Phia Group

Autism Benefits: DOL Enforcement for Sufficient Coverage

On May 22, 2023
About 1 in 36 children in the United States has autism spectrum disorder, which is a lifelong condition that can affect a person’s behavior, communication, interactions, and ability to learn. The Department of Labor (DOL) continues strongly advocating for more comprehensive autism coverage under group health plans and Employee Benefits Security Administration (EBSA) has been working to ensure individuals who need treatment are able to access it. The Phia Group is also working hard to ensure plans are offering robust benefits while remaining compliant with mental health parity laws.

Digitizing Subrogation

On May 10, 2023
When it comes to subrogation, The Phia Group has over 20 years’ experience serving clients nation-wide. Our attorneys are some of the industry’s most well-versed subrogation experts who can relate to a wide swath of health plans – from self-insured to Medicare-based ones. But we know there can be a great deal of attrition and stiff competition in the subrogation space, which is why for the better part of the past decade there has been a company-wide initiative to digitize our products, most notably The Phia System™ and Case Management System.

Unwrapping the Benefits to Your Plan

On May 4, 2023
On January 1, 2022, the No Surprises Act (NSA) officially went into effect, affording protection to patients against surprise medical bills on certain types of claims, including out-of-network emergency services, ancillary out-of-network professional services rendered at in-network facilities, and air ambulance services. While the NSA has spared countless patients from potentially devastating balance bills, its complex and ever-evolving dispute resolution process has created headaches for plans and providers alike. Luckily, Phia Unwrapped includes NSA support services during the Open Negotiation period and, if necessary, Independent Dispute Resolution.

Marty Walsh Goes to Bat for NHL Retirees

On April 11, 2023
The National Hockey League’s collective bargaining agreement (“CBA”) is not set to expire until September of 2026, but it was still a hot topic during NHLPA Executive Director Marty Walsh’s introductory media conference last month in Toronto. In particular, there were several questions directed to the erstwhile Boston mayor and US Secretary of Labor about the union’s plans for managing the health benefits of retired players. Judging by his response, he didn’t appear to be blindsided.

Keeping PACE With COVID-19 Developments

On April 5, 2023
On January 30, 2023, the Biden administration announced its plan to terminate the national emergency and public health emergency declarations pertaining to the COVID-19 pandemic. Effective May 11, 2023, the phasing out of the public health emergency will mean a change in coverage requirements (i.e., vaccines administered out-of-network can involve cost sharing, no longer will there be free at-home COVID tests), while the end of the national emergency will affect the tolling of various health benefits related deadlines. The latter issue is one that resonates particularly strongly with The Phia Group’s PACE (“Plan Appointed Claim Evaluator”) service, whereby Phia manages final internal appeals, defends its decisions in the face of external appeal, and oversees the Independent Review Organization (“IRO”) external appeal process.

Jimmy Carter’s Complicated Healthcare Legacy

On March 21, 2023
In the Bicentennial Summer of 1976—during which Jimmy Carter was campaigning for president—there was nonstop pageantry. Patriotism reached fever pitch as parade floats washed in red, white, and blue streamed through smalltown America while Uncle Sam-inspired merchandise flooded the shelves of department stores across the entire union. But overshadowed by the unprecedented amount of hoopla was the sobering reality that the then-two-century-old nation had a broken healthcare system: at this moment in time, 26 million Americans lacked health insurance altogether while another 28 million possessed only minimal coverage. And Carter, who grew up on a backwoods Georgia peanut farm with neither running water nor electricity, sympathized with the plight of the working poor by endorsing the concept that America needed universal healthcare coverage—to the extent that it was economically (and politically) feasible.

