Service Focus of the Quarter: PACE and Pre-Service Appeals

Not all appeals are created equal. While there are always regulations to follow when handling claims and appeals, obeying the rules with respect to pre-service appeals can be far more difficult than their post-service.

Pre-service appeals bring with them more intensive time-restrictive requirements than post-service appeals. Plan Administrators and TPAs have a hard enough time making determinations in the time allotted for post-service appeals; when faced with far quicker turnaround times on pre-service appeals, it’s even easier to make a claim administration or adjudication error.

You’ve heard about The Phia Group’s Plan Appointed Claim Evaluator (“PACE”) service, whereby we assume fiduciary duties on final-level, internal appeals; but did you know that PACE can now also include pre-service second-level appeals? Now you do!

Many of you already trust The Phia Group’s consultative team as it relates to claims processing, and rely upon our PACE service to protect you as it relates to your post-service claim appeals; second level pre-service appeal review is a logical extension of that, and helps protect the plan and TPA in situations where the plan and TPA are even more crunched for time than usual.

To learn more about PACE, including pre-service options, contact Tim Callender at 781-535-5631 or tcallender@phiagroup.com.

Phia Case Study: Phia to the Rescue!

The Phia Group’s consulting team received an interesting consulting request (via PGCReferral@phiagroup.com) from the broker of a self-funded health plan administered by an Administrative Services Only (“ASO”) carrier. The broker had identified what was believed to be a billing error made by the ASO carrier, and had engaged The Phia Group to help determine what type of recourse, if any, the health plan had against the ASO.

In particular, The Phia Group was tasked with review the plan’s Administrative Services Agreement (ASA) to determine its audit/indemnification rights if it were ultimately determined that the ASO truly had made the suspected errors.

The Phia Group outlined several provisions that the client could invoke in its favor against the ASO, including audit rights and the obligation to correct an erroneous overpayment if the ASO committed negligence, fraud, or misconduct; quality assurance requirements and penalties for non-compliance; and indemnification in certain circumstances, including negligence.

With those provisions in-hand, the health plan and broker were able to put pressure on the plan’s claims administrator to perform the audit necessary to discover its errors.

Fiduciary Burden of the Quarter: Abiding by the Terms of the Plan Document!

Reference-based pricing can be complicated and daunting, but it doesn’t have to be. There are certain techniques for doing it correctly, but even more techniques for doing it incorrectly. One such incorrect technique is to put language into the Plan Document that describes the reference-based pricing methodology, and then subsequently ignoring it.

Some plans utilizing reference-based pricing contain language in the Plan Document that limits payment at a percentage of Medicare, without account for negotiated rates or settlements. We certainly don’t mean to say that the Plan Document should contain two percentages – one “initial” percent and one “settlement” percent – but the language needs to be written such that the Plan Administrator is not violating the terms of the Plan Document if a given claim needs to be settled. Violating the terms of the Plan Document, after all, is a breach of the Plan Administrator’s most basic fiduciary duty.

An example of this is when a Plan Document provides that “This plan will pay all claims at 150% of Medicare.” Well, if a claim needs to be settled at 200% of Medicare, what then? The Plan Administrator has no authority from the Plan Document to make a settlement payment, resulting in (a) the negotiated rate being taxable to the employee, since it’s not a plan benefit, and (b) the Plan Administrator being technically prohibited from making a settlement payment from plan assets.

The Phia Group’s standard reference-based pricing language specifically notes that if there is a negotiated rate (which can be an ongoing contract, case-by-case agreement, or settlement agreement on the back-end of a balance-bill), that negotiated rate is the payable amount. If and only if there is no negotiated rate, then the Medicare-based payment comes into play. That accounts for the possibility of a contract or negotiation of any given claim if necessary, without giving away the farm by promising that there will be negotiations.

At its core, reference-based pricing is nothing more than a method of redefining traditional U&C. All other plan processes remain the same, and fiduciary duties are still intact – which means the Plan Administrator needs to continue to be acutely aware of them, even while navigating reference-based pricing.

The nuances of reference-based pricing are no excuse for violating fiduciary duties; as regulators and lawmakers continue to push back on reference-based pricing, let’s not give them an excuse to condemn it.

