2026
Quarterly Newsletter

Service Focus of the Quarter: PACE

When a claim hits the final internal appeal, every word in the plan document, SPD, stop-loss policy, and network contract suddenly matters. That’s where The Phia Group’s Plan Appointed Claim Evaluator (PACE) steps in. PACE provides directives on second-level appeals, providing an independent, objective review that aligns plan language, applicable law, and real-world facts, so fiduciaries aren’t making high-dollar calls in a vacuum or without a safety net.  Moreover, with PACE, when a plan administrator proceeds in accordance with a PACE directive, The Phia Group acts as a co-fiduciary and indemnifies the plan against damages for fiduciary breach, as well as manages – and covers the costs of – subsequent IRO reviews and external appeals to courts of law.

Even though PACE can function as a bolt-on product, it’s designed to sit at the center of The Phia Group’s broader cost containment and fiduciary protection ecosystem. PACE is compatible with virtually any plan design, from a traditional PPO plan to the most aggressive RBP structure; it becomes the last line of defense that harmonizes all the various moving parts of a claim and appeal.

When a claim reaches its final appeal, PACE is the way to cut through the complexity. Self-funded plans can rely on Phia’s expertise and offer robust benefits without fear of runaway fiduciary risk.

Enhancement of the Quarter

Independent Consultation and Evaluation (ICE) partners already enjoy 24/7 access to e-learning resources, ICE-exclusive content, and SoPhia – our AI-powered consulting tool.

The Phia Group is pleased to announce that both in Q4 of 2025 and into 2026, we’re doubling down on the idea that compliance support shouldn’t only show up when something goes wrong. We’re continuing to expand SoPhia’s practical use cases and helping users quickly get oriented to threshold questions like “Which providers can submit NSA claims?” or “What claims are eligible for IDR?” while still providing a seamless hand-off to ICE consultants when a situation calls for human judgment as well as a practical, industry-focused, anecdotal analysis.

The goal is simple: whether you’re answering a group’s question at noon or catching up on your queue at midnight, ICE and SoPhia keep you a step ahead of the next compliance headache.

Phia Case Study

As you may know, Phia presents both free industry-wide webinars and bi-monthly ICE-exclusive webinars, on which we present more focused, actionable content.

After listening to the latest ICE-exclusive webinar where our attorneys discussed various compliance topics including ERISA’s trust requirement and the regulations that apply to segregation of plan assets from an employer’s general assets, one of our ICE clients – a TPA – reached out to us and asked our team to review their procedures, guidance, and contract language regarding plan assets, because they weren’t confident that their processes matched what was described on the webinar.

We took a deep dive into their various materials related to ERISA plans and found that their standard procedure was to support employers holding cafeteria plan payroll contributions for their cafeteria plan within the employer’s general assets indefinitely, which runs counter to current regulations.

Though ERISA’s trust requirement is technically a plan responsibility, the TPA acknowledged that TPAs are increasingly often being held responsible for the advice and support they provide to their health plan clients, even when the final decision may still rest with the plan; recognizing that an employer can’t fix the past, the TPA began to take proactive steps to change its processes, guidance, and administrative services agreement to comport with the regulatory mechanisms that govern ERISA plan assets.

Fiduciary Burden of the Quarter

The gag clause prohibition was one of many changes made within the Consolidated Appropriations Act, 2021. Since this broad law contained the No Surprises Act, the gag clause rule fell by the wayside for many – and there are still some plans that have yet to pay much attention to it.

Plans are prohibited from entering into agreements that restrict them from sharing price and quality information or claims data with participants or business partners who need it. Every year, plans must attest to the federal government that their contracts with TPAs, networks, PBMs, and other vendors are gag clause-free. For fiduciaries, this should be more than just a box to check once a year in the federal portal; it’s a standing order to understand what’s actually written in service agreements, and to fix problematic language before the attestation year begins.

ERISA’s duties of prudence and loyalty require sponsors to monitor service providers and ensure that contractual terms don’t prevent them from accessing data they need to oversee fees, quality, and outcomes. Submitting an attestation without having exercised that level of diligence can risk exposure to regulatory penalties and undercuts the duties that fiduciaries owe to plan participants and the plan as a whole.