds has been promoted from Consulting Attorney II to Consulting Attorney III. 

• Morganne Samuelson has been promoted from Project Manager to Senior Project Manager. 

• Desmond Campbell has been promoted from Accounting Administrator I to Accounting Administrator II. 

• Saheed Yussuff has been promoted from Accounting Administrator I to Staff Accountant. 

• Deonte Small has been promoted from Accounting Assistant to Accounting Administrator I. 

• Richard Harrison has been promoted from Sr. Accountant to Accounting Manager. 

• Liz Pels has been promoted from Manager, Recovery Service Onboard & Support to Sr. Manager, Case Evaluation & Customer Service. 

• Jen Marsh has been promoted from Recovery Service Onboard & Support Specialist to Senior Team Lead, Customer Service. 

• Skyla Mrosk has been promoted from Sr. Claims Analyst to Sr. Claims Analyst, Trainer & Auditor. 

• Malcolm Rymer has been promoted from Claims Analyst, Outreach Specialist to Claims Analyst, Client Outreach Specialist. 

• Lindsey Stewart has been promoted from Customer Care Representative to Case Analyst. 

• Dennis Ferzoco has been promoted from Claims Analyst to Sr. Claims Analyst. 

• Tomasz Olszewski has been promoted from Sr. Claim & Case Support Analyst to Team Lead, Claim & Case Support. 

• Haley McBroom has been promoted from Senior Claims Recovery Specialist to Team Lead, Recovery Services. 

• Ethan Forrest has been promoted from Claim Recovery Specialist III to Senior Claims Recovery Specialist. 

• Nicole Capozzoli has been promoted from Claim Recovery Specialist III to Trainer. 

• Bridget Binda has been promoted from Case Investigator to Claims Recovery Specialist III. 

• Richard Hunt has been promoted from Facilities Coordinator to Facilities Manager. 

• Diane McAuley has been promoted from Executive Assistant to Senior Project Manager to the Chief Operating Officer. 

• Emily Kewer has been promoted from Case Investigator to Team Lead, Case Investigation. 

• Amanda DeRosa has been promoted from Manager, Recovery Services to Senior Manager, Liability Investigation and Claims Recovery. 

• Hannah Lane has been promoted from Manager, Contracts Administration to Junior In House Counsel.

New Hires

• Sarah Bracken was hired as a Sr. Claim Recovery Specialist. 

• Sean Luckett was hired as a Sr. Claim Recovery Specialist. 

• Sara Welch was hired as a Consultant. 

• Alianna Feria was hired as a Sr. Claim Recovery Specialist. 

• Ben Balke was hired as a Sr. Architect Pricing Engineer. 

• Andrew Schulz was hired as a Sr. Subrogation Attorney. 

• Luke Harrison was hired as a Sr. Claim Recovery Specialist. 

• Angela Norris was hired as a Claims Specialist. 

• Brianna Gatto was hired as a Case Investigator. 

• Alison Abdikarim was hired as a Customer Service Rep. 

• Justin Asher was hired as a Sr. Claim Recovery Specialist. 

• Jaime Smith was hired as a Customer Service Rep. 

• Alex Morison was hired as a Case Investigator. 

• Marilu Flores was hired as a Customer Service Rep. 

• Megan Knox was hired as a Customer Service Rep. 

• Jessica Williams was hired as a Customer Service Rep. 

• Stephen Sockol was hired as an AV Specialist. 

• Jason Whitlock was hired as a Sr. Claim Recovery Specialist.

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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