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Phia Group Media


The Phia Group's 4th Quarter 2021 Newsletter


Phone: 781-535-5600 | www.phiagroup.com


 

The Book of Russo:

‘Tis the season! No… not the Holiday Season. It’s renewal season, and everyone is scrambling to retain current business as well as attract some new lives for 2022. One of the ways with which we at The Phia Group can assist you is by identifying unique ways to ensure both client retention and securing some new business. We can help you accomplish these lofty goals by offering innovative solutions – meant to stop (and reverse) the costly trends with which most plans are dealing – and impress employers and brokers alike. Indeed, when we speak with those entities, they are almost universally dissatisfied with their current offerings, and one of the most important things they want to see from their administrator partners are new tools and services that will make their plans more attractive to their employees… all while remaining cost effective.

Sadly, we all lose when employers give up on self-funding, and recent rules and regulations seem to be dead-set on making our plans less effective and more costly. Staying ahead of these trends and leveraging both data and consumer behavior will be what separates the winners from the losers, and ensures you keep (and retain) clients long term. 

It has come to my attention that many industry members “believe” that they know exactly what we do at The Phia Group, and they jump to conclusions about what we can or can’t do together. Yet, as the saying goes, when you assume… well… you know the rest. There is not a single entity in our industry that cannot benefit from some collaboration; together we learn and do more than any of us could on our own. Recognizing that every situation is different, the bottom line is that your clients need our combined expertise in their corner, especially in light of the ever changing legal landscape. With this as our mission, our services are often “white labeled” by clients, who seek to utilize us like a subcontractor. Other times, clients openly advertise our relationship and tout the tools and partnerships they bring to the table on behalf of their customers. Either way, there exist opportunities that can and will contribute to your success, while benefiting customers as well; lowering the overall cost of health benefits while ensuring better access to quality care.

For those who don’t work with us, reach out and let’s see what – if anything – we can do together. For those that already partner with us, let’s diagnose our current status, see if there is anything we can add or adjust, and confirm you are getting the most from our collaboration. It breaks my heart when a current partner of ours is not enjoying added revenue or success, all because they don’t understand our services or can’t communicate the value-add to their customers. Let’s work together to ensure that doesn’t happen! We want to make sure that you have all of the tools you need, at your disposal, to not only survive… but lead. 

When I started this company over 20 years ago I did so with the goal of inspiring change and fixing what I felt was a broken model. I have seen how, with amazing technology and legal prowess, our partners have succeeded in growing their client base by offering tools that are desperately needed in an ever changing environment. Let us partner with you to ensure a bright future for all. 

- Happy reading.


Services of the Quarter - Plan Appointed Claim Evaluator (PACE)
Phia Fit to Print
From the Blogosphere
Webinars
Podcasts
The Phia Group’s 2021 Charity
The Stacks
Employee of the Quarter
Phia News

 

A Teaser and the Service of the Quarter: Plan Appointed Claim Evaluator (PACE) – Now More Than Ever!

A Teaser! A Rose by Any Other Name…

By: Ron E. Peck, Esq. 

I am very excited to let you know that my recent article, regarding the No Surprises Act and its impact on appeals and disputes, will be published in the upcoming issue of The Self-Insurer magazine, published by the Self-Insurance Institute of America (“SIIA”). Here I provide you with an overview of the topic that will be discussed, why this is so important, and how it all impacts our own Plan Appointed Claim Evaluator (“PACE”) service. 

One upon a time, if a plan beneficiary felt their claim was underpaid – either fully denied, or partially paid – it was fodder for an appeal. Appeals were the only way to secure a review of a disputed plan decision. 

With the “Affordable Care Act” (or “ACA”) being signed into law in 2010, the volume and complexity of appeals increased. More entities could appeal about more things. Additionally, if they weren’t happy with the results of said appeal, an external review option was added. This all meant more work, tougher work, and a lot more fiduciary risk for entities that were responsible for receiving, reviewing, and making decisions in response to appeals. 

That’s why, following the passage of the “ACA, we witnessed growing industry concerns over the volume, sensitivity, and complexity of appeals. This, along with the risk associated with fiduciary duties arising from the handling of those appeals, caused The Phia Group to create the Plan Appointed Claim Evaluator (PACE) service. 

Now, with the passage of the Consolidated Appropriations Act of 2021, the number and difficulty of appeals – as well as risk associated with handling them – will increase even more. Not only will there be more appeals, but the No Surprises Act will also result in providers appealing claims that should be disputed under the “NSA,” (and disputing under the NSA claims that should be appealed). 

