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Implications of the Section 1557 Final Rule

On June 17, 2024
The non-discrimination protections of Section 1557 of the Affordable Care Act are not new, as the Affordable Care Act was originally enacted in 2010. However, the recent Final Rule published on May 5, 2024, provided clarification and additional requirements as they relate to strengthening civil rights protections for individuals.

2024 Benefest: Not Just Massachusetts in Focus

On June 14, 2024
Earlier this month, 2024 Benefest, hosted by the Massachusetts Chapter of the National Association of Benefits and Insurance Professionals (NABIP), took place at the DoubleTree by Hilton Hotel Boston-Westborough. While the conference largely focused on the Massachusetts healthcare ecosystem – panel discussions of which reached the general consensus that, from an affordability and access perspective, these are incredibly challenging times due to unprecedented staffing shortages reducing providers’ daily bandwidth – there was considerable time spent examining federal healthcare developments, including how November’s election will impact employer-sponsored benefit plans.

The Price is Wrong, Y’all

On June 4, 2024
National spending on healthcare was approximately $74 billion in 1970. Fast-forward to 2022, the growth alone on healthcare spending from 2021 was $175 billion, topping out around $4.5 trillion total spending for that year. It’s a well-worn saying in the healthcare industry but it still rings true: “It’s the prices, stupid.” Every ounce of work and creativity that we at The Phia Group, and many of our colleagues in the industry, pour into trying to reduce healthcare costs may ultimately be for naught if the prices continue to rise indefinitely. One of the driving factors behind those ever-increasing costs: consolidation.

HIPAA Final Rule Protects Access to Reproductive Healthcare

On May 28, 2024
On April 26, 2024, HHS Office for Civil Rights (OCR) released a HIPAA Privacy Rule to Support Reproductive Health Care Privacy (Final Rule). This modifies the HIPAA Privacy Rule to enhance the privacy safeguards around protected health information (PHI) related to reproductive health care and serves to protect access to this care in the wake of the Supreme Court’s Dobbs v. Jackson Women’s Health Organization (Dobbs) decision. This decision, overturning the constitutional right to abortion, led to renewed efforts by many states to more heavily restrict and criminalize certain types of reproductive health care, particularly abortion services.

The Stewardship of Hospitals

On May 16, 2024
Hospitals, ambulatory surgery centers, long-term care facilities, primary care physician practices, nursing homes, hospice care. They are the most indispensable institutions of any functioning society, but unlike a Fortune 500 company or professional sports franchise, the identity of their respective owners often remains an afterthought. That is, unless you work for or are served by a financially distressed health care system, such as for example Steward Health Care, the massive private-for-profit healthcare conglomerate that recently filed for Chapter 11 bankruptcy protection.

The End of a (Brief) Era

On May 2, 2024
Five years ago, Walmart, the multi-billion-dollar retail behemoth, opened its first-ever health clinic in Georgia. Soon, dozens more Walmart-sponsored clinics started opening their doors across not just Georgia, but also Arkansas, Florida, Illinois, Missouri, and Texas. Most of these pop-up clinics operated in rural communities where chronic diseases were rampant and (affordable) primary care options were scarce. Irrespective of the pandemic soon unfolding, they served their purpose: customers shopping for microwaveable dinners and bath supplies could stop by for a doctor’s appointment, get stitched up, take a flu test, or even get X-rays done, all for a very reasonable fee. As many of these shoppers/patients either lacked health insurance or had high deductible plans with imposing out-of-pocket costs, these clinics represented their only viable option for obtaining any semblance of proper healthcare. Surely, some had not been to a doctor of any type for years.

IDR: The Confusion Never Ends!

On April 8, 2024
It seems like every day that The Phia Group's consulting team is presented with an IDR-related issue brought up by either a provider in an appeal or simply a TPA trying to iron out or streamline its processes. Sometimes the question centers around the specifics of the IDR process, but sometimes the question instead focuses on the very concept of IDR itself and when it becomes applicable to begin with.

Reimbursing . . . Medicaid?

On April 3, 2024
Imagine that you have recently lost a loved one, are still in the midst of grieving, feeling sleep deprived, dealing with a bevy of uncomfortable logistical issues, and then told . . . that you may have to forfeit your house.

Lenmeldy: The World’s New Most Expensive Drug

On April 1, 2024
The U.S. Food and Drug Administration (FDA) stoked the fire that is the ever-present discussion surrounding gene therapy when it approved Lenmeldy on March 18, 2024. Lenmeldy is the first FDA- approved gene therapy to treat metachromatic leukodystrophy (MLD), a rare disease that affects the brains and nervous systems of children in their late infantile and early juvenile years.

Wegovy: Not Just a Weight Loss Drug

On March 20, 2024
Earlier this month, the wildly popular weight loss medication was approved in the US to help prevent life-jeopardizing cardiovascular events in people who are overweight, obese, and/or have a history of cardiovascular disease. The FDA’s stamp of approval for drugmaker Novo Nordisk to include cardiovascular benefits to Wegovy’s label meant it was the first weight loss drug to market itself in this manner. Now the million-dollar question (no pun, intended) becomes, will this label expansion make insurers feel more inclined to provide coverage? For good measure, will Medicare, currently barred by law from covering drugs for weight loss alone, be compelled to include Wegovy under its umbrella?

The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Plans

On March 11, 2024
It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”

How the Recent Industry Cyberattack Impacts You

On March 7, 2024
Late last month, an apparent massive cybersecurity incident involving the potential theft of patient data – this could entail personally identifiable information, sensitive health information, and financial information -- and encrypted company files seemingly paralyzed one of the nation’s largest pipelines for healthcare payments and prior authorization processing. Impacting a substantial percent of Americans’ medical claims (billions of claims totaling over a trillion dollars per year), millions have been affected. But perhaps the worst part is that many don’t even know it – and won’t be aware until they need to visit their physician or refill a prescription and face new hurdles in getting their customary treatment.

Millions Saying Good-Bye to Medicaid

On February 22, 2024
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

On February 9, 2024
Las Vegas does not have the only sphere that can provide an extraordinary experience for its participants. Let me introduce you to the subrogation sphere where participants may first appear to have conflicting interests but can become allies. When a health plan member is injured because of a third-party action it sets into motion a dance involving many players, potentially including the plan participant, at-fault party, medical providers, stop loss carrier, and the health plan. Each player is trying to determine which player is the proper payor of the plan participant’s medical expenses.

Are Measles Making a Comeback?

On January 31, 2024
The ever-serious epidemiologist out of Minnesota, who forewarned of a global pandemic years ago and has garnered the not-so-flattering nickname “Bad News Mike,” has a new dire message about the recent measles outbreak, one to which children are most susceptible, that has started to trickle through pockets of Europe and, more recently, the US: