2026
Quarterly Newsletter

PACE

Many plans and TPAs view the final appeal determination as just another claim decision, but we don’t think that really does it justice. By the time a claim reaches that final appeal stage, it’s an incredibly important fiduciary decision, often regarding a contentious or sensitive high-dollar claim; meanwhile, the member and provider are often frustrated to boot. The final appeal stage is where a fiduciary error can really come back to haunt a plan in external review or even in court, and that’s exactly why Phia has developed its Plan Appointed Claim Evaluator (PACE) service.

PACE is designed to give the plan the tools for fulfilling its responsibilities. By providing an independent, objective review when the stakes are highest, Phia ensures that the plan or TPA isn’t simply left to make its final appeal decision alone in a vacuum. Our experts review the plan language, facts of the case, applicable law, and clinical documentation, and issue a directive specifically designed to give the plan a framework to base its decision on. We have one goal in mind: making sure the plan has all the information it needs to make a correct, defensible determination. PACE helps health plans make the right decision and prevents TPAs from making fiduciary determinations on their own, which can avoid unwanted liability in multiple ways.

Contact Phia today at info@phiagroup.com to learn more about our Plan Appointed Claim Evaluator (PACE) service.

Enhancement of the Quarter

The No Surprises Act was supposed to protect patients from surprise medical bills, and it has generally accomplished that goal. But for health plans and the TPAs and brokers that advise them and administer those health plans, it has also created an entirely new operational mess involving the logistics of the initial payment, calculation of the QPA, open negotiation, IDR strategy, procedural deadlines, provider behavior, and the pervasive question of whether a claim even belongs in the NSA process in the first place.

This is where The Phia Group’s NSA support services continue to provide unsurpassed value. Our ever-growing team of attorneys and support staff helps clients evaluate NSA applicability, review payment strategy, engage in open negotiation, identify procedural defects, respond to IDR filings, and navigate the otherwise increasingly technical dispute process. In other words, we help plans avoid overpaying simply because the process can be confusing and intimidating.

Phia’s services continue to evolve as the rules, regulatory guidance, provider strategies, and market trends evolve. We never sit still because the self-funded industry never sits still; whether the issue is the NSA, stop-loss reimbursement, appeals, plan document language, fiduciary duties, or vendor oversight, our goal is to help our clients make better decisions before small problems become time-consuming and expensive ones.

Phia Case Study

A self-funded plan offered an HSA-qualified HDHP with a $4,000 individual deductible. Midway through the year, the plan’s TPA discovered that one particular member had satisfied only about $2,000 of the total deductible, and then the plan paid a claim without applying the remainder of the deductible. The TPA, a client utilizing Phia’s Independent Consultation and Evaluation (ICE) service, asked us what this meant for the plan’s QHDHP status and, even more urgently, for the patient’s HSA eligibility. The TPA had a meeting with the group and broker the next day, so they needed a response ASAP.

One of The Phia Group’s attorneys was able to quickly put the TPA’s mind at ease, explaining that the regulatory framework is structured to render the individual eligible for HSA contributions once the member meets the IRS minimum deductible — even when that is less than the plan’s actual deductible. So, luckily, the member had already satisfied the statutory minimum HDHP individual deductible of $1,700 when the plan began to pay first-dollar. So while the plan should correct the application of the patient’s deductible going forward, there was no HSA disqualification issue to worry about.

The best part? Since this was part of the ICE service, our prompt response came at no additional cost.

Fiduciary Burden of the Quarter

Vendor services and contracts can be very tricky sometimes. When combined with positive word of mouth, it’s very easy to not notice compliance concerns within a given service model; as we’ve seen countless times, a program’s popularity and positive impact on claims spend or employee satisfaction isn’t proof that the service is without significant issues.

The fiduciary burden is to carefully scrutinize plan vendors, both prior to contracting and during the provision of services, to avoid issues where possible, or at least to spot them when they arise. Vendor contracting decisions have typically been considered settlor decisions rather than fiduciary decisions, but courts are getting more stringent as plaintiffs get more creative in their arguments. Though an initial contract negotiation may be a settlor function, continued use of that contract can be viewed as a fiduciary function, and every day the fiduciary chooses to stay in a particular vendor arrangement can create new fiduciary scrutiny.

That doesn’t mean that every vendor relationship is problematic, of course; it’s just a reminder that they need to be carefully analyzed and understood, and the fiduciary must ensure that the arrangement does truly benefit the plan and its participants.