Amongst the many interesting rules and changes so introduced, the NSA seeks to prevent providers from balance billing patients in specific instances. Balance billing happens when a payer pays to a payee less than the amount to which that payee thinks they are entitled. Historically, the payee would file an appeal, and if the appeal fails, they would then balance bill the patient. In other words, providers generally balance bill patients only when they know they can’t get anything else from the plan. Most providers learn that the plan won’t pay anything else after they file an appeal and lose. Indeed, in the past, any reduced payment would be deemed an adverse benefit determination, and would be eligible for appeal. Skip to 2021, however, and here we find ourselves dealing with a true issue – what is appealed, and what is not? What adverse benefit determination must be appealed, and which triggers the NSA? 

Certainly, some adverse benefit determinations clearly fall into the bucket of appeals. Yet… not all claims fall so neatly into these buckets. We deal with a vast variety of reduced and denied payments, arising from a tremendous variety of causes. With the creation of an alternative means to challenge a plan’s payment now being established by the NSA, in addition to the appeals process, we can expect an increase in appeal volume (as providers seek to trigger the NSA but mistakenly submit an appeal), complexity (as the players attempt to parse out what should be appealed, and what should trigger the NSA), and confusion (as matters go from an appeal of unpaid claims to a dispute over reduced payments of the same claim, following an overturned denial). 

In addition to added volume and complexity, there is added fiduciary risk. Plan administrators have learned over time to handle appeals in strict accordance with applicable law and the plan document. The terms of the plan document regularly dictate what is payable, and how much is payable. Now, are these plan administrators authorized to pay something additional during the NSA’s requisite “negotiation period,” without exceeding the authority granted to them by the plan document and Employee Retirement Security Act of 1974 (“ERISA”)? Would an additional payment during negotiations constitute a payment in excess of the maximum allowable amount, and thus, constitute a breach of their fiduciary duty? 

In summary, it is safe to say that these new regulations and laws will increase the number of entities that may file appeals and broaden the scope of issues about which appeals may be filed, as well as complicate the process applicable to handling adverse benefit determinations and appeals. Additionally, the other “dispute resolution” procedures established by law – separate and distinct from formal appeals – will result in confusion regarding which conflicts are meant to be appealed, versus those that should now be handled via an alternative methodology. 

This is why the time for PACE is now. PACE is a fiduciary transfer service addressing final-level internal appeals. It is designed solely to help health plans ensure that they have made correct determinations in response to an appeal, as well as insulate the plan from liability, allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations. 

PACE includes: 

• Assessment of eligible final internal appeals via written directive as a fiduciary; 

• Plan Document and stop-loss policy “Gap Reviews” ensure compliance, eliminate coverage gaps, and ensure PACE readiness; 

• Advanced-level webinars exclusively for PACE clients; and, 

• Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (and PACE covers all external review costs!) 

We also offer PACE Certification, through which your organization can enhance your PACE understanding and utilization, improve your internal appeals processes, ensure regulatory compliance, and improve your business as a whole. 

To learn more about PACE or PACE Certification, contact Garrick Hunt, at Ghunt@phiagroup.com or 781-535-5644.

Success Story of the Quarter: Proactive Problem-Solving

The Phia Group’s Provider Relations team was presented with a situation where a self-funded health plan attempted to “carve out” dialysis from its plan, as well as from its network. Their hope was to instead pay all dialysis benefits at a percentage of Medicare. This particular health plan also contained an exclusion, excluding from coverage any dialysis claims incurred once the patient became Medicare-eligible (regardless of whether the patient actually signed up for Medicare). 

The dialysis provider engaged a law firm to recoup nearly $350,000. It is worth noting that we have dealt with this law firm in the past, and they do not shy away from litigation. 

Phia analyzed the issues, and opined that the plan’s practices were prohibited by applicable law and the network contract; the plan was neither permitted to pay dialysis claims at an amount less than the network rate, nor deny all dialysis claims for individuals who have not actually enrolled in Medicare. We provided to the plan administrator a detailed explanation as to why this was the case, and what was missing from their arrangement that – if it had been handled properly prior to their incurring the claims – would have enabled them to carve dialysis out of the plan and network. 