Maximizing Subrogation and Reimbursement in Medical Malpractice Claims

On March 13, 2023
The idea of healthcare subrogation and reimbursement seems straightforward. A third party causes an injury to a plan member and the Plan seeks recovery for the benefits advanced by the health plan from either the at-fault party or from the proceeds of the settlement. However, it can be much more complicated. Some of the most complex cases occur when a plan member makes a medical malpractice claim. Medical malpractice subrogation and reimbursement typically involve high dollar claims and the member is usually suffering from a permanent condition or has died. These cases can be difficult not only for the member who has suffered injuries, but for the health plans as well.

Price Transparency: A Chief Concern at SIIA’s Recent Kanas City Forum

On March 9, 2023
KANSAS CITY, MISSOURI – In the opening presentation of the SIIA Price Transparency Forum held at the Kanas City Marriott Downtown last month, SIIA’s Senior Vice President of Government Relations, Ryan Work, made a bold prediction: if healthcare costs remain on this decades-long rising trajectory it could lead to the demise of employer-based healthcare as we know it.

Confusion Over Recent Insulin Cost Capping Discussions

On March 6, 2023
I recently drafted an article regarding legislative proposals to “cap” patient out of pocket costs for insulin. In it, I explained that – while the individual patient’s out of pocket cost may be reduced at the time of purchase – the total cost of the medication is not reduced. Instead, a greater share is shifted onto the health benefit plan or insurance. That payer would then – likely – increase the cost of coverage (premiums, contributions, etc.), resulting in the patient ultimately paying the cost of the drug… simply in a different way. Shifting who pays a designated portion of a price doesn’t reduce the price itself. The only way to reduce the price of something is to reduce the price.

Hospital Prices: Fully Transparent or Still Somewhat Opaque?

On February 23, 2023
In the throes of the first pandemic winter, still months before coronavirus vaccines would roll out in earnest, the Hospital Price Transparency Rule went into effect. It was a promising development in the world of healthcare cost containment—hospitals were now obligated to provide a single, machine-readable digital file containing standard charges for all services and items provided by the facility.

The State of Paid FMLA: Thirteen States and Counting

On February 15, 2023
Crucial healthcare and employee benefits issues were addressed during President Biden’s recent State of the Union, including a commitment to expanding paid family and medical leave. Thirty years ago, the Family and Medical Leave Act (FMLA) was passed and created new opportunities for employees faced with the difficult decision of having to choose between work and family. FMLA allows eligible employees to take unpaid, job-protected leave for family and medical reasons and continue their group health coverage.

SPD Payment Limitations Under the No Surprises Act

On February 9, 2023
Ah, the Plan Document! It’s the “supreme law of the land” governing the health plan’s benefits. Would that make ERISA the Declaration of Independence of self-funding, maybe? Freedom from the tyranny of state or federal laws that attempt to make their own rules for the plan rather than letting the plan govern itself?

Are Non-Competes Out the Window?

On February 2, 2023
Not just yet. Recently, the Federal Trade Commission (FTC) proposed a new rule that would ban post-employment non-competition agreements for all workers, including independent contractors, in nearly all workplaces. The proposed rule falls under Section 5 of the Federal Trade Commission Act, which bans unfair methods of competition. This proposed rule would greatly impact the entire healthcare industry.

Robotic Lawyers – the Future of Small Claims Courts?

On January 24, 2023
A couple months ago, Forbes magazine published a story hypothesizing five professions that could be eliminated by Artificial Intelligence over the next decade: factory workers, couriers, investment analysts, customer service reps, and security guards. It sounds farfetched, but could “small claims attorney” also join the dreaded list in the not-too-distant future? An intrepid startup, DoNotPay, which bills itself as “the world's first robot lawyer,” has designs on such a development—and perhaps even bigger things—coming to fruition.

No Matter the Remedy – No Language, No Luck!

On January 23, 2023
Recently, the 9th Circuit, a jurisdiction that has historically not been kind to benefit plans engaging in third party recovery activity, issued a decision that gives life to benefit plans whose participants shirk their obligations to reimburse their benefit plans from settlements they obtain in third-party liability cases.