Phia Group

Prior Authorization Measures, They Are a-Changin

On June 26, 2025
The message has been well received by the giants of the health insurance industry: it’s time to ease up on prior authorizations.

Challenging the FDA: How Four States Are Pushing Back Against New Mifepristone Restrictions

On June 13, 2025
For a quarter century, Mifepristone, the medication used to block a hormone necessary for pregnancy development, has been widely used throughout America. If anything, over the past few years, since the Supreme Court overturned Roe vs. Wade and permitted individual states to outlaw abortions, the pill, used in conjunction with Misoprostol, has become even more popular among women seeking to terminate their pregnancies. And yet, despite its far-reaching popularity and well-documented efficacy, the Food and Drug Administration (FDA) has maintained stringent restrictions on Mifepristone.

ERISA Isn’t Always a Shield: The Limits of Fiduciary Preemption

On June 12, 2025
In the recently decided case of BlueCross BlueShield of Tennessee v. Nicolopoulos, the Sixth Circuit delivered a clear message to insurers and third-party administrators (TPAs) who also act as ERISA fiduciaries: ERISA’s broad preemption clause does not always provide immunity from state-level regulation. This case underscores the enduring significance of ERISA’s “savings clause,” especially when state regulators act against insurers in their more traditional role.

The ‘Piano Man’ Cancels Tour: Billy Joel Announces Rare Brain Condition

On June 5, 2025
For decades, Billy Joel has lit up stadiums across the globe, delighting fans with classic hits like “Only the Good Die Young,” “Uptown Girl,” and “Scenes From an Italian Restaurant.” People of all ages can recognize his songs with just a few notes on a piano. A musical icon since his debut in the early 1970s, Joel has won six Grammy Awards and has watched 43 of his songs make it to the Billboard Hot 100 chart.

Tiara Yachts v. BCBS Michigan: A Cautionary Tale

On May 29, 2025
When it comes to self-funded health plans, fiduciary duties often tend to lurk in the background – acknowledged and respected, but not always fully understood. The recent Sixth Circuit decision in Tiara Yachts, Inc. v. Blue Cross Blue Shield of Michigan brings those duties into sharp focus, offering a valuable lesson for TPAs, brokers, and plan sponsors.

Cunningham et. al. v. Cornell University: A Fascinating Interpretation of ERISA

On May 22, 2025
In what has been a very busy spring for the Supreme Court, it recently heard the case of Cunningham et. al. v. Cornell University, in which the plaintiffs, representing over 30,000 current and former employees enrolled in Cornell University’s 403(b) retirement plans (which contained approximately $3.4 billion in net assets), claimed that the plan fiduciaries violated ERISA by neglecting to remove low performing investments and engaging in prohibited transactions, namely paying excessive recordkeeping fees to retain two recordkeepers. While most of these claims had been dismissed by lower courts—the Second Circuit interpreted ERISA to mean plaintiffs were required to show that services were unnecessary or fees were unreasonable to state a claim—the plaintiffs ultimately prevailed as the high court, in a unanimous 9-0 ruling delivered by Justice Sotomayor, agreed to reverse the lower courts’ rulings.

Eggs, housing, . . . and healthcare? A new survey found that healthcare has never been so unaffordable for Americans this decade

On May 2, 2025
Not even a month ago, on April 4, the results of the West Health and Gallup poll survey, conducted from mid-November to late December last year, were published, revealing that quality, affordable healthcare eludes 35 percent of Americans (representing some 91 million adults), a four-point jump from 2023 and the highest mark since 2021. Meanwhile, approximately 29 million Americans, or 11% of those surveyed, reported that they lacked the means to afford medication and care as recently as over the past three months. Just as unnerving—but most certainly not surprising—is that the disheartening trend has been most prominent among lower-income individuals (those who belong to families earning less than $24,000 per year) as well as Hispanic and Black Americans; conversely, there has been negligible change in this regard among mid- to high-income earners and whites. Hence, one reason why there is the ever-widening healthcare social disparity plaguing our nation.

Navigating Mental Health Parity: What Self-Funded Plans Need to Know

On April 24, 2025
In 2008, under the George W. Bush administration, the Mental Health Parity and Addiction Equity Act (MHPAEA) was enacted to ensure that health insurance plans did not impose more restrictive limitations on mental health and substance use disorder (MH/SUD) benefits – assuming they were initially covered – than those imposed on medical and surgical (M/S) benefits. More specifically, health insurers were forbidden from applying limitations such as prior authorizations, unreasonably high copays, or visit restrictions to mental health/substance use disorder treatments when medical/surgical treatments did not have such imposing constraints.

A Discussion of the Executive Order to Lower Drug Prices

On April 23, 2025
The high costs associated with prescription drugs consistently provoke conversation in the self-funded healthcare industry. Not only is it an issue that most health plans encounter, but it is also a concern that trickles down to the member-level. Whether you’ve personally experienced the effects of high-cost drugs, or they have impacted a close family member, we can all empathize with the stress of having to pay for an expensive prescription.

AI to the Rescue? How Machine Learning May Revolutionize Drug Repurposing

On April 15, 2025
Without question, artificial intelligence beholds many downright frightening risks when implemented in the healthcare field. Without proper oversight, AI could have the final say in depriving a patient of a necessary procedure or steering them towards a suboptimal physician. Or the still nascent technology, if unchecked, could account for a HIPAA breach with the slapdash handling of PHI. Yet, that being said, AI is undoubtedly here to stay and as far as the healthcare industry is concerned, this technological revolution is brimming with astonishing potential, as evidenced by the recent development of AI expediting the repurposing of existing drugs for treatment of rare diseases.

Tariff Talk - How Trump’s Pharmaceutical Tariffs Could Impact You (and How You Can Prepare)

On April 11, 2025
As the self-insurance industry braces for potential changes under President Trump’s administration, one issue looms large: impending tariffs on pharmaceutical drugs. These proposed tariffs, aimed at boosting domestic manufacturing, could ripple through the healthcare ecosystem, affecting employers sponsoring self-funded health plans, third-party administrators (TPAs), stop-loss carriers, brokers, and vendors. For an industry built on balancing cost control with quality care, understanding these impacts and preparing strategically is critical. More importantly, as we navigate these changes, we must remain steadfast in our commitment to ensuring that our members get access to quality, affordable prescription drugs.

Care Empowered Pricing as a Money Saver

On April 10, 2025
For over a quarter century, The Phia Group has championed a broad spectrum of cost containment initiatives to empower health plans and ultimately, their respective participants. The Phia Group believes that its latest endeavor—Care Empowered Pricing (CEP)—may be its most robust cost containment program yet. At its core, CEP is engineered to, quite simply, save plans money and as you can see below, there are a number of ways our revolutionary offering does so.

Overhauling HHS – Can a Leaner, Meaner HHS Make America Healthy Again?

On April 7, 2025
The second Trump administration has not been shy about taking steps to shake up U.S. health policy. There has been a flurry of executive orders on a range of healthcare topics, including stepping up enforcement of price transparency rules; a push to expand coverage for and lower the out-of-pocket costs for in vitro fertilization; and taking steps to redefine sex-based discrimination in federal policy and to discourage treatments for gender dysphoria. Even so, the executive action poised to have the broadest impact on health policy may just be the sweeping changes being made to the Department of Health and Human Services (HHS).

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