Recent Posts

• New Requirements Under the Mental Health Parity and Addiction Equity Act (“MHPAEA”)
  
  November 20, 2024
  By: Kendall Jackson, Esq. The deadline to comply with several of the new final rules regarding the Mental Health Parity and Addiction Equity Act (“MHPAEA”) is quickly approaching. On September 9, 2024, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released new final rules that updated existing regulations to provide additional clarity for plans and their vendors on what is required and what will be considered compliant and non-compliant for parity purposes when performing a nonquantitative treatment limitation (NQTL) comparative analysis. The final rules generally apply to group health plans, including self-funded non-Federal governmental health ...
• Navigating Balance Billing and Post-Payment Disputes: Solutions for TPAs and Self-Funded Employers
  
  November 14, 2024
  By: Scott Bennett and David Ostrowsky As rising healthcare costs continue to challenge employers and third-party administrators (TPAs), Reference-Based Pricing (RBP) has emerged as a powerful strategy for cost containment. However, RBP, while promising, is not without its pitfalls. Chief among them is balance billing, in which providers charge patients for the difference between their billed charges and the RBP plan’s payment. Additionally, the No Surprises Act (NSA) has introduced Open Negotiations and Independent Dispute Resolution (IDR) processes, which, while protecting patients, expose employers to post-payment disputes. Addressing these concerns effectively requires comprehensive tools, support, and strategic implementation. Addressing the Challenges ...
• Having NSA Problems? Better Call The Phia Group
  
  October 31, 2024
  By: David Ostrowsky The Independent Dispute Resolution (“IDR”) process was designed to be a cornerstone of the No Surprises Act (“NSA”), a means for resolving claims for payment for out-of-network items and services and a vital mechanism for buttressing the NSA’s protection for plan members against potentially devastating balance billing expenses. Unfortunately, since the NSA took effect on January 1, 2022, things have gone awry on many fronts. The case volume has overloaded the IDR process; courts have been split over whether and how parties can enforce arbitration awards; payers, including group health plans, have paid close to four times ...
• The Future of Birth Control in America
  
  October 28, 2024
  By: David Ostrowsky Since the US Supreme Court decided to undo nationwide abortion rights in summer 2022, women’s reproductive rights has arguably been the most pressing topic in healthcare. Naturally, as we enter the final stretch of election season – as well as the Biden administration – the all-important, polarizing matter has resurfaced. Earlier this month, the departments of Health and Human Services, Labor and Treasury proposed to broaden a federal mandate (under the Affordable Care Act) obligating private health insurers to cover condoms, birth control pills, and “morning after” pills for women on private health insurance plans – even ...
• Cobenfy: A Potential Game-Changer for Schizophrenia Patients – But at What Price?
  
  October 9, 2024
  By: David Ostrowsky As you’re reading this blog, millions worldwide are suffering from the horrors of schizophrenia, one of the most complex, debilitating, and stigmatized mental disorders inflicted on humanity, the symptoms of which typically manifest themselves in early adulthood, though they are not always so easy to detect. Those afflicted by this condition are desperately trying to manage an array of frightening symptoms (hearing voices, delusions, memory lapses to name a few) while carrying on with their lives. In this country alone there are approximately 2.8 million Americans living with schizophrenia; tragically, many of those 2.8 million Americans won’t ...
• Healthcare and Politics… Ugh. Old News!
  
  September 27, 2024
  By: Ron Peck, Esq. Donald Trump recently stated that while he will never give up on repealing the Affordable Care Act (ACA), he was not running on terminating the ACA.  This is likely a smart decision, given that a recent Kaiser Family Foundation (KFF) poll[1] revealed that for Republican voters, repealing Obamacare was an important issue for a very small percentage of respondents. Is this demonstrative of a more widespread loss of interest in healthcare as a political talking point? As someone whose day-to-day career is centered around health benefit plans, cost containment, and the attempt to ensure plan participants ...
• The First Ten: Medicare Unveils Inaugural List of Negotiated Drug Prices
  
  September 16, 2024
  By: David Ostrowsky Last month, while many of us were busy vacationing or doing last-minute back-to-school shopping, the Biden administration announced that it had reached an agreement with the titans of the pharma industry to lower prices on the 10 costliest prescription drugs under Medicare, thus bringing to fruition Democrats' decades-long push to allow the government to negotiate directly with pharmaceutical manufacturers. While individual plans had previously been able to haggle over prices with Big Pharma, this development marks a seminal moment as it is the first time that Medicare used its clout to be able to negotiate for ...
• Section 1557 Final Rule: Where Do We Stand?
  
