Recent Posts

• Plan Language, Rx, and Lawsuits to Watch (and File): Innovation for a Changing Industry
  
  November 13, 2019
  In the face of evolving pricing models, ever-increasing drug costs, difficulties in administering claims, and increased regulatory burdens, the players in the self-funding industry need change. Not just any change, though; creative change that promotes cost-containment and makes life easier for those who support health benefit plans in one way or another.
• 2020 Forecast - Storm Clouds, Clear Skies, and the Issues that will Dominate Next Year
  
  October 23, 2019
  2020 is almost here, and The Phia Group continues it’s webinar series dedicated to preparing you for renewals, and the coming year. Join the team for this free webinar as they discuss the issues that impacted 2019, and are poised to dominate 2020, including (but not limited to) Mental Health Parity, Paid Leave, Health Insurance Taxes, Drug Prices, Regulations, and Coupons.
• 2020 Renewal Season - Decisions Today, Uncertain Tomorrow
  
  September 17, 2019
  It’s plan renewal season, and we find ourselves making decisions that will define how plans will operate over the next year. This is no easy task! First, we confront known issues and hurdles – such as increasing drug costs, regulatory crackdowns, and aggressive providers – looming before us. Additionally, despite the need to make these decisions now, the future is more uncertain than ever before. Between litigation challenging the constitutionality of the ACA and an already wild 2020 Presidential election, no one truly knows what next year will look like. How can we make decisions today at renewal, that address the issues of tomorrow – both known and unknown? Join The Phia Group for a “can’t miss” review of important issues impacting plan renewals, address known roadblocks, and perform an assessment of the candidates’ positions on healthcare – with an eye toward what we should be doing today to prepare for an uncertain tomorrow.
• Back to School: 2020 Renewals
  
  August 21, 2019
  As players in the self-funded industry have found out the hard way, keeping business often isn’t easy. Fiduciary obligations and other difficult situations can arise when we all least expect them, and when we are worst-equipped to deal with them (such as in the height of renewal season). By popular demand, this month’s webinar will focus on when fiduciary duties can arise, who needs to be careful, and how those duties might affect your 2020 renewals.
• Trump’s Executive Order on Transparency: How it Will Effect Each Segment of Our Industry
  
  July 23, 2019
  On June 24, 2019, President Trump issued his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” This Order requires hospitals to publicly post their prices, and is designed to give healthcare consumers more choice and better decision-making capabilities.
• The Impact of State, Federal Laws, and Current Market Trends on Self-Funding
  
  June 20, 2019
  Attention, self-funders: things are happening! State and federal governments have been busy beavers, either passing legislation or at least looking into it. Whether it's surprise billing laws, Medicare-for-all initiatives, or public exchange options, you need to know about it.
• To Pay, or Not to Pay … The Guide to Handling Claims, Denials, and Appeals
  
  May 23, 2019
  Join The Phia Group’s legal team as they discuss the good, bad, and ugly truths about the claims process, and how to safely navigate the various TPA and health plan duties associated with it.
• Evolving Healthcare Issues and Events You Need to Know
  
  April 22, 2019
  The healthcare space is rapidly evolving – and self-funding is no exception. Legislators, regulators, and courts are constantly providing new guidance – some good, some not. For this month’s webinar, we’re going to present some current events; we’ll discuss how they can help or hurt self-funded players, and what you can do to take advantage of them (or avoid the pitfalls created).
• Transparency: A Building Block of Self-funding
  
  March 14, 2019
  Whether from unpredictable provider charges, “black box” claims repricing, mysterious PBM rebates, or unobtainable claims data, entities operating in the self-funded space such as employers, TPAs, brokers, and stop-loss carriers have been forced to deal with a systemic lack of transparency.
• What We Love About Self-Funding in 2019
  
  February 14, 2019
  Valentine’s Day is upon us, and we’re feeling the love. Too often we, as an industry, spend our time discussing issues, problems, and concerns, and don’t dedicate enough time to the features and opportunities that make self-funding great. We focus so much on “how we save” self-funding, that we forget to celebrate the reasons why self-funding is worth saving in the first place. Join the team as they discuss what makes self-funding such a great option for so many employers and employees, as well as the incredibly cool new innovations rolling out in 2019, that will be sure to make self-funding a sweetheart for even more employers this year and beyond.
• The Affordable Care Act in 2019: A Look Ahead
  
