Photo Of Phia Group PACE Team Member - Joanna Wilmot

“Like many of our innovative ideas, the PACE product is popular with our customers because it removes difficult claims decisions from employers, so they can focus on their work priorities.”

JOANNA WILMOT
Protect The Plan - PLAN APPOINTED CLAIM EVALUATOR® (PACE)

Protect forward-thinking plan sponsors against fiduciary liability. 

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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.”

This in turn is then followed by: “For More PACE Case Studies Click Here” with the link taking the reader to a new page. 

Keeping PACE with The Phia Group

  • Plan Document Review and Revision to Ensure Compliance
  • 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