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Enhancement of the Quarter: Patient Defender Value Reports
Clients of Patient Defender will be excited to hear that we have created a brand new report for them. Clients of The Phia Group’s innovative Patient Defender service can access this quarterly snapshot of the service and the client’s activity. It contains a myriad of data, including both currently active and historical items.
While the Patient Defender service itself can be a life-saver for groups subject to claims being balance-billed, this report provides information that demonstrates the true value of the service, allowing users to continue to make informed decisions about their actions.
With over 35,000 employee lives represented in these reports, we have already received positive feedback, and we will continue to monitor clients’ usage and feedback!
To learn more about these reports or to receive a sample report, please contact our Sales Manager, Garrick Hunt, at 781-535-5644 or GHunt@phiagroup.com. Likewise, to learn more about Patient Defender, Phia Unwrapped, balance-billing support services or any other services The Phia Group offers, Garrick is available to you.
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Service Focus of the Quarter: Phia Unwrapped
If you’re not familiar with reference-based pricing (or “RBP”), get familiar. RBP started as an outlier in the industry, but it’s getting more and more popular, even being embraced by many networks and providers as the new norm. As helpful as RBP can be for non-contracted claims, however, it is not without the risk of balance-billing and member disruption – which is why many TPAs and groups that would otherwise embrace RBP instead shy away from it.
To anyone who sees the value in RBP but can’t tolerate the risks: The Phia Group is here to help!
The Phia Group has for decades provided services meant to supplement and enhance RBP programs; from balance billing support – which is plugged into plans that choose not to use any network, to Phia Unwrapped. Phia Unwrapped is designed to pair with plans that opt to supplement, rather than replace, a primary PPO, targeting out of network claims and allowing a health plan to shed its wrap network … and with it the meager but expensive discounts it allows providers to charge (or requires plans to pay, depending upon how you look at it).
Phia Unwrapped is anything but traditional; by replacing wrap network access and modifying non-network payment methodologies, this service enables health plans to secure payable amounts that are unbeatably low. Phia Unwrapped places no minimum threshold on claims to be repriced, and sets no limit on balance bills eligible for negotiation. Looking at those instances in particular, The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full.
Out-of-network claims run through The Phia Group’s Unwrapped program yield an average savings of 74% off billed charges (three times the average wrap discount). There’s very little member disruption to boot, since the plan would keep its existing PPO and use Phia Unwrapped only for non-contracted claims. Phia Unwrapped can also be a way for a plan to switch from a traditional ”mega” network, with no meaningful steerage and therefore no meaningful discounts, to a narrower network with real steerage and real discounts, recognizing that a narrow network potentially means more non-network claims – which is exactly what Phia Unwrapped is designed to not only address, but leverage.
Success Story of the Quarter: Reviewing Proposed Service Agreements
The Phia Group’s consulting department (via PGCReferral@phiagroup.com) was recently asked by a broker to review a proposed service agreement between an employer group and a vendor. After the broker confirmed our written scope of work and flat fee quote, we got to work, and immediately noticed some odd provisions in the vendor’s draft agreement.
Chief among them was a provision that guaranteed the vendor a certain PEPM fee per contract that the vendor was able to enter into with any medical provider. Percentage-of-savings fees are the norm as payment for obtaining contracts, since payment should ideally depend on the value added, but the PEPM fee increase per contract seemed unusual. Although there is a possible world in which that provision benefitted the group, there were no provisions whatsoever to qualify the extent of this requirement. The example we provided to the group (based in New York) when discussing the language was that if the vendor calls fifty doctors in California and negotiates 1% discounts with all of them, that’s fifty contracts, and fifty separate additions to the PEPM cost of the vendor’s service – despite the fact that the CA-based doctors would be unusable by the NY-based employees, and, maybe more importantly, that those negotiated discounts would be a joke.
We provided the broker with a full explanation of our issues with this language, as well as numerous other problematic or otherwise notable things we saw within the agreement. The broker subsequently requested from the vendor a list of its contracted discounts, with which it received and was thoroughly dissatisfied. The vendor refused to change its payment model to a percent-of-savings, and the deal was terminated.
