Attorneys Brady Bizarro and Andrew Silverio discuss the pending case of Lewandowski v. Johnson & Johnson, a lawsuit brought against plan fiduciaries for violating their fiduciary duties under ERISA. How did they violate those duties? By failing to negotiate drug prices and sufficiently oversee their PBM or investigate alternatives. No matter who wins, this case highlights the importance of ERISA’s fiduciary duties and the gravity of the decisions fiduciaries are (or should be) making.
Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
On Dec. 27, 2020, the No Surprises Act (NSA) was signed into law, with an eye towards protecting patients against so-called “surprise” balance bills. The law leaned heavily on “good faith” negotiations between payers and providers, as well as “objective” decision making via independent dispute resolution. Three years later, The Brookings Institution reported that you are paying nearly four-times what Medicare pays (an average of 390%) and are spending at least 50% MORE than an average PPO network. The bottom line? Providers are winning and you are paying MORE now than you did before the NSA’s passage.
The Phia Group can help you formalize a process that ensures timely triaging of disputes, insert an objective third party for correspondence with providers and IDR, utilize intelligent out-of-network pricing methodologies, implement multifaceted benchmarking for objective yet aggressive defense, and utilize a tiered program to ensure continuous advocacy on behalf of your plan. Want to join the winning team?
Click Here to View Our Full Webinar
To obtain a copy of our webinar slides, please reach out to mpainten@phiagroup.com.
Canton, MA – April 24, 2024 – The Phia Group’s CEO, Adam V. Russo, was presented with the Be A Beacon Award at the Free Market Medical Association (FMMA) Annual Conference in recognition of his outstanding leadership and achievements in transforming healthcare.
The award represents those who have gone above and beyond in their support and promotion of the free market movement with award recipients chosen by the FMMA Founders. FMMA said of this year’s recipients, “We are grateful for your leadership and vision, and this award is a well-deserved recognition of your invaluable contributions!”
Adam Russo commented, “I was proud and honored to receive the Be A Beacon award this year, especially from an organization that has so many innovative leaders. This award is a reflection of The Phia Group's continual innovation and commitment to excellence in every aspect of our organization.”
For more information about The Phia Group and its commitment to care and plan empowerment, please contact Garrick Hunt at ghunt@phiagroup.com or 781-535-5644.
About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, is a leading provider of health care cost containment solutions. With offices across the United States, The Phia Group offers comprehensive claims recovery, plan document, and consulting services designed to contain health care costs and protect plan assets. By delivering industry-leading consultation and cost containment solutions, The Phia Group empowers plans to achieve their goals. Learn more at phiagroup.com.
About Free Market Medical Association: Free Market Medical Association headquartered in Oklahoma City, OK is a free market movement in healthcare promoting transparency. Founded in 2014 by Jay Kempton and Dr. Keith Smith, their goal is to bring together buyers and sellers of healthcare goods and services – reducing costs and increasing quality. For more information visit fmma.org.
Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo:
It's conference season yet again, and like Johnny Cash, I’ve been everywhere – Arizona, California, Florida, Oklahoma City, the Caribbean, and every place in-between … and in all places, I am spreading the message to the masses. Your message, my message, Phia’s message. A message of optimism and hope. A belief that together we can improve the quality of healthcare, reduce the costs we pay for it, improve access, and put the “benefit” back in “benefit plan.” I am honored to be educating brokers and employers on better ways to fund their health plans, and am witnessing a new level of interest from those entities unlike any I’ve seen before.
I am explaining to technologists and software developers the various compliance rules and regs, and all the other “tough stuff” that we must deal with every day in the self funded industry. The audience has grown – in size and composition. It is a great time to be on the road! Yet, I see those familiar faces in the crowd as well. I love getting to see old friends and meet new ones, but it’s not all positive. The horrible part of hitting the road is saying goodbye each week to my family. You know the feeling… but I know the cause is worth it. I humble myself, knowing that it could be a lot worse. I could be in the military overseas, fighting for our freedom, not seeing my family for months or even years. I could be any one of our plan participants, in-patient at a hospital for weeks or months… missing my family just as much, but gazing at my own mortality instead of your shining faces. Yeah – I think about those who have got it worse, and it gives me the jolt I need to work even harder, on their behalf.
As you know, at The Phia Group our mission is to ensure that every American has access to high-quality, low cost care. It's a tough battle, but I know we are winning. The tools we have rolled out, and those that we are developing now, will make the difference. Whether it's our Ignite software, our A/I powered compliance and appeals software, or the vast algorithms we have created to identify recovery trends and ways for you to lower your costs, the best will keep getting better. Yet, the challenges aren’t getting any simpler either. There is no better example right now than what is happening with the No Surprises Act (“NSA”). I urge all of you to read the article provided here, about the Brookings Institute findings. Let this one example show you just how much you and your plans are overpaying for these out-of-network facilities. We know that with the right processes, the right education, and the right compliance team, you can cut those NSA expenses by almost 50%. You owe it to your clients to take a look at your current process… and we can help.