  January 16, 2019
  This year, we mark the ninth anniversary of the healthcare law that transformed our industry. The Affordable Care Act has been under assault from the White House, from Congress, and now, it has been declared unconstitutional by a federal court. Despite the embattled state of the ACA, the Trump administration has set an agenda for the ACA's implementation this year, and it remains the law of the land. In this webinar, The Phia Group's legal team will explore the many legal and political battles that threaten the ACA's existence while covering those key provisions that have changed, those that have remained the same, and everything in between.
• What to Expect in 2019 – Part 2
  
  December 12, 2018
  To build on last month’s webinar (Part 1), join The Phia Group’s legal team for an hour on December 12, 2018, as they present the second part of this two-part series on What to Expect in 2019. Touching on topics such as appeals, stop-loss trends, reference-based pricing, and much more, this webinar will highlight current industry happenings and our predictions to help you look forward to the coming year. Just like last month: miss this one, and you’ll be left behind.
• What to Expect in 2019 - Part 1
  
  November 13, 2018
  The future is here! As we’re about to enter 2019, the undercurrents of the self-funded industry are as exciting as they are dynamic, and changes are happening at an unbelievable pace. Join The Phia Group’s legal team as they present Part 1 of this two-part series on What to Expect in 2019, which will highlight current industry happenings and our predictions to help you look forward to the coming year. Miss this one, and you’ll be left behind.
• Specialty Drugs: Trends and Issues Affecting Self-Funded Plans
  
  October 18, 2018
  No matter what corner of the industry you’re in, you know that health plans have had a constant need to contain costs as a result of skyrocketing medical bills. The rising cost of Rx drugs has certainly been an issue as well – and specialty drugs are a hot-button issue as health plans struggle to find ways to manage them.
• Back to School: Renewal Time
  
  September 18, 2018
  In the self-funded industry, being diligent with respect to employer groups, vendors, and contracts is always important – but sometimes knowing what to put on a checklist in the first place is more difficult than checking off the items. Renewal time means it’s time to impress prospective clients, keep existing clients happy, and make sure the vendors and contracts being utilized are the best possible fit for your groups. Join The Phia Group’s legal team for an hour on September 18, 2018 at 1pm EDT as they outline a laundry list of what employers, TPAs, brokers, and stop-loss carriers should look for this time of the year – and provide some guidance on how the industry’s players can stay ahead of the curve.
• Breaking the Mold: Creative Solutions for Everyday Problems
  
  August 14, 2018
  Network contracts, stop-loss claims, and intricate medical claim determinations are just a few of the complications that self-funded health plans and their partners need to be able to successfully navigate. Check out our webinar that includes creative solutions for managing these.
• Hottest Industry Trends and Topics – This is What You Asked For
  
  July 12, 2018
  The industry is ablaze! From specialty drugs, to association health plans, to the “right to try” law, we’re all feeling the heat.
• Final Rule on Association Health Plans and YOU: Phia's Take
  
  June 21, 2018
  On Tuesday, June 19th, the Department of Labor issued a final rule on Association Health Plans. Supporters claim the rule will allow millions of Americans to access more affordable coverage options. Critics contend that it will reduce patient access and weaken the insurance markets, leading to increased costs for all. Join The Phia Group's legal team in this special edition webinar in which they will break down the final rule and explain the significant impact it is expected to have on the self-funded industry.
• The Buck Stops…Where? Pointing Fingers in the Self-Funded Industry
  
  June 12, 2018
  In a financial climate where saving money has to be made a top priority, so many entities within the insurance industry have fallen victim to someone trying to shift blame onto them. Regardless of fault, it’s in everyone’s best interests to work together to overcome issues rather than point fingers – but it’s not always that simple.
• The Case for Collusion: How the Power Players May Have Defrauded Us All
  