Success Story of the Quarter: Unwrapping the OON Claim

A health plan utilizing The Phia Group’s Phia Unwrapped service incurred an out-of-network claim billed at $72,000. The health plan paid its Medicare-based benefits, and the patient was subsequently balance-billed for the entire balance, which was right around $60,000. After the initial patient advocacy layer of Phia Unwrapped, the provider continued to bill the patient, and The Phia Group then engaged the provide

r to negotiate the balance. This particular provider felt that it was unconstrained by any notions of fair market value, even stating that – and we quote – “if there is no law that limits the billing, we can bill however we please.”

We ultimately went above the billing department and found contact information for the hospital’s CFO, whom we contacted and implored him to be reasonable. We pointed to benchmarks, fair market value, other area providers’ bills, cost-to-charge ratios, and more.

Ultimately, without a word, and without knowing what exactly tipped the scales, we received a signed copy of our proposed agreement. We are now in the process, with the client’s approval, of securing a direct contract with this facility at a rate that our client can accept as reasonable.

A Case to Remember

Edward Brice Brimacombe v. OptumInsight, Inc. d/b/a Optum; Bank of America; et. al., Sup. Ct. AZ County of Maricopa, Case No. CV2018-055781, September 19, 2018

Delays, miscommunication, and a lack of preparation will eliminate subrogation rights every time. The case of Edward Brice Brimacombe v. OptumInsight, Inc. d/b/a Optum; Bank of America; et. al., Sup. Ct. AZ, Case No. CV2018-055781, was filed on September 19, 2018 in Maricopa County, by an attorney representing a plan participant. He has done so in an effort to have the court void the Bank of America Benefit Plan’s subrogation lien. We learn many important lessons from this case, as we seek to protect plan rights and strengthen subrogation efforts.

First, in this case, the attorney representing the plan participant contacted neither the employer (the plan sponsor, Bank of America) nor the benefit plan’s subrogation vendor (OptumInsight). Rather, they contacted the carrier whose administrative services only (ASO) and network were utilized by the plan; United Healthcare. As part of The Phia Group’s subrogation implementation, we issue notification to all employees regarding who we are, and what we do, and we take active steps to identify opportunities to recover – and put all parties on notice – before they even have a chance to contact (the wrong) entities.

Second, it’s been alleged that the representative at the United Healthcare ASO did not understand what was being asked, or what subrogation is. It’s a reminder that we all have a duty to make sure anyone who may take such calls either understands this part of the plan’s administration, or knows to whom they should refer the inquiry. It is an integral part of The Phia Group’s implementation process.

Third, the attorney says that months later (in July of 2017), OptumInsight (the subrogation partner of the plan in question) did reach out to the attorney, seeking details about the case, but showing no knowledge of what the attorney claims had transpired previously. We, as an industry, need to ensure we always communicate – or appear to have communicated – avoiding any suggestion that there is no communication between the ASO/TPA, plan sponsor, and subrogation vendor. That’s why The Phia Group makes it a priority to obtain access to our clients’ claims management systems… so that we can have read-only access to the notes, and be aware of such calls and correspondence prior to talking to the applicable parties.

Fourth, the participant’s attorney claims that he responded and offered an opportunity to reassert the previously waived lien, but (he says) he did not receive a response to that offer for months. This shows us that delays will result in the right to lien recoupment being lost, in light of new case law and common sense. The bottom line is that we’re operating against the clock, and personal injury attorneys know that delays on our part put the recovery at risk. That’s why The Phia Group sticks to firm deadlines.

Fifth, OptumInsight advised the attorney that the carrier lacked authority to waive the plan’s rights, however, the participant’s attorney advised that by “acting” as if they did have the authority, they exercised legally binding implied authority. This teaches us that ASOs and TPAs must not speak for the plan or act as if they have authority in instances where they do not have such authority. This is why The Phia Group’s subrogation clients are also provided with preferred access to such other services as Independent Consultation and Evaluation (“ICE”) and Plan Appointed Claim Evaluator (“PACE”) services; to ensure we identify such issues and nip them in the bud before they cause any harm, as well as protect TPAs and ASOs from unwanted fiduciary liability.