Additionally, on a personal note, this May will mark 11 years since one of my best friends was killed by cancer. Robert "Staga" Pokorski was not only like a brother to me, he was also a loving husband and father to two beautiful young children. Then, a few years later, I lost my father-in-law to cancer. Jack Sheehan was a legend, and so many of my stories feature this larger-than-life character. I know I am not alone. For too many of us, it’s not a matter of “if” but “when” cancer will impact you or someone you love. Only by investing in research can we reduce the chances that cancer will win. At the same time, more effective, efficient diagnoses and treatments reduce the cost we pay to fight cancer. It’s a win-win. Join me as I fight alongside my friend and Phia Group CLO – Ron E. Peck – in our fundraising effort, on behalf of the renowned Leukemia and Lymphoma Society (“LLS”). Take a minute to click this link, https://pages.lls.org/voy/ma/ma24/arusso or use the QR code below, and donate. Every dollar counts, and every donor has my eternal gratitude. I don’t want to lose another person I love to cancer, and I don’t want you to lose someone you love either.
Thank you for believing in The Phia Group and happy reading.
Service Focuses of the Quarter Phia Fit to Print From the Blogosphere Webinars Podcasts The Phia Group’s 2024 Charity Employee of the Quarter Phia News
Service Focus of the Quarter: No Surprises Act & IDR Support
As you probably know, the No Surprises Act has created what seems like a never-ending set of hoops for health plans to jump through. In the course of providing our Phia Unwrapped and Independent Dispute Resolution (IDR) support services, we have discovered that not only are there more and more hoops all the time, but that the hoops actually seem to be getting smaller and smaller.
According to a recent Brookings study (https://www.brookings.edu/articles/a-first-look-at-outcomes-under-the-no-surprises-act-arbitration-process), the mean IDR decision is actually 50% higher than the mean in-network commercial payer’s cost, coming in around 370% of Medicare (including an average of 401% of Medicare for emergency claims and a whopping 511% of Medicare for neonatal/pediatric care). Somewhat ironically, that pricing is far higher than what CMS seems to have expected, and is actually closer to historical non-network prices, likely frustrating the very purpose of the IDR process in many cases. Though the NSA was created specifically to increase the burden on health plans, we’re not confident that the regulators intended the added burden to be quite this large.
In response, Phia’s services have evolved as well, with an increased focus on a multi-benchmark system to develop settlement offers that are reasonable not only to providers, but (far more importantly, in our view) for health plans as well. Our relationships are becoming deeper and our cadence is quickening, leading to increased efficiency and unprecedented settlement leverage. In our experience, quick response times and bona fide settlement efforts prior to IDR will almost always be more favorable to a health plan, which is where Phia really shines. The benefit of accessing Phia’s NSA-related services is attaining favorable settlements with a focus on avoiding IDR whenever possible, since IDR is unpredictable and more often than not lands in favor of higher payments. Even if a claim progresses to IDR, however, Phia has an arsenal of data and logic to promote more favorable outcomes.
To learn more, contact sales@phiagroup.com.
Enhancement of the Quarter: NQTL Report Cards
Users of Phia’s Independent Consultation and Evaluation (ICE) service will now have access to a benefit specifically geared toward the federal Mental Health Parity law! For groups that aren’t sure what MHP is all about, or that are hesitant to do a full non-quantitative treatment limitations (NQTL) analysis until the Department of Labor gives more guidance, or who want to know how their plan language stacks up compliance-wise, our team of experts can now provide a “report card” of parity-related information from a given SPD.
Whether it is a group’s finalized plan document or a template, our team will review the provisions and provide a high-level summary of MHP-related compliance issues. This is included within the ICE service, so your groups can rest assured knowing that we’ve got their backs.
Federal law still requires health plans to generate full NQTL comparative analyses, but this is a way to find out where the health plan is bleeding, and bandage up the wounds, as soon as possible.
Phia Case Study: The Unusually Narrow Hazardous Activities Exclusion
A TPA recently presented Phia’s consulting team with a stop-loss denial and asked if we could help opine on the merits of the denial. Specifically, the claim involved a bull-riding accident; the health plan excluded hazardous activities, but only in connection with professional or semi-professional sporting activities, which – the plan determined – did not apply here; and so, the plan paid this claim. The claims exceeded the plan’s specific deductible, and thus were submitted to stop-loss for reimbursement. The carrier subsequently denied the claim for reimbursement, citing the SPD’s hazardous activities exclusion, though it’s not clear whether the carrier misinterpreted the exclusion or simply saw the word “hazardous” and decided that it applied.
Phia analyzed the claim and language and provided a thorough written analysis, concluding that not only did the plan’s hazardous activities exclusion not apply here, since this had nothing to do with semi-professional or professional sporting activities, but the No Surprises Act in fact wouldn’t even allow this exclusion to be used in this case since it is a “general plan exclusion” that has been rendered inapplicable to emergency claims pursuant to federal guidance.
Since the stop-loss policy did not contain its own hazardous activities exclusion but rather the carrier relied on the plan’s exclusion, and since the plan did not need to exercise any discretion to allow this claim, Phia’s review also concluded that the carrier’s denial did not appear to be substantiated by any limitation found within the policy.
