“Healthcare costs are a major concern for millions of people all over the nation, including you. Working for The Phia Group allows us to make a difference by containing those costs, and sharing what we've learned and done with a gracious audience.”

MATTIE SESIN
Director, Recovery Services

Recent Publications
 August 2016
A hard day’s work should lead to a fair day’s pay. This is one of the most basic tenets of our economy and it is about fairness. The Fair Labor Standards Act (“FLSA”) seeks to promote fairness, and employers are required to comply with its provisions. With the upcoming changes to the overtime rules set to take effect on December 1, 2016, employers would be prudent to begin planning new policies and procedures now. This article explains how The Phia Group, a mid-size employer in the healthcare industry, implemented plans to stay in compliance with the FLSA. Read more.

October 2016
How to avoid common pitfalls when managing a self-funded health plan
Author: Brady C. Bizarro, Esq.
  Since the passage of the Affordable Care Act in 2010, employers have  become increasingly aware of the potential financial benefits that come with adopting a self-funded health plan.

Read more
October 2016
Self-Insurance: You Can Increase Benefits While Minimizing Risk
Author: Ron E. Peck, Esq.
  In the United States, if you have health insurance, chances are it’s through your employer. This is true, even in a post Patient Protection and Affordable Care Act (“PPACA”) world, where individuals can choose to purchase individual policies on the so-called “exchange.” These two worlds of insurance, meanwhile, do not exist in separate universes. The insurance carriers that offer policies of “traditional” fully funded insurance to employers (policies where the carrier collects a premium and takes on all of the risk – including payment of medical bills), also underwrite the individual policies on the exchange.

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 October 2016
Self-Insurance: A Game Changer for Businesses Battling Healthcare Costs
Author: Ron E. Peck, Esq.
  Just a few weeks ago, a report from the Kaiser Family Foundation revealed insurance premiums for employer-sponsored family plans topped $18,000 this year. As the price of health care and health insurance skyrockets, employers and employees alike are digging deeper and asking: "What is health insurance? Is it all the same? Can we do something to save money but maintain benefits?"

Read more
September 2016
Think Outside of the Wrap
Author: Adam V. Russo, Esq.
  Networks are getting bashed every day in our industry. Some of it is justified, but some of it…not so much. I feel as if this is a recent phenomenon, but has it been going on for years? I am sure that whoever invented health plan networks saw it as a brilliant idea at the time, and so did their customers.

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 September 2016
Tips from the Pros: Why self-funding your company’s health plan is good for business
Author: Ron E. Peck, Esq.
  Massachusetts has a rich history. Since its founding, the United States  routinely found its path lain out before it by the Commonwealth. From  rebellion and the Boston Tea Party to government-monitored health  insurance exchanges and RomneyCare, it often seems that where we go, others follow.

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August 2016
Recent Challenges to the Uniform Enforcement of Subrogation and Reimbursement Provisions Under ERISA
Author: Catherine Dowie
  As most court cases interpreting ERISA mention, ERISA is “not a model of legislative drafting”. This sweeping and complex piece of legislation constantly seems to require clarification, particularly enforcement of plan subrogation rights under section 502(a)(3), which requires that relief sought by the plan be ‘equitable’ (as opposed to legal) in nature.

Read more
July 2016
A Missed Opportunity: How Massachusetts Nearly Addressed Its Hospital Pricing Problem
Author: Brady C. Bizarro, Esq.
  The roots of health care reform in Massachusetts stretch back to at  least 2004, a time when lawmakers and industry experts were concerned  with increasing uninsured rates, rising costs, free-riders, and the  problem of adverse selection. The health care reform law that passed in  2006 under then-Governor Mitt Romney was intended to make the Commonwealth the first U.S. state to achieve near-universal health
insurance coverage, and it was based on the idea of managed competition.

Read more
 July 2016
The Once and Future Law – Learning from Massachusetts’ Cost Containment Efforts 
Author: Adam V. Russo, Esq.
  The election is over.  For most of us that means a return to the status quo.  We get up in the morning, we
go to work, and we look forward to dealing with healthcare reform.  Speaking of The Patient Protection and Affordable Care Act ("PPACA"), if you think that you've seen a lot of regulation over the past years... well... "you ain’t seen nothin’ yet!"  As a proud resident of Massachusetts, I can say that with confidence. 

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 June 2016
A Dose of Reality
Author: Ron E. Peck, Esq.
  Utilization review. Precertification. Medical case management. It seems as if health plans have been, for lack of a better word, micromanaging how medical care is sought and obtained by plan participants, for decades upon decades. It makes sense. Whether I’m a fully insured carrier or a self-insured plan sponsor, I know that a complicated pregnancy, chronic illness, cancer diagnosis, or any other number of conditions will seriously hurt – if not sink – my plan. So, it makes sense. It makes sense that I ask patients, providers, and everyone else to check in. Give me a heads up. Let me know what’s going on, and put an independent team in place to identify the most effective, yet cost-conscious course of care. Everyone wins.

Read more
May 2016
United Cuts Ties with the Exchanges – But Who is to Blame?
Author: Andrew Silverio, Esq.
  Late last year, UnitedHealth, the nation’s largest health insurer, warned that in 2016 it may make the decision to pull out of the Obamacare health insurance exchanges completely, starting in 2017 (it had already cut its advertising on all ACA plans). Not surprisingly, this sparked a great deal of commentary among both supporters and critics of the ACA, some leveled and thoughtful, some bordering on panic. Now, approaching the halfway point of 2016, it is becoming clear that United will make good on those representations.

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 April 2016
One Step Forward, Two Steps Back? Is repeal really the answer?
Author: Pamala Parette
  Watching football is one of my favorite pastimes. I enjoy closely scoring games, and a quarterback that appreciates team effort towards a defined goal. Those quarterbacks who direct their offense with an eye towards flawless execution through smart decision-making, favoring incremental gains and forward progress, rather than forcing passes down the field at the slightest amount of pressure. It is often said that football is a game of inches, and while touchdowns can (and do) result from spectacular plays; it’s called a “Hail Mary” for a reason. Wins do not have to be spectacular, and I, for one, prefer a “move the chains” approach to the game where each small success achieved leads (safely) to the ultimate goal, a touchdown and, ultimately, a win.

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 April 2016
How Powerful Is the Plan Document, Really?
Authors: Jon Jablon, Esq., and Tim Callender, Esq.
  A self-funded plan’s governing plan document and the Plan Administrator’s discretion used when interpreting that document are jointly considered to be somewhat like decisions issued by the United States Supreme Court – they are “the supreme law of the land.” To some extent, that can prove accurate with respect to the plan document; the Employee Retirement Income Security Act of 1974 (ERISA) provides that a plan document’s text must be strictly adhered to, and fiduciaries of the benefit plan are not permitted to deviate from the document’s terms.

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 March 2016
All’s Fair in Love and Subro…The Supreme Court Challenges Our Current Understanding of “Fairness”
Author: Christopher M. Aguiar, Esq.
  Legal writing in statutes and case law, alike, can be difficult to understand. Phrases like ‘heretofore’, and ‘notwithstanding’ often make it quite the headache to read for those with an untrained eye. Many, including much of legal academia, argue that the law is better served with clarity. With that in mind, allow me to state this as clearly as possible: on January 20th, 2016, The Supreme Court of the United States ruled that a plan participant who receives benefits from its health plan due to injuries caused by a third party, and later receives a settlement from any third party related to those injuries, may avoid reimbursing the benefit plan by simply spending the settlement money. This is true even when that plan participant knows that some or all of those settlement funds are to be reimbursed to the benefit plan, in full. And this, the Supreme Court opines, is equitable?

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 March 2016
No Standard Standard of Review
Author: Jon Jablon, Esq.
  It’s far from a novel concept that Plan Administrators of self-funded health plans governed solely by ERISA are subject to a fiduciary duty to prudently manage plan assets and act in the best interest of plan participants.

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 January 2016
Secrets to Making Reference-based Pricing Work
Author: Adam V. Russo, Esq.
  In order for reference-based pricing (RBP) to work, health plan sponsors should do it in a way that involves implementing best practices for cost analysis, claim repricing, plan design, patient advocacy (including balance billing protection when necessary), and member education.

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 January 2016
Top Ten Lessons of a Reference Based Pricer
Author: Jason Davis
  Where two gather to discuss reference-based pricing (“RBP”), you will have three opinions. Few would argue that the use of fixed fee schedules instead of traditional cost-containment methods (like  preferred-provider organizations [“PPO”]) is not one of the (if not the) most hotly debated and misunderstood topic in our industry.

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December 2015
Challenges to Subrogation Rights in Montanile
Author: Catherine Dowie
  The facts of the latest healthcare subrogation challenge on the Supreme Court’s docket (Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan) will be familiar to many. As you may recall from our June 2015 Phia Factor article, following a motor vehicle accident, Robert Montanile’s health plan paid over $120,000 on his behalf, subject to all plan terms, including a subrogation and reimbursement provision. Mr. Montanile hired an attorney to bring a claim on his behalf, and that attorney secured a settlement of $500,000.00.

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October 2015
Cracking the Code: ICD-10 is Upon Us!
Author: Andrew Silverio, Esq.
  ICD-9, the now ubiquitous method of categorizing disease and injury, was adopted in the United States in 1979, and has been the standard for decades. Every medical provider, health plan, insurance adjuster, or claims processor encounters ICD-9 codes regularly, if not on a daily basis. All of that is about to change.

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 October 2015
Fundamental Rights and Vague Responsibilities.
Author: Jon Jablon, Esq. and Kelly E. Dempsey, Esq.
  No matter your opinion on Obergefell v. Hodges – the recent Supreme Court case holding that interpreted the fourteenth amendment as granting same-sex couples the right to marry – it is undeniably an important occurrence in our country’s culture. While this holding will have profound impacts on many lives, its effects are not quite limited to simply the act of marriage. For instance, areas of the law that will be changed include bankruptcy law, Medicare entitlement, wills and inheritances, taxes – and health plans.

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October 2015
Case Study – How Current Market Assumptions Are Harmful for Our Industry.
Author: Adam Russo, Esq.
   If a Tree Falls…
On June 23, 2015 a very interesting case was allowed to proceed in the United States District Court in New Jersey entitled Johnson & Towers, Inc. v. Corporate Synergies Group, LLC. Although my mind was blown away by this case, I saw very little discussion across the industry. It was almost as if a large tree had fallen in an empty forest. It’s been two months and there have been no bulletins, no strategies in place to deal with this case and the potential outcomes, no warnings to association members…nothing!

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 October 2015
Why Are Hospital Charges So High? Because Nobody Questions Them
Author: Adam Russo, Esq.
  When the Consumer Doesn’t Care What it Costs…
When a friend of mine with quality health insurance received his hospital bill, what did he do? He opened the statement and looked at one thing – his amount due. This dollar figure isn’t $30,000 or even $8,000; it’s the amount of the co-pay or deductible on his in- network claim. Typically, we are talking about anywhere from $5 to $250 – this is all he cares about and also why we have major problems with our healthcare system today. He doesn’t know or care that the charges were $140,000 and that his self-funded health plan (even after the great discount) paid $110,000, even though the actual cost of the hospital services was less than $20,000. If he had walked in with a Medicare card, the hospital would have been paid $25,000. The worst part of this horror story was that he complained to me for having to pay a $200 co-payment even though he has full health insurance coverage.

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 September 2015
The Real Causes of High Healthcare Costs
Author: Adam V. Russo, Esq.
  Adam Russo, Esq., Co-Founder and CEO of The Phia Group LLC, discussed what “insurance” means to the various buyers of healthcare, and why understanding what costs mean to different players in the healthcare system is essential to guiding meaningful reform around transparency and healthcare cost containment. Following is a summary of his talk at the Free Market Medicine Association (FMMA) 2015 Conference in Oklahoma City, OK.

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 July 2015
The Road to Recovery: Subrogation Gets Its Day In Court … Again
Author: Christopher M. Aguiar, Esq.
  In a country with a seemingly infinite amount of regulation and concerns regarding benefit plan compliance following the passage of the Affordable Care Act in 2010, one would expect much attention from courts in the employee sponsored health benefits arena. Most might be surprised when they realize the amount of attention that subrogation has received in The Supreme Court of the United States, the highest court in the land, over the last 25 years.

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 July 2015
Ready or Not, Here it Comes! The Employer Mandate is Finally Applicable
Author: Kelly E. Dempsey, Esq.
   The Employer Shared Responsibility provision of the Patient Protection and Affordable Care Act (“ACA”) went into effect for certain applicable large employers on January 1, 2015.[1] The Employer Shared Responsibility provision is often referred to as Pay or Play, the Employer Mandate, or 4980H subsections (a) and (b). The applicability date of the Employer Shared Responsibility provision (“Employer Mandate”) depends on an employer’s size, as well as, whether or not the plan is a non-calendar year plan and meets the non-calendar year plan transition relief (provided by the final regulations issue on February 12, 2014.

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 April 2015
Implant Wars
Author: Jason Davis
  Despite a reported downturn in inflation, US Healthcare continues to produce shocking examples of out-of-control costs. This reality is clearly seen in the treatment of musculoskeletal diseases. All told, the total direct costs are estimated at over $500 billion per year and rising.

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Thompson Publishing
May 2014 Choose Wise Definitions to Perfect The Well-managed Self-funded Plan
Author: Adam V. Russo, Esq.
The best way to ensure that your self-funded health plan is running efficiently is with strong definitions of key plan document terms. Forward-looking definitions can stop problems before they turn into major plan costs, and the right definitions make the difference between getting taken for a ride and keeping your hands on the steering wheel.
Read more
April 2014 Know the Type of Self-funded Plan You Want to Be
Author: Adam V. Russo, Esq.
An unnerving fact of the self-insured industry is that most employers do not know what type of plan they actually are. Do they want to be innovative in the way they approach self-funding, or passive by allowing vendors to call all the shots? Do they choose an administrator because of cheap administrative fees and network access, or do they choose it to ensure they are being smart with their claim dollars? Did they choose the stop-loss insurer with the cheapest price on the spreadsheet or did they actually check to see what they agreed to reimburse in the 15-page agreement? The key to answering these questions is for the organization to do some soul-searching and decide the type of self-funded plan it wants to be. That can be linked to the level of involvement it wants to
have in plan management.
Read more
March 2014 What…Me Worry? The Backdoor Plan to Limit Self-funding
Author: Adam V. Russo, Esq.
Many in our industry say that one of health care reform’s goals is to funnel lives away from employer sponsored plans and into the state-based health insurance exchanges. I’m persuaded that view surely is not amiss.
Read more
February 2014 Will Self-funding Drown or Soar in 2014?
Author: Adam V. Russo, Esq.
Everybody wants to know whether health care reform will create a nourishing or a hostile environment for self-funded health benefits. My educated guess is that we will see employers self-funding in record numbers over the next few years, but that outcome is not guaranteed. Self-funding will soar if people see that it enables sponsors to implement the innovations that are quite advantageous to participants. Examples include new approaches to pricing and charges, medical tourism, new networks and carve-outs of benefit categories to make them more affordable. Self-funding will not flourish, however, unless the federal government and state insurance commissioners try to slow it down or stop the progression entirely.
Read more
January 2014 You Were Smart Enough To Self-fund, So Try Some Innovation
Author: Adam V. Russo, Esq.
The best part of self-funding a health plan is that you control your own destiny in many ways. While you cannot control who needs medical care in most situations, you have a better ability to manage your own plan. Many options exist when it comes to managing a self-funded plan, and I plan to share some intriguing options of which you probably are not aware.
Read more
December 2013 What Now Makes Contraceptive Coverage Much More Complicated
Author: Adam V. Russo, Esq.
The issues relating to health care reform’s contraceptive mandate are getting more complex by the day for self-funded plans and their administrators, and now yet another reform-related problem has emerged. The problem is: The health care reform law requires all plans to cover contraceptives that require a trip to the doctor by classifying them as preventive health benefits that cannot involve any cost-sharing to the patient.Read more
November 2013 Carving the Employee Health Plan Like a Turkey on Thanksgiving
Author: Adam V. Russo, Esq.
One of the biggest benefits of being a self-funded plan is the ability to carve out benefits. This doesn’t mean that you don’t cover things you normally would, but rather that you cover them in a more innovative and cost effective manner. This article will outline the best options for carve-outs and how they work, but also things to watch out for in your attempt to be proactive and cost effective.Read more
October 2013 Planning Ahead Through Your Plan Document (Part 2)
Author: Adam V. Russo, Esq.
In this, the second report in a two-part series, I will outline the way plan document design and wording can save self-funded benefit plans a lot of money. For years I have advised my clients that the best way to ensure that a self-funded health plan is running efficiently is through the plan document.Read more
September 2013 Planning Ahead Through Your Plan Document
Author: Adam V. Russo, Esq.
Self-funded employers, their brokers and third-party administrators always ask what they can do to reduce the overall cost of their health plans. The usual answers we hear from the self-insurance industry are to have a robust wellness program and review your claims data to identify problem areas. But we do not normally hear about something that I have been preaching for a decade: The best way to ensure that your self-funded health plan is running efficiently is through the plan document.Read more
August 2013 The Real Deal Behind the Employer Mandate Delay
Author: Adam V. Russo, Esq.
Employers got a break when the Treasury Department announced July 2 that it is delaying health care reform’s shared responsibility (play-or-pay) penalties and related employer and insurer reporting obligations until 2015.
Read more
July 2013 Skinny Plans: Adhering to the Letter (But Not the Spirit) of Health Reform
Author: Adam V. Russo, Esq.
An increasing number of employers are examining a low-benefits health plan that covers only preventive health services but not high-price major medical claims. Offering this type of low-cost or “skinny” plan is allowed under the health reform law. The question is: Will skinny plans trigger a large-employer exodus to de minimis coverage, and if so, will the federal government rewrite the reform rules to disallow them?
Read more
June 2013 Possible Exchange Problems May Help Boost Self-funding
Author: Adam V. Russo, Esq.
In this world of uncertainty, the self-funded industry needs to establish that our products and services are the best option to reduce the cost of health care and expand coverage to all. This has added importance because if the health insurance exchanges do not do well and insurers begin to pull out,the publics knee-jerk reaction may be that the country needs a government-run single-payer system, since everything else has failed.
Read more
May 2013 What in the Stop-loss Word Is Happening?
Author: Adam V. Russo, Esq.
Recent government studies largely confirm that self-insured health plans function well and play an important role in the health care marketplace. But will health reform contribute smaller employers seeking self-funded status if stop-loss insurers respond to more expensive group health insurance by offering cheap stop-loss with low attachment points? If that happens, the concern is that such a migration will compromise the exchanges’ viability by filling them with too many unhealthy lives. Self-funded employers need to know what is already occurring in the states to address that concern, and what they need to do to counteract it.
Read more
April 2013 An Employer’s Perspective: Defining The Dilema of High Hospital Costs
Author: Adam V. Russo, Esq.
The high cost of health care is making national news these days and as a result, the national media is finally asking a question that the self-insured community has been asking for years: Why aren’t medical facilities paid based on the cost of care given?Read more
March 2013 Why Self-funded Plans Can Thrive In a Post-reform World
Author: Adam V. Russo, Esq.
As 2014 approaches, many employers will see an opportunity to drop health coverage, pay a relatively small penalty and exile employees to health insurance exchanges. But there are many reasons to keep health benefits in-house and many more reasons why self-funding health coverage remains the best option for all sizes of employers.Read more
February 2013 Never Overlook Your Administrative Services Agreement3
Author: Adam V. Russo, Esq.
You have seen your fully insured premiums go through the roof over the past five years. You don’t want to give up insuring your workers and let them go to the health insurance exchanges — not in 2014 anyway. So you have been reading a lot about the advantages of self-funding.Read more
January 2013 Another Big Year for Self-insured Plans – Who Knows What Will Happen
Author: Adam V. Russo, Esq.
My office and I have had to deal with the many complexities of the health reform law for a few years now, but I don’t think the rest of the industry understands the enormity of what is coming down the pike. What we will see in 2013 and beyond is night and day when compared to the current environment. The days of sitting on the couch and griping are over; the time to act is here. As with your new year’s resolution, it’s time to get on the treadmill and move on reform implementation!.Read more
December 2012 Trying to Control Health Plan Costs? Don’t Implement Without Proper Prep
Author: Adam V. Russo, Esq.
The election is over. For most of us that means a return to the status quo. We get up in the morning, we go to work, and we look forward to dealing with healthcare reform. Speaking of The Patient Protection and Affordable Care Act (“PPACA”), if you think that you’ve seen a lot of regulation over the past years… well… “you ain’t seen nothin’ yet!” As a proud resident of Massachusetts, I can say that with confidence.Read more
November 2012 Saving on Health Care Costs Takes Preparation!
Author: Adam V. Russo, Esq.
Once upon a time, the media reports regarding health care weren’t about “care” at all. They centered on who should be responsible for making the payments. The focus wasn’t on cost — it was on the number of uninsured Americans and insurance profit margins. It wasn’t until, in Massachusetts (for instance), everyone became insured that we realized having insurance doesn’t make health care any cheaper. Today, the biggest stories relating to health care aren’t about the big, bad insurance companies. The main focus is going elsewhere: on providers, the cost of care and what we actually get for our money. We know that health care isn’t getting any cheaper; in fact costs continue to grow. But why?Read more
September 2012 Why Implementing Health Reform Will Fuel Skyrocketing Costs
Author: Adam V. Russo, Esq.
If the health reform mandates are not recalibrated, we will witness a cost explosion in the health system. To avoid that, the system
must continue evolving, because health reform creates or leaves unresolved several key problems, which include: (1) insurers have
to control the way they increase premiums, but providers don’t have to control increases in what they charge; (2) reform’s significant new taxes on devices and drugs will be passed on to insurers, and then consumers; and (3) the individual mandate has no “teeth,” so people can avoid buying policies without legal repercussions.Read more
August 2012 No Plan Left Behind! The Battle for Self-Funding’s Survival
Author: Adam V. Russo, Esq.
There is a war raging against the self-funded industry. Let me repeat this for those of you who are laughing at my first sentence. There is a war raging against the self-funded industry. While it has taken me a long time to acknowledge that this fight is bigger than a school yard brawl, I finally have to face the realization that there are major forces attempting to drive self-funding to extinction.Read more
July 2012 The Heavy Truth: Why We Must Have Patient Buy-in to Control Health Costs
Author: Adam V. Russo, Esq.
Adam V. Russo, Esq. is the cofounder and CEO of The Phia Group LLC, a cost containment adviser and health plan consulting firm. In addition, Russo is the founder and managing partner of The Law Offices of Russo & Minchoff, a full-service law firm with offices in Boston and Braintree, Mass. He is an advisor to the board of directors at the Texas Association of Benefit Administrators and was named to the National Association of Subrogation Professionals Legislative Task Force. Russo is the contributing editor to Thompson Publishing Group’s Employer’s Guide to Self-Insuring Health Benefits.Read more
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