Phia Fit to Print:

• Money Inc. – How Proposed HSA Legislation Would Afford New Employer and Employee Freedoms – September 1, 2018

• Self-Insurers Publishing Corp. – Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance – September 1, 2018

• Money Inc. – Patient Assistance Programs: Why Many Drive Up Costs for Health Plans and Now, Patients – August 9, 2018

• Self-Insurers Publishing Corp. – Much Needed Correction in the Second Circuit...Is Relief (Equitable, That Is) Around the Corner? – August 2, 2018

• Free Market Healthcare Solutions – How Imperfect Regulatory Action May Still Create Opportunities for Self-Funding – July 14, 2018

• Self-Insurers Publishing Corp. – When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements – July 12, 2018

• Free Market Healthcare Solutions – How Imperfect Regulatory Action May Still Create opportunities for Self-Funding – July 11, 2018

• Money Inc. – State Reactions and their Power over Association Health Plans – July 1, 2018

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From the Blogosphere:

• Communication Breakdown – More Lessons Learned from My Wife’s Battle Against Lymphoma. An important lesson from the Senior Vice President and General Counsel.

• A Contract By Any Other Name. The regulators have been impressively sparse in their opinions of reference-based pricing.

• Has the Life Expectancy of Drug Rebates Been Reduced? The U.S. health secretary (Azar) is making some moves and has indicated that eliminating drug rebates may help reduce costs.

• Know when to fold ‘em! A blog post you can’t afford to pass up!

• Trump Administration Halts Billions in ACA Payments. The Trump Administration has taken quite a beating from the Affordable Care Act..

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

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Webinars

• On September 18, 2018, The Phia Group presented, “Back to School: Renewal Time,” where we discussed 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.

• On August 14, 2018, The Phia Group presented, “Breaking the Mold: Creative Solutions for Everyday Problems,” where we discussed complications that self-funded health plans and their partners need to be able to successfully navigate.

• On July 12, 2018, The Phia Group presented, “Hottest Industry Trends and Topics – This is What You Asked For,” where we discussed specialty drugs, association health plans, the “right to try” law and more.

Be sure to check out all of our past webinars!

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Podcasts:Featuring Video Podcasts!

• On September 24, 2018, The Phia Group presented, “Crossing Bridges,” where Adam, Ron and Brady chat with friend and industry ally, Mark Stadler – President and CEO of BridgeHealth.

• On September 5, 2018, The Phia Group presented, “The View from Nova Healthcare,” where our hosts interview Laura Hirsch, President of Nova Healthcare Administrators.

• On August 15, 2018, The Phia Group presented, “The View from SIIA’s Political Perch,” where our hosts, Adam Russo and Brady Bizarro, speak with Ryan C. Work – Vice President of Government Affairs at the Self-Insurance Institute of America (“SIIA”).

• On August 8, 2018, The Phia Group presented, “A Healthcare Homerun,” where our hosts, Adam Russo, Brady Bizarro, and Ron Peck, chat with Mark S. Gaunya – Chief Innovation Officer and Principal of Borislow Insurance.

• On July 26, 2018, The Phia Group presented, “Where is Ron? A Very Personal Podcast from the SVP,” where Phia’s Senior Vice President & General Counsel dials in to describe where he's been, what major health issue is impacting his family, and what he hopes we can all learn from their experiences thus far - as members of the industry, potential patients, and human beings.

• On July 23, 2018, The Phia Group presented “Issues with Inaction: Balance Billing and Wellness Programs,” where Jennifer McCormick, Brady Bizarro and Erin Hussey discuss issues with inaction.

• On July 17, 2018, The Phia Group presented “Make Cost Containment Great Again,” where Brady Bizarro and Adam Russo discuss the hot topics impacting the insurance industry.

• On July 11, 2018, The Phia Group presented “Coaching the Self-Funded Industry,” where Adam and Brady interview Rick Koven, President of Koven Consulting & Coaching.

Be sure to check out all of our latest podcasts!

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The Phia Group’s 2018 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 2018 charity is the Boys & Girls Club of Brockton.

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 Brockton (BGCB) 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 8-18, signed up as club members. In the 25 years since, 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 Brockton youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.

With the upcoming school year arriving, The Phia Group wanted to make sure that the kids from the Boys & Girls Club of Brockton were fully stocked up on school supplies. Our goal was to fill 210 backpacks with all of the supplies that they would need for a successful year. We are happy to announce we have surpassed our fundraising goal and successfully collected 13,754 items. We are so excited to pass these educational tools on to the children of the Boys & Girls Club of Brockton, in hopes of a successful school year!