Phia Case Study: A Common Claim with Complications
A plan participant was involved in a motor vehicle accident while riding a motorcycle, and suffered severe injuries. The Plan suspended payment until the police report was received, after which the Plan excluded claims due to the report indicating that the participant had been driving recklessly, and based on witness testimony, may have been intoxicated. Worth note is that this exclusion was applied despite the accident apparently being primarily caused by another driver rather than the plan participant’s own recklessness.
The police report also noted that the participant’s injuries were too emergent for the officer on scene to be able to determine the participant’s sobriety (or lack thereof), so the police report was not conclusive on the question of intoxication. As a result, the Plan sought the medical records.
The ER physician’s report vaguely mentioned that intoxication was a possibility, but the physician did not have concrete evidence. Subsequently, the lab results came back and lacked any evidence of intoxication.
The Plan felt that the physician’s initial comment about possible intoxication was sufficient to allow the Plan Administrator to deny the claims on the basis of DUI, but the TPA sought out the opinion of The Phia Group regarding whether the claims were deniable on this basis. The TPA correctly noted that while the Plan did not need evidence that proved intoxication “beyond a reasonable doubt,” it did need “some” evidence.
After a review of the file and relevant facts, we concluded that the physician’s initial speculation absent any real basis would not likely constitute evidence upon which a decision could be based without risking arbitrariness; it does not constitute a medical opinion that the patient was in fact intoxicated, nor is it substantiated by the physical evidence provided. We therefore opined that it would likely not be reasonable for the Plan to deny the claim on the basis of intoxication, since there was no evidence of intoxication upon which the Plan Administrator could reasonably rely.
Ultimately, based on this information, the Plan paid the claims, and the participant’s attorney subsequently agreed to reimburse the Plan from any settlement ultimately received from the driver who caused the accident.
Fiduciary Burden of the Quarter: Complaint Remark Codes
Adjudicating health claims is hard work. It can get complicated, especially in light of what can sometimes be tight timeframes within which EOBs must be provided. For that reason, in the face of numerous possibilities for why certain line items might be denied, it can difficult to comply with ERISA’s regulations requiring certain information within a remark code. Compliance with those regulations, however, is still very important.
The Plan Administrator has a duty to ensure that the plan provides reasonable claim procedures, in accordance with regulations found at 29 CFR §2560.503-1. Among other things, these regulations provide that an EOB must provide both “The specific reason or reasons for the adverse determination” and “Reference to the specific plan provisions on which the determination is based.” We often encounter EOBs that identify a given line item as denied or partially denied with a justification such as “denied pursuant to the Plan Document”, and generally something so vague would tend to not satisfy these regulations. It’s also somewhat common for plans utilizing reference-based pricing methodologies to use a remark code to the effect of “denied due to reference-based pricing,” which in our opinion is similarly vague and likely noncompliant. Remark codes like these fail to identify the plan language to justify the denial, and they fail to provide the required level of specificity in rendering a denial.
The purpose of these claims regulations is to promote a “meaningful dialogue” between the plan and claimant such that the claimant may formulate an appeal of a denial if necessary; for that reason, a remark code like “denied pursuant to the Plan Document” cannot possibly suffice, since it does not provide nearly enough information to allow the claimant to have that “reasonable dialogue” and formulate any meaningful appeal of a denial.
The practical effect of issuing remark codes that are too broad or vague to meet the requirements of the claims regulations is that the plan will have failed to provide reasonable claims procedures, and the claimant will be deemed to have exhausted its administrative remedies (i.e. the claimant can jump straight to a lawsuit, since the plan has effectively denied the claimant its right to appeal), effectively nullifying the plan’s internal appeals requirements.
For those of you with children, remark codes like the examples here roughly equate to the classic “because I said so.” That can work well in the parenting context, but not so well under ERISA; luckily, parents are not required by law to provide the child proper reasoning and an opportunity to appeal the decision – but health plans are.
If your remark codes include “denied because the plan said so”, please don’t hesitate to have them reviewed. The Phia Group is here to help!
Webinars:
• On December 16, 2020, The Phia Group presented, “A Transparent 2021 – Further Analysis of the Year to Come,” where we discussed the rules that will impact 2021, including the recently released transparent pricing rules.
• On November 16, 2020, The Phia Group presented, “Desperately Looking Forward to 2021,” where we discussed hot topics, forecasting what we expect to see in 2021, and giving you a head start as you – like we – plan, and look forward, to 2021.