The TPA went back to the carrier, armed with Phia’s review, and we were thrilled when three weeks later the TPA updated us to let us know that the carrier reversed its denial and paid the claim.
Fiduciary Burden of the Quarter: Considering All the Evidence
As you probably know, the law allows health plans a great deal of discretion in interpreting facts and plan document provisions and administering benefits based on those interpretations. But what happens when the facts underlying a claim aren’t clear, or when there is conflicting information in the record?
With some exceptions, judicial review of benefit determinations will defer to the plan administrator’s interpretations of facts and the SPD unless they are deemed “arbitrary and capricious”. To illustrate that and differentiate between the two terms, picture flipping a coin. An example of a decision that is arbitrary would be flipping the coin, and making the decision based on however the coin landed. In contrast, a decision that is capricious would be flipping the coin, checking the result, and then deciding on a whim that you want to choose the other one instead. Benefit interpretations are rarely that simple, of course, but it’s important to realize that while arbitrariness involves a degree of randomness, capriciousness involves applying inconsistent logic rather than choosing randomly – and it’s not always so obvious when a decision rises to the level of capriciousness.
A great example that happens somewhat often is when a health plan receives conflicting information regarding, say, the medical necessity of a given claim. If a plan is in receipt of two conflicting medical reviews – one confirming medical necessity and the other denying it – courts in many jurisdictions would consider it capricious for the plan to simply choose the review most favorable to itself, unless the plan can articulate a reasoned basis for valuing one medical opinion over the other. In many cases, seeking a neutral third opinion to resolve the discrepancy can be a prudent strategy to sidestep that capriciousness – but in the absence of that third opinion, when faced with a “he said, she said” scenario, opting for the review that benefits the plan without a compelling and articulable rationale may well be considered capricious, potentially compromising the plan’s decision-making authority.
Webinars:
• On February 21, 2024, The Phia Group presented “The Skinny on Weight Loss Drugs,” in which we discussed off-label drug usage, international drug importation, defining medical necessity, plan drafting and exclusions.
• On January 16, 2024, The Phia Group presented “Navigating 2024: The Latest, Most Innovative Plan Design Features & Stop-Loss Policy Updates,” in which we discussed a rundown of 2024’s biggest plan document and stop-loss updates, including matters about which our team has been asked the most.
Be sure to check out all of our past webinars!
Podcasts:
Empowering Plans
• On March 29, 2024, The Phia Group presented “Xenotransplantation: A Potential Game Changer for Self-Funded Plans” in which our hosts, Nick Bonds and Jen McCormick, discussed the groundbreaking development of the world's first successful genetically engineered pig kidney transplant at MGH in Boston.
• On March 14, 2024, The Phia Group presented “Weighing the Options” in which our hosts, Ron Peck and Corey Crigger, discussed the impact the surge in demand for weight loss drugs has had on health plans and consumers.
• On March 8, 2024, The Phia Group presented “State of the Union, 2024” in which our hosts, Brady Bizarro and Nick Bonds, discussed some key healthcare initiatives that we’ll be keeping a close eye on in the coming months.
• On February 29, 2024, The Phia Group presented “The Therapeutic Equivalence Approach: A New “Pill”ar of Contraceptive Coverage,” in which our hosts, Kendall Jackson and Jon Jablon, discussed the “therapeutic equivalence” approach to compliance, what it means for consumers, and what it means for health plans.
• On February 15, 2024, The Phia Group presented “Navigating Post-Settlement Fund Pursuits,” in which our hosts, Andrew Silverio and Cindy Merrell, discussed a newly decided case which provides a roadmap for pursuing settlement funds after disbursement.
• On February 1, 2024, The Phia Group presented “Chevron Deference in Peril – What It Could Mean for Healthcare Regulations,” in which our hosts, Brady Bizarro and Brian O’Hara, discussed the legal doctrine involved in two cases now before the Supreme Court – Chevron deference.
• On January 18, 2024, The Phia Group presented “The Continuing Evolution of MHPAEA,” in which our hosts, Jennifer McCormick and Kelly Dempsey, discussed the ever-shifting landscape of the Mental Health Parity and Addiction Equity Act (MHPAEA).
• On January 4, 2024, The Phia Group presented “Higher Healthcare Prices (Made From Concentrate),” in which our hosts, Ron Peck and Nick Bonds, discussed how the trend of provider consolidation is primed to pick up pace in 2024.
Be sure to check out all of our latest podcasts!
Back to top ^
Phia Fit to Print:
• BenefitsPro – Self-funding plan preparation for 2024 – January, 2024
• BenefitsPro – Self-funding plan preparation for 2024 – March, 2024 Back to top ^
From the Blogoshpere:
• How the Recent Industry Cyberattack Impacts You. As this horrific situation has been playing out across pharmacies throughout our country, physicians in both massive hospital networks and small clinics are struggling to obtain prior authorization for exams, medications, and procedures.
• Millions Saying Good-Bye to Medicaid. 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. The subrogation sphere can have a substantial impact on many people.