  May 15, 2018
  At long last, after a lengthy investigation, we are ready to present the allegations of collusion. It is alleged that powerful forces have been working together in a complex scheme to mislead us. To be clear, we are talking about Big Pharma and certain PBMs. A new class action lawsuit has been filed against CVS Health alleging that it knowingly colluded with PBMs to raise generic drug prices. The claim is that health plans and consumers alike have been overpaying for drugs. We have seen this playbook before. This time, however, there is potential for TPAs and their groups to join the lawsuit to recoup funds allegedly overpaid to CVS. Join The Phia Group’s Special Counsels for an hour as they share reports on this alleged fraudulent scheme and discuss the ways in which our industry can fight back and tackle the underlying problem of specialty drug prices.
• 4 Horsemen of the Plan-pocalypse
  
  April 19, 2018
  Nostradamus? Miss Cleo? The Phia Group? In a psychic feat of foresight, The Phia Group’s team has gazed into their crystal ball and identified four issues that may not presently be keeping you up at night, but will certainly be disturbing your slumber very soon. From being forced to pay for surrogate pregnancy and births, to the IRS actively issuing letters notifying employers of 2015 tax year penalties; from a new wave of fraud, errors, and abuse leading to heretofore unseen overpayments, to case law addressing the rights of plans to utilize reference based pricing – you’ve been warned! We predict this complimentary webinar will open your eyes. Miss this webinar at your own peril… You’ve been warned!
• Transparency: Using it to Your Advantage
  
  March 20, 2018
  Join The Phia Group’s legal team as they discuss the need for, and effects of, contractual and price transparency on the self-funded industry – and how health plans, TPAs, and brokers can use transparency to their advantage.
• Evolve or Dissolve – Responding to Today’s Tax Law to Save the Health Benefit Plan Industry Tomorrow
  
  February 27, 2018
  Join The Phia Group's Adam Russo, Ron Peck, and Brady Bizarro as they discuss what you need to know about the new law, and how to navigate the treacherous path that lies ahead.
• Keeping it Under Wraps: What the Networks Don’t Advertise
  
  February 22, 2018
  It’s 2018, and the importance of cost-containment is at an all-time high. Everywhere you look in the self-funded industry is a vendor trying to help health plans control costs; as can be expected, some methods are effective and maximize savings, whereas others…well…not so much
• Plan on Saving by Saving Your Plan – Applying Lessons Learned to Create the Perfect Plan Document
  
  January 30, 2018
  Join The Phia Group’s legal team as they explain the Flagship template, differences from the existing template, and why the Flagship may be right for you.
• A Taxing Time: The Tax Bill’s Impact on Self-Insurance
  
  January 18, 2018
  On December 22nd, President Trump signed a $1.5 trillion tax bill. Among other things, it effectively ends the Affordable Care Act’s individual mandate. It will have a major impact on individual and employer-sponsored health insurance. Millions of Americans may be without health insurance coverage in the coming years. For self-funded plans, this bill may lead to higher costs due to ripple effects across the entire health insurance market while also opening doors to increased cost-containment opportunities. There are other legislative proposals and agency action which could impact our industry, and many states are considering proposals of their own.
• With Great (Cost-Containment) Power Comes Great (Fiduciary) Responsibility!
  
  December 19, 2017
  Join The Phia Group’s legal team for an hour at as they describe various ways to cut costs, what must be done to ensure that fiduciary duties are being met, and what happens if they are not.
• Living in the Now: Prepare for 2018
  
  November 14, 2017
  A new year is approaching, and we are in the middle of renewal season; meaning it’s time for some serious preparation. Making sure your clients are cared for is no easy task; are you prepared to protect your plans, save them money, and grow your own business in 2018?
• Best Practices for Today's Plan Documents
  
  October 17, 2017
  There’s a reason the law governs how plan documents must be formed and distributed – and it’s that the plan document remains the be-all-end-all of the plan’s and member’s rights. For this reason, it is crucial to ensure that the plan document is compliant to a T, is clear and comprehensible, and is able to contain costs.
• It’s Time To Renew – Revisiting Stop Loss Trends
  
  September 21, 2017
  It’s that time of year again – renewal season! What is often overlooked is the type of stop loss carrier to partner with for the next plan year. Stop loss choices are often made just on the premium cost, however plans should look at more than just the price. Stop loss is something most self funded benefit plans rely upon to ensure their financial viability and long term success.
• A True Impact on the Bottom Line – Identifying Current Issues, Implementing Solutions & Seeing Results!
  