Phia suggested that the plan get out in front of the issue rather than wait for the law firm to make its next move (which we worried may be a drastic one). The plan agreed, and when we reached out to start negotiating, the law firm told us that this dialysis provider was in fact preparing to file suit against multiple plans for similar offenses, but due to this plan’s proactive resolution efforts, the provider would remove this plan from the complaint and negotiate rather than file a lawsuit. Phia was able to leverage the nature of the employer group (a non-profit organization that provided various social services to low-income and indigent individuals), and ultimately achieved a reduction from the already network discounted price (additionally savings exceeding $127,000 off of the discounted rate they were contractually and legally obligated to pay). Had this case gone to court, there is a very good chance that the provider would have been owed the full contractual amount, and perhaps even attorney’s fees as well. 

With our help, the plan has also since adjusted it’s document and network arrangement to enable a legal and enforceable carveout program.

 


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Phia Case Study: Gap-Free Analysis Reveals Dangerous Plan Change

A broker client of The Phia Group’s Independent Consultation and Evaluation (ICE) service engaged us to perform a “Gap-Free Analysis” on an employer’s new stop-loss policy, since the employer had just changed stop-loss carriers. Included at no extra cost as part of our ICE service, this review compares the stop-loss policy against a plan document to identify “gaps” – or areas where the plan may have to pay certain amounts that the stop-loss carrier may deny. 

Our consulting team noticed that the new policy (which had already gone into force) contained a broad and alarming exclusion for any amounts paid by the plan in excess of 150% of Medicare… but this particular plan utilized a PPO, and didn’t pay claims based on Medicare at all! The result is a significant gap in coverage where the employer may be contractually required to pay the network rate, in this case 85% of billed charges, but the stop-loss carrier is not required to reimburse above 150% of Medicare, (despite the plan being contractually obligated to pay more than that amount). 

For instance, on a $100,000 claim, if the contracted rate is $85,000, but the stop-loss carrier calculates 150% of Medicare as $30,000, then the stop-loss policy excludes the difference of $55,000 – and the employer is left in the lurch! 

Fortunately, we spotted the issue before an impacted claim was paid. Now – since there is no massive reimbursement hanging in the balance – the employer, broker, and TPA have reached out to the carrier to see what, if anything, can be done about this matter. Had Phia been asked to review the policy prior to its effective date, this could potentially have been avoided – but in any event, spotting this issue early on can still help avoid surprises and give the employer time to find a solution. 

At the end of the day, this is just one alarmingly common example of a stop-loss gap, which come in all shapes and sizes. To help avoid or mitigate these types of issues with your groups, be sure to have Phia perform Gap-Free Analysis prior to stop-loss renewal! 

To learn more about The Phia Group’s Independent Consultation and Evaluation service or a Gap-Free Analysis, contact Garrick Hunt, at Ghunt@phiagroup.com or 781-535-5644.

Fiduciary Burden of the Quarter: No Surprises Act Compliance

Although most relevant provisions don’t go into effect until January 1, 2022, now is the time when health plans must prepare to comply with the No Surprises Act (or NSA). The NSA contains a broad framework of health plan requirements, many of which are brand new, and some are even downright weird. From a practical perspective, plans (or, realistically, TPAs) will need to revamp certain longstanding processes, such as information present on ID cards and EOBs, and even the most basic payment amount calculations for certain claims. 

One issue in particular is in the area of emergency services. Pursuant to the No Surprises Act, health plans are prohibited from systematically classifying emergency claims based on CPT or other data, and must instead use the “prudent layperson” standard. This means that on a case-by-case basis, the health plan must determine whether a “prudent layperson” – that is, a person of average medical knowledge – would reasonably believe the situation to be one which, if gone untreated, would result in one’s health or life being in serious jeopardy. 

The “prudent layperson” standard is far from a brand new concept, but until now it has not been applied on such a sweeping scale. Health plans and their TPAs may now need to engage additional resources in order to make these determinations. Having to examine the specific circumstances of each claim, and even factors specific to each patient, may add an unprecedented layer of complexity to what might have previously been simpler and more systematic claim determinations.



Webinars:

• On September 21, 2021, The Phia Group presented, “Stories from the Front Lines – A Collection of Recent Relevant Case Studies,” where we share cautionary tales meant to enlighten, and ensure you don’t make the same mistakes or fall into the same traps. 

• On August 24, 2021, The Phia Group presented, “The Provider Perspective – Analysis and Response to How Providers are Reacting to Recent Rule Changes and Reform,” where we assess how providers are – presently, and in the future – likely to react (or not react) to the new healthcare pricing rules, as well as address best practices to fight back against abusive provider billing tactics. 