• On October 19, 2020, The Phia Group presented, “New Opportunities to Save, Create Revenue & Avoid Scary Practices,” where we discussed some of the industry’s scariest blunders and gruesome practices.
Be sure to check out all of our past webinars!
Podcasts:
Empowering Plans
• On December 23, 2020, The Phia Group presented, “Balance Billing During COVID-19 and Beyond,” where our hosts, Brady Bizarro and Mitch Hilbert, discuss how balance billing has been on an uptick during COVID, and how patients can possibly prevent this from occurring.
• On November 30, 2020, The Phia Group presented, “COVID-19 Vaccine Candidates – What Health Plans Need to Know,” where our hosts, Brady Bizarro Andrew Silverio, discuss current COVID-19 vaccine candidates and everything health plans and employers need to know about them.
• On November 13, 2020, The Phia Group presented, “Election Aftermath – Where Things Stand,” where our hosts, Ron Peck, Brady Bizarro, and Nick Bonds reunite to discuss their developing thoughts on the presidential election results.
• On November 9, 2020, The Phia Group presented, “2020 Election Results (So Far) – Our Takeaways,” where our hosts, Ron Peck and Brady Bizarro, are joined by Nick Bonds, to discuss the 2020 election results.
• On October 26, 2020, The Phia Group presented, “The Final Debate & Election Predictions,” where our hosts, Brady Bizarro and Nick Bonds, break down the final presidential debate of the campaign season, focusing in on the candidates’ healthcare plans.
• On October 19, 2020, The Phia Group presented, “Behind the Scenes – Town Halls, Nominees & Medicare-for-All,” where our hosts, Ron Peck and Brady Bizarro take you behind the scenes, avoiding the bright lights of presidential town halls and Supreme Court confirmation hearings.
• On October 13, 2020, The Phia Group presented, “Healthcare on Stage & COVID-19 in the White House,” where our hosts, Ron Peck and Brady Bizarro guide you through a chaotic week for healthcare news, including the first presidential debate, COVID-19 infecting the President and much of the West Wing, and more.
Be sure to check out all of our latest podcasts!
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Phia Fit to Print:
• BenefitsPro – https://www.benefitspro.com/2020/12/17/leave-entitlements-under-the-ffcra-set-to-expire/ – December 17, 2020
• BenefitsPro – Hispanic and Latino health and the Affordable Care Act – December 07, 2020
• Self-Insurers Publishing Corp. – Best Practices For Updating The Employee Handbook In A Pandemic – December 3, 2020
• BenefitsPro – Remembering why we do it: Employer-sponsored health plans – November 20, 2020
• BenefitsPro – ACA in court: Reactions from around the industry – November 11, 2020
• Self-Insurers Publishing Corp. – Cobra Coverage and COVID-19 – November 5, 2020
• Self-Insurers Publishing Corp. – Planning Ahead: COVID-19 And Other Considerations For 2021 Health Plan Renewals – October 2, 2020
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From the Blogoshpere:
• Offer More for More! If and when private health benefits cannot compete with a public option on price, they will need to re-invent the industry.
• Updating the Employee Handbook in Unprecedented Times. Have you made your updates yet?
• There is no Such Thing as a 1099 Employee. A 1099 employee isn’t an employee of yours at all!
• FFCRA Leave Entitlements Set to Expire December 31, 2020. How much do you know about the Families First Coronavirus Response Act?
• I Hate Surprises! Surprise billing expected to come to a halt.
To stay up to date on other industry news, please visit our blog.
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The Phia Group’s 2021 Charity
At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.
The Phia Group’s 2021 charity is the Boys & Girls Club of Metro South.
The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.
The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8-18, signed up as club members. In the 25 years since, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.
Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.
Thanksgiving Dinner Delivery
Thanksgiving dinner delivery to The Boys & Girls Club of Metro South was a little different this year. The Phia Family was out and about the week of Thanksgiving, delivering dinners to the The Boys and Girls Club of Metro South, so the families could pick up their meals when they picked up their children. Additionally, our Phia Family in Idaho and Louisville were out and about spreading the same cheer to five families in the Boise area and five families in the Louisville area. In total, we delivered 32 meals this year! Check out the great picture we were able to get from that special day! We hope everyone had a wonderful Thanksgiving!