• Are Measles Making a Comeback? Will we start seeing more and more of these outbreaks?
• A New Year Brings New (Higher) Prescription Drug Prices. Pharmaceutical companies are hiking prices on their drugs
To stay up to date on other industry news, please visit our blog. Back to top ^
The Phia Group's 2024 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 2024 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 to 18, signed up as club members. In the 30-plus years since then, 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 programs.
Annie: The Play
The Phia Group invited 30 children from The Boys & Girls Clubs of Metro South to watch Annie at the Inly School. They were accompanied by a large number of Phia employees and had a blast watching Adam and the cast put on a phenomenal show!
Phia News: Candy Heart Contest
As is tradition, Phia held its annual Candy Heart Contest. The Phia Family made some great guesses, but there was one person who came particularly close to guessing the exact number. Congratulations to Regina Cattel on guessing 1076 pieces of candy corn. This was a very close guess, as we had 1089 pieces of candy hearts in the jar!
Get to Know Our Employee of the Quarter: Adam Doherty & Elizabeth Galewski
Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition.
The Phia Explore team unanimously agrees that there are no individuals more deserving than Adam Doherty and Elizabeth Galewski to be recognized as The Phia Group’s Employee of the Quarter for Q1 of 2024.
Congratulations, Adam and Elizabeth, and thank you for your ongoing and future contributions.
Phia Attending the SIIA National Conference
Several of Phia’s industry experts will attend SIIA’s 2024 National Conference in Phoenix, Arizona, from September 22nd – 24th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website:
Get more details: https://siiaconferences.org/nationalconference/2024/Index.cfm
Job Opportunities:
• Case Investigator
• Claim and Case Support Analyst
• Director, IT Infrastructure
• Case Analyst
See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers
Promotions
• Jackie Andrews has been promoted from Sr. Director, Provider Relations to Vice President, Provider Relations.
• Alex Houle has been promoted from Director, Provider Relations to Sr. Director, Provider Relations.
• Brady Bizarro has been promoted from Sr. Director, PGC to Vice President, PGC.
• Andrew Silverio has been promoted from Compliance and Oversight Counsel to Director, PGC.
• Daiana Williams has been promoted from Director, Recovery Services to Senior Director, Recovery Services.
• Ekta Gupta has been promoted from Manager Data Services Group to Director Data Services Group.
• Zach John has been promoted from Sr. Manager, Applications Development to Director, Applications Development.
• Andrew Mead has been promoted from IT Helpdesk Coordinator to Systems Administrator.
• Sneh Gaonshindhe has been promoted from Sr. Software Developer to Manager, Applications Development.
• Angela Grande has been promoted from Team Lead to Manager, Provider Relations.
• David Ostrowsky has been promoted from Content Specialist to Manager, Corporate Communications.
• Trina Garcia has been promoted from PACE Specialist II to Health Benefit Plan Consultant III.
• Michelle Rowland has been promoted from Health Benefit Plan Consultant to Health Benefit Plan Consultant III.
• Tara Otoka has been promoted from Health Benefit Plan Consultant to Health Benefit Plan Consultant III.
• Diana Newburg has been promoted from PACE Specialist II to Health Benefit Plan Consultant III.
• Maghen Keefe has been promoted from PACE Specialist I to Health Benefit Plan Consultant II.
• LaTrisha Keierleber has been promoted from PACE Specialist I to Health Benefit Plan Consultant II.
• Michelle Haga has been promoted from PACE Specialist I to Health Benefit Plan Consultant II.
• Corrie Cripps has been promoted from Health Benefit Plan Consultant III to Health Benefit Plan Consultant IV.
• Olesya Avramenko has been promoted from Health Benefit Plan Consultant III to Health Benefit Plan Consultant IV.
• Emily Rodriguez has been promoted from NQTL Consultant I to Consultant I, MHPAEA.
• Bryan Dunton has been promoted from Consulting Attorney I to Consulting Attorney II.
• Nick Bonds has been promoted from Consulting Attorney II to Consulting Attorney III.
• Morganne Samuelson has been promoted from Project Manager to Senior Project Manager.
• Desmond Campbell has been promoted from Accounting Administrator I to Accounting Administrator II.
• Saheed Yussuff has been promoted from Accounting Administrator I to Staff Accountant.
• Deonte Small has been promoted from Accounting Assistant to Accounting Administrator I.
• Richard Harrison has been promoted from Sr. Accountant to Accounting Manager.
• Liz Pels has been promoted from Manager, Recovery Service Onboard & Support to Sr. Manager, Case Evaluation & Customer Service.
• Jen Marsh has been promoted from Recovery Service Onboard & Support Specialist to Senior Team Lead, Customer Service.
• Skyla Mrosk has been promoted from Sr. Claims Analyst to Sr. Claims Analyst, Trainer & Auditor.
• Malcolm Rymer has been promoted from Claims Analyst, Outreach Specialist to Claims Analyst, Client Outreach Specialist.
• Lindsey Stewart has been promoted from Customer Care Representative to Case Analyst.
• Dennis Ferzoco has been promoted from Claims Analyst to Sr. Claims Analyst.