• On July 12, 2021, The Phia Group presented, “Surprise, surprise! Analyzing the No Surprises Act Part Deux,” where we dive into the world of surprise bills and dissect this important law. From discussing what we know, to outlining what is yet to come, anyone who will be impacted by this law (and – spoiler alert – that includes you). 

Be sure to check out all of our past webinars!

Breakout Sessions

• Following our August webinar, The Phia Group presented two breakout sessions, “A Failure to Negotiate” and “Ready, Set, Comply.” 

If you would like a copy of the slide deck, please reach out to, Matthew Painten, at mpainten@phiagroup.com

 


Podcasts:

Empowering Plans

• On September 30, 2021, The Phia Group presented, “Workers' Compensation & COVID-19 Claims,” where our hosts, Rebekah McGuire-Dye and Cindy Merrell, discuss how current Workers’ Compensation regulations impact health plans, and who is responsible for employee’s Covid-19 related claims. 

• On September 17, 2021, The Phia Group presented, “You Can’t Always Get What You Want,” where our hosts, Chris Aguiar and Cindy Merrell, discuss what happens when limited settlement funds force Plans to consider a reduction. 

• On September 1, 2021, The Phia Group presented, “Boost Your COVID-19 Vaccine Knowledge,” where our hosts, Brady Bizarro and Kelly Dempsey, discussed what employers and their plans need to know about important COVID-19 vaccine updates. 

• On August 20, 2021, The Phia Group presented, “Right to Repair and Healthcare,” where our hosts, Andrew Silverio and Nick Bonds, discussed President Biden’s recent executive order on right to repair. 

• On August 6, 2021, The Phia Group presented, “A Lightning Round of Healthcare Updates,” where our hosts, Nick Bonds and Brady Bizarro, discussed a number of healthcare topics to keep you updated on the latest topics buzzing around the industry. 

• On July 23, 2021, The Phia Group presented, “Time to Vent!,” where our hosts, Ron Peck and Jen McCormick, discussed key mistakes and false beliefs dominating the media, politics, and the general public, before dissecting how those errors have impacted recent rulemaking. 

• On July 9, 2021, The Phia Group presented, “Ahlborn Revisited,” where our hosts, Rebekah McGuire-Dye and Lisa Hill, discussed whether or not the term “medical expenses” covers ALL medical expenses, or only past medical expenses, for purposes of subrogation & reimbursement.

Be sure to check out all of our latest podcasts!


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Phia Fit to Print:

• BenefitsPro – How will the federal vaccine/testing mandate impact self-funded group health plans? – September 24, 2021 

• Self-Insurers Publishing Corp. – Who is on First? Operational Hurdles and Holes Found in Portions of the NSA – September 4, 2021 

• BenefitsPro – 2022 Coverage of Preventive Services in Non-Grandfathered Group Health Plans – August 23, 2021 

• Self-Insurers Publishing Corp. – The Liability Landmine: The Surprising Decision In Doe V. UBH – August 7, 2021 

• BenefitsPro – Plan Representatives as Fiduciaries: How Far Down the Totem Pole does the Designation Apply? – July 30, 2021 

• Self-Insurers Publishing Corp. – New administration cast doubt on Trump's Importation Plan – July 2, 2021

• BenefitsPro – The COVID Long-hauler Dynamic – July 1, 2021 

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From the Blogoshpere:

Covid-19 Vaccine Boosters – Are they Ethical? COVID-19 vaccine boosters discussed. 

Biden Administration Announces Sweeping New Vaccine Mandates. On September 9, 2021, President Biden announced his COVID-19 Action Plan. 

The Status of Major Legal Challenges to the ACA. The Supreme Court dismissed the latest challenge to the Affordable Care Act (“ACA”) in a 7-2 decision. 

A Failure to Communicate. The time has come to explain in terms everyone can understand what insurance is, and what it is not. 

Canadian Drug Importation – Back on Track (but not for everyone). Look into the future of fully legal foreign drug importation programs. 

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

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The Stacks:

Who Is On First? Operational Hurdles and Holes Found in Portions of The NSA

By: Tim Callender, Esq. – September 2021 – Self-Insurers Publishing Corp. 