Angel Tree
Each year employees of The Phia Group pick nametags from the Angel Tree that sits in our main lobby. On those tags are names, ages and the wish lists of children from The Salvation Army. This year we had over 130 nametags! The Phia family loves to give back to the community; our greatest joy is providing these children with all of their holiday wishes.
Christmas Came Early
The Phia Group had the pleasure of bringing Christmas joy to the Boys & Girls Club of Metro South. Adam Russo and his helpers virtually passed out hundreds of gifts to over 130 children. We hope these children enjoy their new toys as much as they enjoyed spending time with virtual Santa!
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Get to Know Our Employee of the Quarter:
Kaitlyn Lucier
To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.
The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Kaitlyn Lucier, The Phia Group’s Q4 Employee of the Quarter!
Kaitlyn has been able to handle any challenge that has been thrown at her with ease. She has done a phenomenal job training the new hires in CSD. She is always available to help others in need and being able to rapidly answer a question along with giving informative answers, so others are not lost. She is a valuable asset to CSD and is an outstanding hard worker.
Congratulations Kaitlyn, and thank you for your many current and future contributions.
Get to Know Our Employees of the Year: Philip Qualo
To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.
The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Philip Qualo, The Phia Group’s 2020 Employee of the Year!
Philip has done a phenomenal job with the Diversity Inclusion Committee- conducting the meetings, putting together all of the plans, reviewing with the Executive team & providing staff with the information. He has put in a lot of extra hours working late many nights, to ensure that everything was completed along with his PGC tasks. He definitely deserves recognition for all of his hard work!
Job Opportunities:
• Chief Financial Officer
• Customer Service Representative
• Senior Vice President, Sales
• Claim Analyst
See the latest job opportunities, here: Our Careers Page
Promotions
• Liz Pereira has been promoted from Case Investigator to Case Analyst
New Hires
• Nathan Letourneau was hired as a Claim and Case Support Analyst
• Alexander Araujo was hired as a Customer Care Representative
• Brittany Farr was hired as a Customer Care Representative
• Thalea Gauthier was hired as a Customer Care Representative
• Alexia Holloway was hired as a Customer Care Representative
• Catherine Villanueva was hired as a Customer Care Representative
• Lisa Hill was hired as a Sr. Subrogation Attorney
• Anthony Jean was hired as an Accounting Administrator I
• Thomas Cole was hired as a Claim Analyst
• Skyla Mrosk was hired as a Claim Analyst
• Andrew Mead was hired as an IT Intern
• Alexandre Houle was hired as a Provider Relations Clinical Claims Specialist
• Aastha Vats was hired as an ETL Specialist
• Julie Padden was hired as an Executive Assistant
• Sheena Roberts was hired as a Sr. Administrative Assistant
• Kristen Melanson was hired as a Claim and Case Support Analyst
• Hillary Burmester was hired as a Claim Recovery Specialist
• Kaitlyn MacDonald was hired as a Health Benefit Plan Consultant I
Phia News:
Candy Corn Contest
We set up our annual Candy Corn Contest in the front lobby of our Canton office and asked everyone to guess how many pieces of candy corn were in the jar! For those working from home, we sent out pictures of the candy jar with measurements, and had over 100 submissions. The winner of this contest was Lisa Decristoforo, and the total count was 811. Lisa guessed that there were 803 pieces of candy corn. It’s hard to believe that all of those pieces of candy fit into that small jar!
Pumpkin Carving Contest
In October, The Phia Group held its first Pumpkin Carving contest. We had over 20 submissions and it was a tough decision to make, but the Phia family had to pick one. Congratulations to the winner, Catherine Baskerville. We are all so impressed with your creativity and carving skills. We look forward to our next Pumpkin Carving contest!
Mask Contest
With everyone being asked to work from home, we wanted to make sure we kept all employees engaged and entertained. We put our thinking caps on and asked everyone to submit photos of their most creative masks, and we had the Phia family vote for their favorite mask during a virtual staff meeting. We are proud to announce that Regina Cattel was the winner of this contest, with her super fun tiger mask!
The Phia Group Reaffirms Commitment to Diversity & Inclusion
At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.
We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.
The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.
We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.
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