• Tomasz Olszewski has been promoted from Sr. Claim & Case Support Analyst to Team Lead, Claim & Case Support.
• Haley McBroom has been promoted from Senior Claims Recovery Specialist to Team Lead, Recovery Services.
• Ethan Forrest has been promoted from Claim Recovery Specialist III to Senior Claims Recovery Specialist.
• Nicole Capozzoli has been promoted from Claim Recovery Specialist III to Trainer.
• Bridget Binda has been promoted from Case Investigator to Claims Recovery Specialist III.
• Richard Hunt has been promoted from Facilities Coordinator to Facilities Manager.
• Diane McAuley has been promoted from Executive Assistant to Senior Project Manager to the Chief Operating Officer.
• Emily Kewer has been promoted from Case Investigator to Team Lead, Case Investigation.
• Amanda DeRosa has been promoted from Manager, Recovery Services to Senior Manager, Liability Investigation and Claims Recovery.
• Hannah Lane has been promoted from Manager, Contracts Administration to Junior In House Counsel.
New Hires
• Sarah Bracken was hired as a Sr. Claim Recovery Specialist.
• Sean Luckett was hired as a Sr. Claim Recovery Specialist.
• Sara Welch was hired as a Consultant.
• Alianna Feria was hired as a Sr. Claim Recovery Specialist.
• Ben Balke was hired as a Sr. Architect Pricing Engineer.
• Andrew Schulz was hired as a Sr. Subrogation Attorney.
• Luke Harrison was hired as a Sr. Claim Recovery Specialist.
• Angela Norris was hired as a Claims Specialist.
• Brianna Gatto was hired as a Case Investigator.
• Alison Abdikarim was hired as a Customer Service Rep.
• Justin Asher was hired as a Sr. Claim Recovery Specialist.
• Jaime Smith was hired as a Customer Service Rep.
• Alex Morison was hired as a Case Investigator.
• Marilu Flores was hired as a Customer Service Rep.
• Megan Knox was hired as a Customer Service Rep.
• Jessica Williams was hired as a Customer Service Rep.
• Stephen Sockol was hired as an AV Specialist.
• Jason Whitlock was hired as a Sr. Claim Recovery Specialist.
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.
Listen in as Kelly Dempsey and Brian O'Hara hit it out of the park in this Empowering Plans episode about Essential Health Benefits (EHBs)! The regulating bodies are at it again and issued ACA FAQ #66 on April 2, 2024! Listen in for a quick refresher on EHBs - how they started, where they are now, and where we’re going - and Phia’s interpretation and analysis of FAQ #66.
By: Jon Jablon, Esq.
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.
By definition, the IDR process, as prescribed by the No Surprises Act, is intended specifically and only to choose between two competing offers. For IDR to become applicable, the plan must have first tendered some initial payment (or at least adjudicated the claim as covered). To contrast, a complete denial of a given line item of service based on a plan exclusion does not render the claim eligible to be challenged at IDR. Put bluntly, the IDR Entity is not a clinician, and its job is not to scrutinize or invalidate complete denials. The IDR Entity is much more like an arbitrator than a judge; its job is to choose between two payment amounts, not to decide whether a given denial was appropriate.
To reiterate, if a claim is denied entirely, it does not trigger the NSA’s IDR-related protections at all. The NSA is intended to apply to claims that are payable in some amount.
If a claim is denied in its entirety and that denial is compliant with the NSA, that claim falls outside the NSA's protections and regular plan appeals come into play. As expected, other NSA-interpreting regulations provide that external review – not the NSA's IDR, but the “ordinary” external review established by the ACA so many years ago – “must be available for any adverse benefit determination by a plan or issuer that involves medical judgment, as well as rescissions.” This was apparently meant to underscore that a complete denial of a claim – regardless of whether that claim falls under the NSA’s protections – is subject to regular appeals processes, including IRO review when applicable. That much seems intuitive, since, after all, a claim that does not fall under the NSA is an ordinary claim like any other, subject to ordinary claims and appeals guidelines.
The question then often becomes: what happens when a complete denial is overturned on appeal, and it turns out the claim did fall under the NSA after all? Our interpretation is that once a payment is made, the NSA would kick in if applicable, and that “initial” payment – even though not made "initially" – would be subject to open negotiations and IDR just as if the payment had been made "initially". If a denial is reversed, the NSA process effectively starts from there; after all, it seems like it would be the mother of all loopholes if a health plan was able to deny a claim at first, only to later reverse the denial but avoid the NSA's processes with respect to the payment.
As a final note, when trying to answer questions relating to the No Surprises Act, it's important to look through the lens of consumer (i.e., patient) protection. The Phia Group has been at the forefront of making these NSA process interpretations, and always thinking of Congressional intent – to help American workers avoid exorbitant costs – has proven invaluable in helping Phia and the industry at large navigate the NSA's complexities. As a TPA or broker, whenever you are asked to give your advice regarding the NSA and its application, we urge you to do the same.
As always, if you have any questions, please don't hesitate to reach out to Phia's consulting team!
