Protect forward-thinking plan sponsors against fiduciary liability, and plan members from balance-billing and collections activities.
Plan Appointed Claim Evaluator (PACE®)
Be an industry leader and implement a new profit center by shifting fiduciary burdens away from current and prospective clients, and onto the PACE!
The self-funded industry already turns to The Phia Group for our legal and analytical expertise. Now, acting as your PACE, we handle final internal appeals as a fiduciary.
When a benefit plan sponsor chooses to utilize the PACE service, we assume the fiduciary role, stand behind our directive, and defend our decisions in the face of external appeal and judicial scrutiny.
The Phia Group will also facilitate the retention of Independent Review Organizations (IRO) in accordance with applicable law, help facilitate the IRO external appeal process, and coordinate with stop-loss – including appealing denials by the excess carrier if and when applicable.
“Case Study #1: Plan’s Denial Upheld by PACE
Executive Summary: The Phia Group Interprets a Complex Exclusion Saving the Plan Over $3,000.00 in Review Fees and $60,000.00 in Claims
A Plan Administrator denied out-of-network claims related to self-inflicted injuries under the Plan’s “self-inflicted” exclusion. The claims were in excess of $60,000.00. The member appealed, citing his own history of alcoholism as the medical condition which caused the injuries (and therefore requiring the claims be paid under federal law). The Plan did not find any evidence of alcoholism in the related medical records or in the member’s claim history. The original denial was upheld. The member appealed again, and the final, internal appeal was referred to the PACE. The PACE performed a legal and medical review as part of the PACE service, which reviews would have cost the Plan over $3,000.00 in legal and medical review costs. The PACE found no medical evidence to suggest the member was an alcoholic or that alcoholism caused the self-inflicted injuries then issued a directive that confirmed the Plan Administrator’s interpretation of the exclusion.”
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Keeping PACE With The Phia Group
- Plan Document Review To Ensure Compliance and PACE Readiness
- Multifaceted Implementation Ensures Awareness and Seamless Utilization
- Advanced Level Webinars Are Presented Exclusively for PACE Clients
- The PACE Performs an Assessment of Final Internal Appeals and Issues Directives as a Fiduciary
- Unsurpassed Legal Analysis, Clinical Review, and Access to URAC-Accredited IROs
- The PACE Ensures Claims Are Processed in Accordance With Plan Terms
- Relevant Stop-Loss Policies and Network Contracts Are Reviewed
- TPAs Facilitating the PACE Service Receive an Administrative Fee PEPM
Frequently Asked Questions About Plan Appointed Claim Evaluator:
What is the Plan Appointed Claim Evaluator®, or PACE®?
PACE® is a fiduciary transfer service. The Phia Group assumes fiduciary duties for final-level internal appeals, so plan administrators, TPAs, and brokers don’t have to.
Which plan designs are compatible with PACE?
All plan designs are compatible with PACE. From reference-based pricing plans to traditional PPO plans to “skinny” plans, all self-funded plan administrators have fiduciary duties, and will face difficult appeals.
Can we use PACE with any administrator?
Unfortunately, not every administrator is compatible with PACE, but the vast majority of administrators are. This would be assessed on a case-by-case basis.
What happens if the PACE’s decision is appealed to an IRO?
If a claim deemed deniable by the PACE becomes subject to review by an Independent Review Organization, The Phia Group will both pay for the full cost of the IRO review and provide any assistance necessary during the external review to defend the decision.
As a TPA or broker, what does it cost my organization to use PACE?
Absolutely nothing. The Phia Group’s PEPM fees for the PACE service are paid by the individual plans that utilize the service rather than by the TPA or broker. In fact, TPAs and brokers even have the opportunity to add a new profit center through their administrative assistance with the PACE service.
What is the best way for us to market PACE to our groups?
As part of the PACE implementation process, The Phia Group will meet with you to determine the best way to market PACE to groups. The Phia Group prefers to hold this meeting on-site, but it can also be done remotely. During this meeting, co-branded marketing, sales, and implementation strategies will be outlined and a thorough plan for success will be created to suit your unique book of business.