  August 22, 2017
  The Phia Group’s legal team frequently addresses the biggest issues impacting the health benefits industry today. Join them as they dissect the conflicts threatening every entity involved in the business of health benefits, and share real life examples of clients who implemented forward thinking solutions… and those that didn’t.
• Consulting Headlines – The Hottest Topics in Benefit Plan Administration
  
  July 13, 2017
  Extra! Extra! Have you heard the news? Laws are changing, regulations are shifting, and benefit plans are scrambling to keep up.
• A Network by any Other Name
  
  June 22, 2017
  PPOs, EPOs, HMOs… The days of simple network categories is past. Today, innovative providers are offering up-front transparent pricing, subscription-based direct primary care (DPC), value based pricing, ACOs, medical tourism, international prescription plans, on-site clinics, telemedicine and direct contracting with “centers of excellence.”
• Decisions, Decisions: Which Plan Types Work Best for Which Groups, and Why?
  
  May 16, 2017
  Between a traditional PPO plan, a MEC or “skinny” plan, reference-based pricing, narrow network, cafeteria plan, or high-deductible health plan, who can choose? They all have their nuances, and which plan type is best for a given plan sponsor will depend on factors including risk tolerance, geographical location, employee base, and more.
• The Double-Edged Sword of Discretion: How Even Great Plan Document Language Can Cause Gaps in Coverage
  
  April 27, 2017
  Nearly all Plan Documents have some mention of discretionary authority. The ability to interpret the terms of the plan is necessary to receive deference from the courts, and is needed since not every conceivable scenario can be planned for within the plan document.
• Medical Bill Blues: Pre-Payment Contracting and Negotiation, Pricing Alternatives, and Post-Payment Recovery of Overpayments
  
  March 23, 2017
  It’s common knowledge that not every network contract adds real value, nor can medical providers always be relied upon to bill responsibly. As the fiduciary duty to be prudent with plan assets becomes increasingly relevant, it's important that self-funded health plans, and those who service them, not fall behind.
• Top Miscues Employers Make When It Comes To Their Health Plans ... And What We All Can Do To Become Health Plan Heroes
  
  February 15, 2017
  Employers who self-fund their health plan act as a traditional employer, a plan sponsor, and a plan administrator. Juggling this many roles, conflicts and contradictions are bound to happen. For instance, an employee handbook’s handling of disability leave may conflict with the health plan document as it relates to employment and plan coverage.
• Back to The Self-Funding Future – Which Echoes of 2016 Will Continue to Impact Self-Funding in 2017
  
  January 19, 2017
  The past decade has ushered in both outrage and opportunity for self-funded plans, and 2016 was no different. The characteristics of self-funded plans continued to alter in concert with new laws and regulations. While these bureaucratic efforts often hindered our ability to self-fund, for those daring enough to change with the times, we saw increased growth and prosperity. We will no doubt see these issues and opportunities continue to evolve in 2017, and only those that prepare will thrive.
• 2017 Phia Forecast
  
  December 13, 2016
  2016 has been another huge year for self-funding, and a year of significant change for healthcare in general – and with the results of the recent presidential election, 2017 is slated to be an exciting year as well. 2016 has played host to all sorts of new federal regulations, state laws, market trends, and cost-containment options, and we expect 2017 to be even more unpredictable…but still great for self-funding.
• The First 100 Days: President-elect Donald Trump, Healthcare, and Self-Funding
  
  November 21, 2016
  The election is behind us, and no matter who you supported, it was one of the most divisive in recent history. Regarding the contentious topic of healthcare, President-elect Donald Trump has promised to repeal the Affordable Care Act and replace it with a better, more efficient system. The future of our industry is sure to change.
• The Good, The Bad, and The Ugly – Ethics: Simple Mistakes vs. Breach
  
  November 15, 2016
  As the Department of Labor hones in on what is ethical (or unethical) and what constitutes fiduciary liability, plan administrators, third party administrators, brokers, and various advisors who service self-funded plans must make a renewed effort to ensure that their actions are in compliance with current legal and ethical standards. All self-funded entities must take steps to avoid actions that may be deemed unethical or in violation of their considerable responsibilities - and even when exercising good faith, it is still possible to act unethically.
• How Low Can You Go? Managing Specialty Drugs, Reducing Overall Pharmacy Spend, and Unraveling the Mystery Behind PBMs
  
  October 27, 2016
  Pharmacy Benefit Managers, or PBMs, are an important factor in the cost and value of self-funding - yet many TPAs, brokers, and plan sponsors feel it is impractical to even look into changing the status quo. Self-funded plans and those who service them, however, should be constantly on the lookout for effective alternatives to their current procedures - especially in this aggressive economic and legal climate.
• Independent Consultation & Evaluation: ICE, ICE, Baby!
  