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The Stacks

Current Litigation Highlights Ongoing Need for Review of Plans for Mental Health Parity Compliance

By: Corrie Cripps – September 2018 – Self-Insurers Publishing Corp.

Plan sponsors of self-insured group health plans have to balance the need for cost-containment strategies while ensuring compliance with federal health benefit mandates. Mental health parity compliance is particularly challenging to navigate as case law is still being developed in this area.

The Mental Health Parity and Addiction Equity Act (MHPAEA), as amended by the Affordable Care Act (ACA), generally requires that group health plans ensure that the financial requirements and treatment limitations on mental health or substance use disorder (MH/SUD) benefits they provide are no more restrictive than those on medical or surgical benefits. Click here to read the rest of this article

Click here to read the rest of this article

Much Needed Correction in the Second Circuit...Is Relief (Equitable, That Is) Around the Corner?

By: Christopher Aguiar, Esq. – August 2018 – Self-Insurers Publishing Corp.

Third party subrogation and reimbursement rights and the State of New York have always had a bit of a contentious relationship. At every turn it seems New York is tinkering with its state laws in a way that weakens the rights of insurance companies and (they think) benefit plans of all kinds. Many arguments are available both for and against the viability of a benefit plan’s rights in New York. As you can expect, Private Self-Funded ERISA Plans enjoy the benefit of preemption and surely do not have to be concerned with these changes in New York State Law … Or do they?

Click here to read the rest of this article

When Benefits and Exclusions Create a Crossroads between Plan and Employer Requirements

By: Erin M. Hussey, Esq. – July 2018 – Self-Insurers Publishing Corp.

Plan Administrators of self-funded plans are able to customize their benefit offerings to meet the needs of the employer group, as long as that customization is compliant. Compliance for self-funded plans subject to the Employee Retirement Income Security Act (“ERISA”) includes federal health-related regulations such as the Patient Protection and Affordable Care Act (“PPACA” or “ACA”) and the Mental Health Parity and Addiction Equity Act (“MHPAEA”). The lurking problem exposing employers, who sponsor those self-funded plans, to unexpected liability are the federal employer-related regulations. The Equal Employment Opportunity Commission (“EEOC”) and the Department of Justice (“DOJ”) have taken action to enforce compliance with certain employer-related regulations such as the Americans with Disabilities Act (“ADA”) and Title VII of the Civil Rights Act of 1964 (“Title VII”).

Click here to read the rest of this article

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Phia’s Q4 Speaking Events:

Phia’s Speaking Engagements:

Adam Russo’s 2018 Speaking Engagements:

• 1/23/18 – Q4 Intelligence Conference – Tampa, FL
• 2/2/2018 – Benefit Intelligence School District Conference – Phoenix, AZ
• 3/7/2018 – SIIA Self-Insured Health Plan Executive Forum – Charleston, NC
• 3/9/2018 – CGI Business Solutions Seminar – Manchester, NH
• 3/14/2018 – Pareto Structure Meeting – Park City, UT
• 4/12/2018 – Caprock Health Care Forum – Dallas, TX
• 4/25/2018 – Berkley Captive Symposium – Grand Cayman Islands
• 4/26/2018 – Innovative Risk – Grand Cayman Islands
• 4/30/2018 – World Health Care Congress – Washington, DC
• 5/17/2018 – Prairie States Broker Event – Chicago, IL
• 6/21/2018 – GBSI Conference – Springfield, MO
• 6/26/2018 – Leavitt Annual Event – Big Sky, MT
• 8/24/2018 – WellHealth Workshop – Berkley Captive Program – Itasca, IL
• 8/29/2018 – Gus Bates Insurance – Fort Worth, TX
• 9/24/2018 – SIIA’s Annual National Educational Conference & Expo – Austin, TX

Ron Peck’s 2018 Speaking Engagements: • 1/25/2018 – HealthFirst TPA Client Conference – Tyler, TX
• 3/6/2018 – SIIA National Conference – Charleston, SC
• 3/7/2018 – CGI Business Solutions Seminar – Manchester, NH
• 3/23/18 – Health Rosetta - Module 5: Next-Gen Plan Design – Boston, MA

Tim Callender’s 2018 Speaking Engagements:

• 2/14/2018 – BevCap Captive Group, 10th Anniversary Meeting – Kona, HI
• 4/25/2018 – Cypress University – Las Vegas, NV
• 5/7/2018 – UBA Spring Conference – Chicago, IL
• 5/16/2018 – Sun Life MVP Forum – Kansas City, KS
• 5/24/2018 – Pareto Captive Services, Contrarian Re Captive Meeting – Nashville, TN
• 6/25/2018 – Leavitt Conference – Big Sky, MT • 7/17/2018 – HCAA TPA Summit – Minneapolis, MN
• 9/17/2018 – United Benefit Advisors, Fall Conference – Cincinnati, OH

Jen McCormick’s 2018 Speaking Engagements:

• 4/17/2018 – Texas Association of Benefit Advisors – Dallas, TX
• 5/16/2018 – IOA RE – Indianapolis, IN

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Get to Know Our Employee of the Quarter:
Judith McNeil

Congratulations to Judith McNeil, The Phia Group’s Q3 2018 Employee of the Quarter! In addition to her great customer service skills, Judy is an extremely reliable employee who goes above and beyond to ensure that there is always adequate coverage in the Customer Service Department & that all tasks are completed in a timely manner. She is one of the first to volunteer to come in early or stay late & will do so with a smile on her face. Judy’s passion for her job has been recognized and acknowledged by both coworkers and Plan members. Her work ethic has left an impression on coworkers to the point where when they think of Customer Service, they think of Judy.

Congratulations Judith and thank you for your many current and future contributions.

Phia News

Phia on the Front Cover!

Check it out! Adam Russo and Ron E. Peck represent The Phia Group on the cover of the Free Market Healthcare Solutions magazine! In their modeling debut, Phia's classic Dynamic Duo explain what we do at Phia and how we are helping you take control of your health plan!

Click here to check out the magazine!

The American Red Cross Visits Phia!

The American Red Cross came to visit The Phia Group and 13 of our employees successfully donated a pint of blood. With those 13 donations, we were able to save 39 lives. We take great pride in knowing the impact this can have. To learn more about the American Red Cross and how you can help save a life, make sure you check out The American Red Cross website.

Phia Welcome Video

We are pleased to announce our new Phia Welcome video! This video was designed to ensure that our vision, mission and purpose was made clear to not only our clients, but to the general population. Here at Phia we would like to urge any and every one to take a look – it concerns us all. Not only do hardworking Americans deserve access to quality and affordable healthcare, we want to secure and maintain that this is a possibility for all. The Phia Group drives success through passion and we hope you can see the root of our fervent efforts through this presentation of our enterprise.

New Client Account Manager – Matthew Painten

As you may know, Matthew Painten has recently been promoted to Client Account Manager at The Phia Group, in addition to his Marketing Management role. Although you may already have a direct point of contact at Phia, please feel free to start communicating with Matthew directly for any and all of your requests. You may email him personally at MPainten@phiagroup.com or send an email to CAM@phiagroup.com.

Job Opportunities:

• Health Benefit Plan Drafter, Consulting
• Health Benefit Plan Attorney I
• Staff Attorney, Provider Relations
• Accounts Payable Coordinator, Accounting
• Claim Recovery Specialist – WC, Recovery
• Claim and Case Support Analyst, Recovery
• Sales Administrative Assistant, Sales
• Claims Specialist, Provider Relations
• Sales and Marketing Internship
• Information Technology Internship

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

Promotions

• Ekta Gupta was promoted from ETL Specialist to Manager, Data Services Group
• Zack Mclaren was promoted from Case investigator to Senior Claims Recovery Specialist
• Catina Griffiths was promoted from Case Investigator to Case Handler

New Hires

• Carlos Alvarez was hired as a Case Investigator
• Neal Wang was hired as an ETL Specialist
• Megan Colter was hired as a Health Benefit Plan Consultant
• Michael Litman was hired as an Intake Specialist
• Diana Newburg was hired as a Health Benefit Plan Consultant – PACE
• Nicole Russo was hired as a Case Investigator
• Catherine DeQuinzio was hired as a Case Investigator
• Derek Gorini was hired as an IT Systems Administrator

Phia Fun Day:

The Phia Group's annual Phia Fun Day was nothing short of a success. The Phia Family spent the day at George's Island off Boston Harbor; there they explored Fort Warren, played beach games, and swam! Our employees more than deserve a fun day in the sun and we were happy to provide for them the best! We can't wait for next year!

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