Case Study #1
A TPA received a letter indicating that it wrongly accessed a PPO discount four years earlier, and that the discount, totaling $52,000.00 was due. The letter demanded payment, citing that the claim had been paid after the PPO contract required. At the time, the TPA delayed payment of these claims for accident details; the TPA could not consider the claim “clean” because it was waiting for details from the participant regarding third-party liability and illegal acts. As a result, the TPA could not remit payment for the claim – because it was not clean – until after the period of 30 calendar days outlined in the PPO agreement had expired. The TPA engaged us to respond to its letter, subject to our hourly fee. The letter took two hours to write, was billed at $600, and was sent nine days later. The letter explained that the PPO contract requires payment for clean claims for covered services – but until the TPA had the information it needed, the claim was not clean, and there was no way to tell whether it was a claim for covered services. The TPA was never contacted again; presumably, the risk of losing in a breach-of-contract dispute outweighed the recovery of this particular suit.  This is a growing trend, and one type of plan exposure frequently referred to The Phia Group.
 
Plan Exposure:      $52,000 
Phia Intervention Saved:    $51,000
Case Study #2
A TPA and their benefit plan client paid claims arising from the treatment of illness/injury caused by an infection, attributable to a bowel nicked during surgery.  Claims exceeded $300,000.00 and this particular benefit plan’s specific deductible was set at $50,000.00.  The excess claims were submitted to stop-loss, who independently determined that the applicable benefit plan’s summary plan description (plan document) excluded coverage for claims arising from or attributable to a third party’s negligence.
 
The Plan and TPA appealed to no avail.  They came to The Phia Group, which provided “ghost-writing” services, aiding them in their second appeal.  The matter of “third party liability,” negligence, and accepted risks of certain medical procedures were set forth.  In addition, it was agreed upon that The Phia Group would investigate the matter for subrogation potential, and any funds so recovered would first be payable to the stop-loss carrier (per the applicable policy).  With this agreement in place, the excess funds (exceeding the deductible) were reimbursed to the Plan.
 
Plan Exposure:      $350,000 
Phia Intervention Saved:    $200,000
Case Study #3
The Phia Group’s recovery team received a file in which a Plan participant had been involved in a motorcycle accident.   The Plan received approximately $300,000.00 in claims and ongoing treatment. Liability was heavily contested.   The Plan participant retained an attorney; when the Plan engaged The Phia Group as its third party liability attorney, the participant’s attorney demanded that the Plan waive their interest, before the claims were even paid.
 
The Phia Group advised the attorney of the Plan’s rights, and successfully convinced the attorney that if and when claims were paid, a waiver of the Plan’s interest would be inappropriate.  The attorney continued to demand a significant reduction; however upon a review of the Police Report, it was uncovered that the Plan participant was operating his motorcycle under the influence of a controlled substance.   The Phia Group informed the client, and the Plan denied the claims.  The attorney appealed the Plan’s decision.  The Phia Group consulted the Plan in preparing a response, outlining both how the exclusion did apply to the claims at issue as well as matters of discretion to interpret the terms of the Plan and resolve ambiguities.
 
The Phia Group was also able to assist the Plan in drafting new exclusionary language eliminating the ambiguity present in the original version.   
 
Plan Exposure:      $300,000 
Phia Intervention Saved:    $300,000
Case Study #4
A broker servicing a self-funded health plan contacted The Phia Group regarding a surrogacy agreement that one of the group’s employees had signed and provided to the group.  The group questioned what the surrogacy agreement meant and how it played into the Plan’s benefits.

The Phia Group reviewed the agreement separately and against the applicable Plan Document, and helped the plan to understand what benefits were payable under the Plan and what benefits the plan was able to recover from another source. As a result of this review, the Plan discovered that it was entitled to receive over $18,000 in reimbursable expenses of which it admitted it would not otherwise have been aware.
   
Plan Exposure:      $18,000 
Phia Intervention Saved:    $18,000
Case Study #5
A client of The Phia Group’s faced a situation in which the group’s Plan Document  referenced an extension of coverage for up to 24 months based on disability (although that term was not well-defined). To contrast, the employer’s Employee Handbook referenced an extension of coverage for up to 36 months, or longer if deemed appropriate by the employer. To make matters worse, the group’s stop-loss policy provided coverage only for twelve months of disability – and only while the member was “totally disabled,” although that term was not well-defined either.

The health plan’s broker referred the Plan Document and stop-loss policy to The Phia Group’s consulting team to perform a Gap-Free Analysis. As part of this analysis, it was discovered that the Plan Document’s leave provisions did not align with those in the stop-loss policy. The Phia Group’s team also included a note to ensure that if the Plan Document was changed, the Employee Handbook may need to be changed to align as well. Upon receiving the Gap-Free Analysis, the group’s broker asked The Phia Group to review the Employee Handbook and make whatever changes were necessary for the documents to align; upon review, the additional discrepancy was discovered and remedied.

Three months later, after the Plan Document and Employee Handbook were amended to alleviate the gaps in coverage, a member requested 18 months of leave from the employer. The employer was free to grant the leave based on other terms in the Employee Handbook, but the employee was informed that after twelve months, coverage under the Plan would terminate. As luck would have it, during the fifteenth month of the employee’s leave, she incurred significant medical claims that, if paid by the Plan pursuant to its former language, would have been denied by stop-loss. By addressing gaps in coverage, the Plan successfully avoided a large stop-loss denial.
 
Plan Exposure:      $151,500
Specific Deductible:
  $45,000
Phia Intervention Saved:    $151,600
Case Study #6
The Phia Group was asked by a health plan’s third-party administrator to review a stop-loss claim denied due to a combination of insufficient disclosure and payments by the plan in excess of the maximum allowable amount. Specifically, the stop-loss carrier contended that the plan failed to disclose large claims incurred by this particular plan participant between the time of the policy’s initial disclosure and the date the carrier received the plan’s initial premium payment.
    
The plan sponsor contended that it fulfilled its disclosure obligations by notifying the carrier of the plan participant’s known risk at the time of initial disclosure, and that actual claims incurred based on that risk were not specifically required to be continually disclosed. This argument created an impasse, since the policy’s disclosure requirement language was fairly vague and either interpretation was potentially viable. From all angles, it looked like reimbursement would not be forthcoming, and a longstanding relationship was about to crumble.

The Phia Group was asked to provide its assessment of this matter; after reviewing the entire file in detail, The Phia Group recognized the impasse and the unlikelihood of a simple solution. The goal, then, became fostering meaningful communication between both parties. To that end, The Phia Group drafted a detailed letter to the stop-loss carrier outlining the plan’s position, legal arguments to bolster that position, a good faith appeal to the carrier explaining why our entire industry benefits when carriers and plans work together, and of course the business case for the carrier’s reconsideration.

As a result of our efforts, The Phia Group was able to open a dialogue with the carrier; after many hours of negotiation and discussion, the stop-loss carrier was willing to make the plan a generous settlement offer, representing the vast majority of the claims that would have otherwise been denied.
   
Plan Exposure:      $950,000 
Phia Intervention Saved:    $950,000