For Immediate Release
4/5/2024
Canton, MA – The Phia Group, a leading provider of health care cost containment solutions, proudly announced today that it has been honored with the 2024 Top Workplaces USA award. This prestigious recognition, presented by Energage, underscores The Phia Group's commitment to fostering an exceptional workplace environment for its employees by providing such outstanding benefits as ongoing education, philanthropic events, and zero-cost health coverage for employees that have been with the company for five or more years.
The Top Workplaces USA award, established by Energage, celebrates organizations across the United States that prioritize employee satisfaction and cultivate a positive workplace culture. Winners are chosen based on feedback gathered from employee engagement surveys, with thousands of organizations competing for this esteemed honor.
The Phia Group’s CEO, Adam V. Russo, emphasized the company's dedication to its employees, stating, "Our mission at The Phia Group is centered around reducing medical costs and improving the quality of health care. We understand that our people are integral to achieving this mission, which is why we prioritize their satisfaction and well-being. This award reaffirms that our efforts to create a supportive and empowering workplace have not gone unnoticed."
The Phia Group's commitment to employee satisfaction extends beyond recognition; it serves as the cornerstone of the company's success. By cultivating an environment where employees feel so heavily valued, The Phia Group is more empowered to deliver outstanding service to clients.
For more information about The Phia Group and its dedication to empowering plans and creating an exceptional workplace environment, please contact Garrick Hunt at ghunt@phiagroup.com or 781-535-5644.
About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, is a leading provider of health care cost containment solutions. With offices across the United States, The Phia Group offers comprehensive claims recovery, plan document, and consulting services designed to contain health care costs and protect plan assets. By delivering industry-leading consultation and cost containment solutions, The Phia Group empowers plans to achieve their goals.
About Energage: Energage is a mission-driven company dedicated to helping organizations channel employee feedback into actionable insights and ultimately credible employer recognition. Through initiatives like Top Workplaces, Energage enables organizations to champion employee engagement and promote a robust workplace culture. With a commitment to making the world a better place to work, Energage helps organizations benefit from an engaged workforce and inclusive culture.
By: David Ostrowsky
It is the most nightmarish version of a wolf at the door.
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.
Such a dire predicament befalls tens of thousands of Americans whose recently deceased relatives were Medicaid beneficiaries who received long-term care services (i.e., nursing home care or in-home healthcare) and never reimbursed their respective state of residence. (Although it should be noted that many who receive such care don’t realize Medicaid is expected to be reimbursed after they pass away.) By law, states are required to try to pursue reimbursement by obtaining the assets -- the most expensive of which is often one’s house – of the heirs. Subsequently, said relatives can be compelled to sell their house, to which they certainly have a strong sentimental attachment, or risk government authorities seizing the property. Ultimately, more often than not, they are left in dire straits.
This awkward and unforgivingly cruel process stems from a 1993 federal law that mandates every state recover funds from the assets of the recently deceased, who, during their final years, tapped into Medicaid for expenses. When someone is alive, they can still qualify for Medicaid based on their liquid assets -- irrespective of their home’s value. However, the home does apply to the estate recovery process for late Medicaid recipients who were over 55 when enrolled.
While the federal government requires every single state to enact Medicaid estate recovery programs to recoup funds from Medicaid expenditures, the particulars of the programs are at the individual states’ discretion. For example, there are states that place a lien on a home while others refuse to. Some states’ Medicaid offices are very aggressive in trying to recover funds from literally all medical costs (e.g., doctor visits and prescriptions) while others just focus on getting reimbursed for long-term care. According to a recent Associated Press report, some of the more lenient states include Alaska and Arizona, which have gone after merely dozens of properties over the past several years while other states such as New York and Ohio have pursued thousands of homes. In other words, there are states that would rather not pursue recovery but are required by federal law to do so.
Naturally, this situation, which has been in place for decades, hits low-income Americans the hardest while perpetuating the vicious cycle of stark wealth disparities and intergenerational poverty.
But now, it seems at least possible that there may be an end in sight.
Last month, U.S. Representative Jan Schakowsky (Illinois, 9th congressional district), Co-Founder and Co-Chair of the House Democratic Task Force on Aging and Families, reintroduced the Stop Unfair Medicaid Recoveries Act of 2024 that aims to repeal the federal legislation mandating state Medicaid programs pursue the deceased’s estates for reimbursement of Medicaid long-term care services. Citing pragmatic reasons – naysayers contend that the program collects only 1% of the more than $150 billion Medicaid spends yearly on long-term care – and appealing to her colleagues’ emotions, Schakowsky delivered an impassioned plea in the March 6th official press release:
“Imagine losing a loved one and putting them to rest, only to have Medicaid come knocking on your door demanding you now pay for the long-term care your departed relative received – an amount that has reached, in some cases, hundreds of thousands of dollars. Sadly, this is the reality for thousands of American families each year due to the federally mandated Medicaid Estate Recovery program. Often the only means for Medicaid to reclaim this money is by seizing the family home causing incredible emotional and financial suffering to the beneficiary’s family. . . . In many cases, Medicaid estate recovery keeps families in poverty and forces seniors and disabled individuals to forego care. Further, Medicaid estate recovery disproportionately harms low-income, blue-collar families and communities of color.”
