Plan Appointed Claim Evaluator® (PACE®)
Protect Your Plan Against Fiduciary Liability Arising from Final Level Appeals
Joined The Phia Group in 2013
The Phia Group ensures that all relevant materials from plan documents to stop-loss policies align for maximum clarity and regulatory compliance with PACE.
Claims Denied
Each Year1
Of Appealed Claims
Are Overturned1
Of Claims Reviewed By PACE During Final Appeal Are Overturned That Would Have Otherwise Led To Reimbursement Issues
Appeal Topics by Percentage
No Medical Necessity
36%
Experimental and Investigational
35%
Off-Label Use of Rx
15%
Other Exclusions
14%
Michael Hicks
Manager, Claims Operations
HMA
“We had a client have a problem at another TPA tied to a second level appeal that was mismanaged. As this client naturally never wanted to have that experience again, we explained to them the benefits of The Phia Group’s PACE service. This client was subsequently delighted, which is one of many reasons that we offer PACE to all of our clients.”
Rachel Lanser
Chief Client Officer
VBA Software
"The Phia Group is a technology-driven partner and is really dedicated to making the member experience better, and that is, ultimately, for all of us in this industry, the best thing."
Frank Maneen
Director, Commercial Markets & Strategic Relationships
CareFirst Administrators
"Our clients ask us for fiduciary support on appeals and are relieved that we are partnered with The Phia Group for PACE as they do not have the tools to review appeals thoroughly and do not feel comfortable making those decisions on behalf of the Plan. The PACE team takes care of everything tied to second-level appeals, which leaves our clients focused on their core business and confident that the appeal process is managed by objective third party of experts. The Phia Group’s PACE program provides best practices for the industry."
The Phia Group’s Appeals Technology and Expertise
The Phia Group utilizes PATS, our proprietary state-of-the-art appeals technology, to ensure nothing is overlooked in the decision-making process. Our subject matter experts provide:
Objective Oversight of Appeals
Coordination Between Entities
Clinical Review
Access to URAC-accredited IROs
Document Analysis
PACE Savings in Action
A Plan Sponsor of a self-funded plan was billed over $1,000,000 for a newborn baby and care rendered by an in-network hospital provider (Provider).
What You Can Expect with The Phia Group
Plan document review to ensure compliance and PACE readiness.
Extra legal support to ensure adherence to plan design.
Multifaceted implementation to ensure seamless utilization.
Review of all relevant stop-loss policies and network contracts.
Advanced-level webinars, presented exclusively for PACE clients.
An administrative PEPM for any TPAs utilizing PACE services.
Unsurpassed legal analysis, clinical review, and access to URAC-accredited IROs.
Appeals management with objective and dedicated oversight.
An Extra Layer Of Review For Second-Level Appeals
The Phia Group provides additional oversight of your tools and resources.
Want to Learn More About What Our Other Services Can Do For You?
The Phia Ecosystem
Our services work together—or individually—to help you recognize your full cost containment potential.
PACE FAQs
PACE (which stands for Plan Appointed Claim Evaluator) is a service whereby you receive an objective review and guidance on final appeals, share fiduciary liability with a third party, and receive indemnification against damages arising from fiduciary breach. The Phia Group thereby assumes decision-making responsibility for eligible final-level internal appeals, so plan administrators, TPAs, and brokers don’t have to.
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.
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.
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 part of the PACE implementation process, The Phia Group will convene 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 needs.
Since Phia Unwrapped is designed only for non-contracted claims where the plan does have a primary network structure, there are no concerns regarding compliance. Network adequacy is not an issue for Phia Unwrapped, since users of this service will have dedicated primary networks.
When Plans Win, So Do Families
We believe that everyone should have access to high-quality and justifiably priced care.
Contact us today to get started.
