Phia Group

Second Circuit Affirms Private Right of Action for MAO's in Aetna Life Insurance Company v. Big Y Foods Inc.

On December 22, 2022
The Medicare Advantage program, created in 1997, allowed private health insurance companies (“Medicare Advantage Organizations” or “MAO’s”) to contract with CMS to deliver Medicare benefits for a fixed fee per month per enrollee (“capitated payment’). Medicare Advantage Organizations have become increasingly popular and in 2022 close to half of all Medicare eligible beneficiaries are enrolled in a Medicare Advantage Plan. While the Medicare Secondary Payor Act and Federal Codes state that MAOs have the same recovery rights as traditional Medicare, the primary cause of action for MAOs to enforce their rights is through a freestanding provision in the MSP Act, which is separate from the provisions granting the United States the right to seek reimbursement that “there is established a private right of action for damages (which shall be in an amount double the otherwise provided) in the case of a primary plan which fails to provide for primary payment…” 4s U.S.C. 1395y(b)(3)(A). This section does not identify which individuals or entities may take advantage of this private right of action nor against whom these actions may be taken.

Traditional Insurance to Self-Funded Plan | The Phia Group

On March 4, 2022
Wondering what to do about the increasing costs of providing health benefits? Learn about moving from a traditional insurance model to a self-funded plan.

The Health Care Tug-of-War

On October 15, 2019
The conversations around impeachment, gun control, immigration are pertinent, but it is important to recognize the roll of politics in the healthcare debate.

The Art of the Pill: Will Trump Fully Buy Into an International Price Index?

On October 7, 2019
The discussion of lowering prescription drug costs is certainly on the raise, but will Trump fully buy into an International Price Index?

Network Contract Drafting: You’re Doin’ It Wrong

On July 1, 2019
Our consulting team came across a network agreement that had the nuance of indicating that the provider would bill amounts in line with market standards.

Suicidality On the Rise Amongst Missouri’s Child Medicaid Population

On April 10, 2019
A recently released study highlighted some alarming numbers relating to the rates of suicidal thoughts and actions among children. Click to read more.

The New Medicare and Medicaid Bills

On February 19, 2019
Learn more about the Medicare for All Act of 2019 and how it would transform U.S. health care system if it is passed.

Stop-Loss: The Forgotten Player in the Reference Based Pricing Game

On December 20, 2018
Learn why you need to put stop-loss high up on the laundry list of considerations when choosing to adopt referenced-based-pricing.

SUPPORT for Patients and Communities Act

On October 29, 2018
It is no secret that this country has an opioid epidemic that has a rising death toll and price tag attached to it. Click here to learn more.

REMINDER: Medicare Part D Creditable Coverage Notices Due to Certain Employees by October 14th

On September 24, 2018
Do you deserve to be receiving these benefits? Find out more about the Medicare coverage that is due to employees by October 14th. Learn more today!

CMS Requires Hospitals to Post Standard Charges Online

On August 9, 2018
Price transparency has never really been synonymous with health care. Click here to see how CMS's is attempting to address this on-going healthcare issue.

Trump Administration Halts Billions in ACA Payments

On July 18, 2018
The Trump Administration has taken quite a beating from the Affordable Care Act. Click here to know what insurance companies will be forced to do.

Freedom Blue II: The ACA’s Unlikely Ally

On March 26, 2018
The Trump Administration recently shut down Idaho’s conservative governor from ignoring the ACA. Read here to know exactly why this happened.

A Backdoor Employer Mandate? Massachusetts Targets Employers to Shore Up the State’s Medicaid Program

On January 15, 2018
Since 2011, approximately 450,000 people have lost their employer-sponsored insurance in Massachusetts. In the same time period, MassHealth enrollment increased by just over 500,000. The MassHealth program is literally drowning the state in debt, and so last year, Governor Charlie Baked signed H. 3822, which has two major components (beginning in 2018).

Behind Closed Doors

On June 19, 2017
Brady C. Bizarro, Esq. discusses the leaked bits of healthcare information from our government so far in 2017. What does this mean for you? Learn more today.