Only time will tell whether Schakowsky’s proposed legislation gains any traction in Congress where it will surely face strong headwinds. But perhaps irrespective of the proposal’s fate, the larger point – and one that often goes unsaid – is that so many Americans in the final stages of life resort to Medicaid in the first place because they are unable to afford what has become prohibitively expensive private health insurance.
By: Kendall Jackson, Esq.
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.
Lenmeldy is just one of several gene and cell therapies that, due to their high cost, lead plans to consider implementing plan exclusions for these therapies. While a self-funded plan has broad discretion as to what benefits it does or does not cover and, generally, may exclude gene therapies completely, plans must also consider the impact of doing so. The avoidance of these costly drugs often seems very appealing until employers come to terms with the real impact of the approach – the fact that participants will likely be left with no coverage whatsoever for treatments which may be their only option. In the case of MLD, Lenmeldy is the only FDA-approved treatment and has a significant impact on the progression of the disease. The risks of severe motor impairment and death substantially decreased in children who were treated with Lenmeldy in comparison to untreated children. As the only treatment for this disease, this gene therapy can drastically improve the quality of life for affected children, which highlights the importance of its availability to those suffering from this disease.
On the other hand, the debate of whether to cover or exclude gene therapies largely stems from the high costs associated with these drugs. Lenmeldy carries a hefty price tag with a wholesale acquisition cost of $4.25 million in the United States, making it the most expensive drug in the world. While this gene therapy is a one-time, single-dose infusion, a cost of this magnitude would be debilitating to many plans. Due to these high-cost drugs, plans may elect to generally exclude gene therapies, but this decision also carries compliance considerations. The first concern would be the language used in the plan document. Gene and cell therapies are new and broad, which can pose difficulties when crafting plan definitions and exclusions. Specificity within the plan is necessary as any ambiguity in the plan language could be troublesome to the plan. Given the broad nature of these terms, the plan must be clear in differentiating between gene therapy in cell therapy if the intent is to treat them differently. The plan should also be sure to not impose a plan limitation that would target a specific individual. While a plan may exclude gene therapies, it is unable to do so in response to an individual’s new diagnosis which necessitates an expensive gene therapy as this would be discriminatory under HIPAA.
There are plenty of factors to consider when discussing the coverage or exclusion of gene therapy. The FDA approval of Lenmeldy is an indication that there is likely a host of other gene therapies that may be approved by the FDA in the future. Considering the topic of gene therapy is not going anywhere, it will be interesting to see if costs will change and what effects these drugs will have on the industry as a whole.
For Immediate Release 03/30/24
Canton, MA – Rarely can an organization with decades of industry leading ascendency truly claim to make a change that will both revolutionize its fundamental essence to the core, as well as deliver to its clients monumental improvements on top of what is already the industry’s best results. In other words, when does the best get even better? This is one such moment. March 30, 2024 will be remembered as the day that The Phia Group publicly announced the addition of the renowned John Blaney as their Chief Innovation Officer.
A pacesetter in modern subrogation tactics, whose leadership in the field reaches back more than thirty years, Mr. Blaney has forgotten more about subrogation than most other seasoned veterans will ever know. Innovator, leader, forerunner… These are only a few adjectives that are frequently used to describe this pillar of the health benefits cost containment industry. To say that John Blaney will bring to The Phia Group a new yet seasoned perspective, resulting in a groundbreaking progression of their subrogation and cost containment offerings, is the definition of understatement. Even better? The biggest winners are The Phia Group’s clients, who will immediately see even more improvements to the already stellar services they enjoy.
When asked about the addition of this prominent veteran to The Phia Group’s roster, CEO Adam Russo remarked, “John is a subrogation pioneer; one of the biggest additions we’ve ever made to our already amazing roster of subject matter experts. I can’t wait for his vast knowledge to expand our success long into the future.”
Forged over the span of thirty years, John Blaney honed unparalleled expertise in the areas of claims recovery, subrogation and automation; from building Primax Recoveries, Inc. – where for thirteen years he served as its President, to developing and transforming strategies that are still in use by some of the nation’s largest, most well respected organizations. Now he brings that long standing and multifaceted experience to The Phia Group.
Mr. Blaney will assess every aspect of the company, ensuring existing offerings continue to evolve, and new opportunities are identified – thereby maximizing The Phia Group’s ability to service clients and empower plans.
Of this new challenge and exciting opportunity, John Blaney had this to say: “I am excited to join a company with The Phia Group’s track record. I look forward to working with this talented team and contributing to the growth and success of this great company.” He concluded with the following, “I am looking forward to being part of this company that obviously cares about its people and clients.”
Learn more at www.phiagroup.com.
Ham it up with attorneys Nick Bonds and Jen McCormick from the Phia Group as they dive into the groundbreaking world's first successful genetically engineered pig kidney transplant at MGH in Boston. Explore the details of this medical breakthrough, its implications for the healthcare industry, and the considerations for the future of dialysis, plan language, and stop loss provisions. Tune in to gain invaluable insights into the intersection of law, healthcare, and cutting-edge medical advancements. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
As if there weren’t enough buzz surrounding Wegovy.
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?
Currently, Wegovy costs over $1,300 per month before any applied discounts. Obviously, for nearly every single American, this out-of-pocket cost is prohibitively expensive – especially considering that many patients may need to take it for the rest of their lives. Furthermore, the age-old rule of supply and demand suggests that the price isn’t likely to drop anytime soon: amid soaring demand for Wegovy, Novo Nordisk has struggled to maintain an adequate supply, although the company has pledged to boost production for the balance of 2024. (Novo Nordisk has also asked European Union regulators to expand the use of the drug for heart problems; however EU regulators have not responded to the request.) Unfortunately, many Americans – whether they are on private employer-sponsored plans or government-sponsored ones – have not been able to get financial relief from their insurance. Wegovy is simply too costly and – until this month at least – considered primarily to be a vanity drug.
But now there appears to be irrefutable evidence that Wegovy doesn’t just help people get ready for their new stylish beachwear, but actually prolongs life by reducing the risks of cardiovascular issues surfacing amongst the most vulnerable patients. Consider that the recent FDA approval stemmed from a 17,000-patient study that demonstrated that people taking Wegovy had a 20 percent lower risk of experiencing a cardiac event than those taking the placebo. It is important to note that the participants already had some form of cardiovascular disease and it has been suggested that further studies need to be conducted to demonstrate whether there are benefits for those who haven’t experienced a cardiac event. Regardless, the salubrious effects are undeniable. As Dr. Melanie Jay, director of the N.Y.U. Langone Comprehensive Program on Obesity, told the New York Times, “when you treat obesity seriously in people who have a high burden of disease, you can get really good outcomes.” Meanwhile, the more common side effects of Wegovy, which have been reported to include nausea, diarrhea, vomiting, and constipation, do manifest themselves in many patients (for older ones, it is fairly common to experience a loss of muscle mass), but are not considered as severe as those that have been linked to weight loss drugs in the past.
Ultimately, many insurers and self-funded plans are now scrambling to justify how they can deny coverage of a medically necessary medication. But aside from the optics, insurers and plan sponsors may have an understandably pragmatic reason to start providing coverage of Wegovy: while covering even some of the costs may seem imposing, the considerable outlay could be offset by the savings realized from reduced spending on long-term medical care relating to obesity and heart disease.
Stay tuned.
Over the last twelve months we have seen major interest in GLP-1s (Semaglutide- Ozempic / Wegovy and Tirzepatide – Mounjaro / Zepbound). Although GLP-1s have been around for years as a treatment for diabetes, the recent popularity is due to their use as a weight loss drug. Join Ron Peck and Corey Crigger as they discuss the impact this surge in demand has had on health plans and consumers. Are health plans and consumers informed about the benefits and drawbacks of this drug? Are consumers too focused on the benefits? Are health plans too focused on cost? Find out as Ron and Corey discuss one of the hottest topics in the industry.
By: Andrew Silverio, Esq.
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.”
At stake were over 14 billion yearly transactions and this attack has seriously disrupted provider billing, interfering with patient care, and even preventing some providers from paying their employees. On top of that, a massive amount of patient information, protected under HIPAA, has been compromised.
Most of the focus among news outlets has been on the impact to providers, which is of course enormous. Those using the affected claim systems have essentially no way to be paid for their services, and many have seen cash flow come to a prompt and complete halt. The government has advised Medicare plans and related entities to relax prior authorization and timely filing requirements and the entity involved has announced a program to actually offer loans to affected providers. However, those of us in self-funding know that it’s no simple matter to simply waive requirements like prior authorization and timely filing limits, and we have heard no word from stop-loss carriers on what action it will take if plans provide some allowances to safeguard patient care. Plans are still able to enforce timely filing limits and other plan terms, but most don’t want to leave patients in the lurch with unpaid claims due to system disruptions entirely outside their control. A plan that chooses to accept a late claim or waive a preauthorization requirement will be at real risk, since the stop-loss carrier is always free to enforce the terms of the plan, and its own policy, strictly and as-written.
The industry is still scrambling to get the system “working” again and establish something resembling a normal claim submission pipeline and cash flow. But once the dust settles, we would expect in the coming months to see some regulatory relief for plans and providers alike, to account for concessions and audibles that had to be made to keep the ship afloat. Looking ahead, hopefully precautionary systemic measures can be taken to account for future incidents. After all, healthcare and technology promise to be forever intertwined and there’s no telling when the next cybersecurity breach will rock the industry as it did last month.
In his third State of the Union address, President Biden touted his administration’s record and outlined the issues he and his team will likely be campaigning on heavily as the 2024 presidential race kicks off in earnest. Sprinkled throughout were a number of policy wish list items, including some key healthcare initiatives that we’ll be keeping a close eye on in the coming months. Attorneys Brady Bizarro and Nick Bonds bring you some of the highlights in this episode of the Empowering Plans podcast.