  September 22, 2016
  Our industry is plagued by issues related to compliance, contracts, and cost-containment – and a myriad of other legal issues as well. Engaging an expert for a second set of eyes is a chore in itself, requiring approval from management or an individual group as well as a cost-benefit analysis of the expert’s fees – sometimes resulting in the decision not to consult a neutral third-party at all.
• Unwrapping Your Wraps
  
  August 23, 2016
  Wrap networks provide plans with discounts off billed charges for claims that don’t fall within the plan’s primary network. But do these wraps really add value? With skyrocketing provider charges and static discounts off of those charges, the modern-day wrap network doesn’t seem to provide much help when it comes to claims costs.
• Back to Basics: Plan Documents 101 (Part 2)
  
  July 13, 2016
  When we think of hot topics in the self-funded industry, plan document drafting is hardly the first thing that come to mind. Instead, issues such as fiduciary duties, reference-based pricing, transgender coverage, employee incentives, and provider abuse are on the tip of everybody's tongues. All these topics, however, share a common feature: they're all reflected, in some way or another, within the plan document. Without compliant and effective plan document language, a plan can't offer robust benefit programs while containing costs.
• Back to Basics: Plan Language 101
  
  June 15, 2016
  Most situations that involve self-funded benefit plans revolve around language within the plan document. Whether deciding if a service is experimental, or figuring out whether a dependent is actually covered, or deciding whether a leave of absence will extend coverage, the plan document controls in just about all situations. For that reason, it's all the more disastrous when poor plan language handicaps plans and TPAs. Like we always say, your rights are only as good as your language.
• The Tangled Web of Contracts
  
  May 12, 2016
  The self-funded industry is made up of a complex system of contracts, and navigation across them is anything but simple. Network contracts supersede plan documents; Administrative Services Agreements “add” plan provisions, stop-loss policies embrace carve-outs but networks prohibit them, employee handbooks promise benefits not provided by the SPD…and those are just a few examples of areas of confusion. Thank you for joining The Phia Group on May 12th, 2016 as its legal team gave a crash course in contracts. Cost-containment can be impacted by the contracts you sign, and there are often exceptions and restrictions buried deep down, or potential issues not considered beforehand. In this webinar, The Phia Group explained some of the contracting pitfalls experienced on a daily basis within the self-funded industry.
• Unraveling FAQ Part 31
  
  May 4, 2016
  Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now; in its latest FAQ, published just last week (FAQs about Affordable Care Act Implementation, Part 31), the regulators reiterate concerns regarding network adequacy and how it relates to - and regulates - reference-based pricing arrangements.
• A Changing Industry: Navigating the current (Events)
  
  April 14, 2016
  The self-funded industry changes rapidly and without notice. In recent memory, the biggest culprit has been the ACA - and in its aftermath, there have been numerous regulatory guidelines and court cases that have helped interpret the ACA's provisions. Still, though, there are many other changes occurring at any given time. Examples include assignments of benefits, discrimination, preemption, bankruptcy, subrogation, stop-loss, and more.
• The Replacements
  
  April 8, 2016
  As the self-funded industry evolves, benefit plans are forced to evolve with it or get left in the dust. Employees need quality coverage – but providing robust yet affordable programs has proven difficult for many self-funders. This conundrum can be addressed by changing inefficient or archaic processes; in response to contractual handcuffs limiting your ability to target cost drivers, too many health plans and TPAs overreact, thinking that the solution is to trash their plan entirely, and to try something new and untested – trading security for savings. When it comes to benefits, don’t remove, don’t reduce... replace! Avoid the extreme sides of the spectrum, achieve balance, and ensure your own viability with “The Replacements.” Thank you for joining The Phia Group on Tuesday, February 16th, as we identified the trouble spots found in all benefit plans, and helped develop strategies to carve them out and replace faulty portions with new alternatives – without harming the rest of the plan!