The Consolidated Appropriations Act (“CAA”) did many things and has created obligations, questions, and confusion for many stakeholders in the healthcare space. This article could cover COBRA topics, mental health parity topics, surprise billing, or any other number of pandora’s boxes opened by the CAA. But no one wants to read a 1M word article filled with legal jargon and uncertain statements on how a pending rule or vague regulation should be interpreted. Instead, this piece aims to spend some brief time focused on some specific obligations that have been handed down in the CAA and throw a few questions against the wall, so to speak, in the interest of starting a dialogue toward understanding how our industry might meet the obligations of the CAA. We will not be looking at all of the obligations within the CAA but will pick out a few of my favorites as examples of the things we need to be considering as the CAA rolls out. The CAA requirements discussed below are in no particular order and, again, have randomly been picked by me as some that seemed to have a few issues glaring right at the top. I tend to be very guilty of finding glee in identifying logistical problems, so, the requirements I decide to write about all have this in common – they will create some headaches – let’s figure out how to get past those headaches. 

Click here to read the rest of this article

The Liability Landmine: The Surprising Decision in Doe v. UBH

By: Jon Jablon, Esq. – August 2021 – Self-Insurers Publishing Corp. 

The industry is buzzing. Congress and the Department of Labor are shaking things up with the Consolidated Appropriations Act – including, of course, the No Surprises Act and new requirements for compliance with the Mental Health Parity and Addiction Equity Act. Even though the fiduciary liability standards we have all come to understand have been relatively static for a long time, a recent Mental Health Parity-related federal court decision has sent a shockwave across the self-funded industry, potentially changing the way TPAs and other entities will need to view fiduciary liability. The decision in question is in response to a motion in Jane Doe v. United Behavioral Health, in the U.S. District Court for the Northern District of California (Case No. 4:19-cv-07316-YGR), decided March 5, 2021. The dispute in this case centered around the health plan’s blanket exclusion of Applied Behavioral Analysis and Intensive Behavioral Therapy – two of the primary treatments for Autism Spectrum Disorders. 

Click here to read the rest of this article

New Administration Casts Doubt on Trump’s Importation Plan

By: Andrew Silverio, Esq. – July 2021 – Self-Insurers Publishing Corp. 

In July of 2019, then president Trump’s HHS announced a “New Action Plan to Lay Foundation for Safe Importation of Certain Prescription Drugs” Much of this release was reiterating and repackaging previous policies and rulemaking authority, but a significant development was the announcement of that the HHS and FDA would review and approve pilot programs organized by the states to facilitate the importation of prescription drugs from Canada. 

An awful lot has happened in the country and the world during the almost two years since this guidance, and we did not see any development at a federal level before the election and hand-off of the presidency. Now, the Biden administration has touched on the issue for the first time.

Click here to read the rest of this article

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The Phia Group's 2021 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 2021 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 8-18, 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 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 programming.

Back to School

Our friends from the Boys & Girls Club of Metro South are going back to school, and the Phia Family wanted to send them some school supplies to go back to school with. The Phia family donated a total of $5,000 in school supplies! The kids were able to pick out a backpack, markers, glue sticks, pens, pencils, notepads, and so much more to help them succeed in school. We hope all of the amazing children are enjoying their new school supplies!

Translating Forms & Letters for the B&GCMS

The Boys & Girls Club of Metro South has come up with a great initiative to promote inclusivity among their membership and families. They will now be offering their Membership Application, Financial Assistance Application, and Member Handbook in five languages: 

• English 

• Cape Verdean Creole 

• Haitian Creole 

• Portuguese 

• Spanish 

This was made possible by The Phia Group raising and donating $5,000 to cover the translation firm’s fee required to convert all three documents. We hope that this will help a large number of families with enrolling their children in The Boys & Girls Club of Metro South!

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Get to Know Our Employee of the Quarter:
Elizabeth Pels

To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. 

The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Elizabeth Pels, The Phia Group’s 2021 Q4 Employee of the Quarter! 

Here is what one person had to say about Elizabeth: “Liz has impressed everyone she has come in contact with, while taking on a new role of subro CST liaison. Her knowledge has impressed our new clients and she has taken her knowledge of processes, to implementations, to make sure that clients’ expectations are accurate when they come on board. Having her on the team has saved CH unnecessary work and cut down on any surprises we have as new clients are onboarded.”

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

 


Job Opportunities:

 

• Claim Analyst 

• Case Investigator 

• Subrogation Attorney 

• Training and Development Specialist 

• Claim Recovery Specialist 

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

Promotions

• Ben Mooney has been promoted from Claim Analyst to Team Leader, Claim Analysis 

• Sue Bivins has been promoted from Senior Data Architect to Manager, Data Qualty & Architecture – Data Services Group 

• Michael Vaz has been promoted from Senior Customer Success & Account Manager to Manager, Intake - Data Services Group

New Hires

• Lindsay Stewart was hired as a Customer Service Rep. 

• Jueyao Fadrigalan was hired as a Claim & Case Support Analyst 

• Malcolm Rymer was hired as a Claim Analyst 

• Kaitlyn MacLeod was hired as a Consulting Attorney 

• Micah Iberosi-Parnell was hired as a Consulting Attorney 

• Emily Rodriguez was hired as an Intake Specialist 

• Shannon Glover was hired as a Case Investigator 

• Saurabh Patil was hired as an ETL Specialist 

• Melinda Bellis was hired as an Associate General Counsel 

• Melanie DeMelin was hired as a Claim & Case Support Analyst 

• Haley McBroom was hired as a Sr. Claims Recovery Specialist 

• Soujana Gouriesetty was hired as an ETL Specialist 

• Jacqueline Davis was hired as a Plan Drafter
 



Phia News:

COVID - Appeals, Subrogation, and Stop Loss Issues No One Saw Coming - Help is Here!

COVID claims are coming - whether you pay or deny claims tied to COVID, you need The Phia Group.

Claims tied to the treatment of COVID-19 are being submitted for payment and are passing through the claims process in record numbers. Many of these claims are substantial, with these considerable costs impacting our industry in both anticipated and unforeseen ways. As with any influx of new claims, we are also seeing growth in the number of denials and appeals arising from these COVID claims, as well as subrogation issues tied to the disease.

COVID claims are routinely denied and/or paid incorrectly, due in large part to the inadequate time provided to consultants, administrators, and payers, to familiarize themselves with the ever changing rules, and thereby standardize appropriate handling of these claims in accordance with law and their plan documents. As a result, we are also seeing an increase in COVID related claim appeals, with heightened fiduciary liability issues also arising from these claim payment decisions.

The Phia Group's PACE Service has existed for years and is the only service on the market where expert plan drafters, attorneys, and seasoned appeals professionals help you navigate these and other difficult appeals, thereby avoiding mistakes and costly liability. PACE ensures claim denials are legitimate, enforceable, and defended.

As with claims processing and appeals, COVID has also created a new world for subrogation. When COVID claims are submitted, complex state law may be triggered regarding if and when COVID is "presumed" to be an occupational expense. The Phia Group was the first subrogation provider to build a custom process backed by its in-house legal team with a focus on identifying COVID related claims, determining whether the applicable geographic location and occupation are addressed by a regulation that presumes a link between the occupation and diagnosis, and quickly asserts a right to reimbursement against responsible parties if possible. The Phia Group has been applying this procedure to its existing process since June of 2020. Without an innovative subrogation solution like ours in place, plans not only lose money, but also fail in their obligation to stop-loss; a failure stop-loss carriers are increasingly unwilling to overlook.

The stop-loss world has been handed a unique and difficult scenario. As it relates to claims arising from or tied to COVID-19, carriers are suspending reimbursement and asking questions such as: what is the Plan Participant's job description; is the Plan Participant a front line worker; what date did they test positive; are they an essential worker; did they file a workers' compensation claim; and so on. The Phia Group has the expertise to assist in these difficult stop-loss collaborations.

Ensuring appeals are handled correctly, aligning plan documents with stop-loss policies, and fully understanding the bigger picture has never been more important. The Phia Group is uniquely positioned to help in this difficult time. With our unrivaled team and technology ready to help, there is no better partner to assist you now and in the days to come.

Contact Garrick Hunt at ghunt@phiagroup.com or info@phiagroup.com to request more information and set a call to learn how The Phia Group can assist you with these COVID claim issues.

Hispanic Heritage Month Celebration

As some of you may know, El Mes de la Hispanidad (Translation: Hispanic Heritage Month) is celebrated from September 15th through October 15th, aligning with the Independence Days of some Latin American countries such as Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Mexico, Chile, and Belize. This is an important celebration in the U.S., as Latinx and Hispanic Americans make up the largest minority group in the country. 

In honor of Phia’s Latinx and Hispanic American employees, family members, and to enhance our diversity inclusion efforts, The Phia Group and the Diversity Inclusion Committee hosted a Hispanic Heritage Month. 

The event included Hispanic food, refreshments, and cultural music!

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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info@phiagroup.com
781-535-5600