  August 30, 2024
  By: Kendall Jackson, Esq. The implications of the Section 1557 Final Rule are currently in flux since the Final Rule was issued on April 26, 2024. The purpose of the Final Rule was to extend the protections against discrimination in healthcare, with a particular emphasis on gender identity. The inclusion of gender-affirming care within the protection against sex discrimination was a huge step forward in strengthening the scope of Section 1557 beyond what was originally afforded when the rule first passed. Unfortunately, there have been several challenges to the Final Rule where various district courts either stayed or enjoined particular ...
• Healthcare in Rural America
  
  August 19, 2024
  By: David Ostrowsky Whether it’s met with great anticipation or utter dread, summer will soon be giving way to autumn. For many people living in picturesque New England, where The Phia Group is headquartered, seasonal change means an upcoming weekend of leaf-peeping. But when we’re checking out apple orchards and roadside maple sugar shacks, it’s easy to forget the sobering reality: life isn’t always so sweet for residents in these one-stoplight rural outposts as many face imposing barriers to healthcare. Healthcare inequality is a glaring problem across our nation, but the issue is particularly acute in rural America where folks grapple ...
• Health Over Wealth
  
  August 5, 2024
  By: David Ostrowsky In 2017, New York Times medical journalist Dr. Elisabeth Rosenthal published “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” It quickly became one of this century’s most influential healthcare books, enlightening the masses about the corporate greed embedded in a trillion-dollar industry, one that is ostensibly grounded in altruistic endeavors. Unfortunately, little has changed in the seven years since Rosenthal’s best-seller hit the shelves of your local Barnes & Noble. If anything, the industry has only become further riddled with opportunities for captains of industry, such as those leading private ...
• What the Overturning of Chevron Means for Healthcare
  
  July 19, 2024
  By: David Ostrowsky   For the past forty years, federal agencies have had considerable latitude to interpret and enforce regulations and subsequently advance regulatory initiatives. Per the precedent established in the Supreme Court’s 1984 decision in Chevron U.S.A., Inc. v. Natural Resources Defense Council, courts have had to defer to federal agencies regarding legal challenges over ambiguously written laws passed by Congress. The rationale was as follows: The public servants employed by the federal agencies, whether they be scientists, engineers, law enforcement officials, economists, or experts in another field, have more specialized expertise in the given matter – even more so ...
• The Supreme Court and State Bans on Gender-Affirming Care for Minors: What’s Next?
  
  June 26, 2024
  By: David Ostrowsky Samantha and Brian Williams of Nashville are no different from any other parents in that they want what’s best for their 15-year-old daughter. The Williams’ situation, however, is different from that of many parents as their child identifies as transgender while residing in a state that restricts access to puberty blockers, hormone therapies, and surgeries for minors undergoing gender transitioning. Per the American Civil Liberties Union, the Williams’ daughter is one of approximately 3,000 transgender adolescents in Tennessee where, by law, medical providers cannot perform procedures that “enable a minor to identify with, or live as, a purported ...
• Direct Contracting and Occam’s Razor
  
  June 21, 2024
  By: Jon Jablon, Esq. Maybe I should be, but I’m not ashamed to admit that when I first heard of Occam’s Razor, I assumed it had something to do with shaving. Whatever the context, many know Occam’s Razor as a principle of decision-making holding that “the simplest explanation is the best one”. Although the real idea is similar, William of Ockham’s logic is a bit more formulaic than that. To paraphrase, Occam’s Razor suggests that when choosing between multiple options, the best choice is the one that requires the fewest assumptions to reach. Put another way, the best option ...
• Implications of the Section 1557 Final Rule
  
  June 17, 2024
  By: Kendall Jackson, Esq. The non-discrimination protections of Section 1557 of the Affordable Care Act are not new, as the Affordable Care Act was originally enacted in 2010. However, the recent Final Rule published on May 5, 2024, provided clarification and additional requirements as they relate to strengthening civil rights protections for individuals. First, it is important to remember that Section 1557 is not applicable to all health plans. Section 1557 applies to “covered entities,” which are health programs or activities that receive HHS funding. “Covered entities” also include HHS-administered health programs or activities, and the health insurance Marketplace. The ...
• 2024 Benefest: Not Just Massachusetts in Focus
  
  June 14, 2024
  By: David Ostrowsky Earlier this month, 2024 Benefest, hosted by the Massachusetts Chapter of the National Association of Benefits and Insurance Professionals (NABIP), took place at the DoubleTree by Hilton Hotel Boston-Westborough. While the conference largely focused on the Massachusetts healthcare ecosystem – panel discussions of which reached the general consensus that, from an affordability and access perspective, these are incredibly challenging times due to unprecedented staffing shortages reducing providers’ daily bandwidth – there was considerable time spent examining federal healthcare developments, including how November’s election will impact employer-sponsored benefit plans. Some takeaways from the discussion: Prescription drug pricing: The ...
• The Price is Wrong, Y’all
  
  June 4, 2024
  By: Nick Bonds, Esq. National spending on healthcare was approximately $74 billion in 1970. Fast-forward to 2022, the growth alone on healthcare spending from 2021 was $175 billion, topping out around $4.5 trillion total spending for that year. It’s a well-worn saying in the healthcare industry but it still rings true: “It’s the prices, stupid.” Every ounce of work and creativity that we at The Phia Group, and many of our colleagues in the industry, pour into trying to reduce healthcare costs may ultimately be for naught if the prices continue to rise indefinitely. One of the driving factors ...
• HIPAA Final Rule Protects Access to Reproductive Healthcare
  
  May 28, 2024
  By: Andrew Silverio, Esq. On April 26, 2024, HHS Office for Civil Rights (OCR) released a HIPAA Privacy Rule to Support Reproductive Health Care Privacy (Final Rule). This modifies the HIPAA Privacy Rule to enhance the privacy safeguards around protected health information (PHI) related to reproductive health care and serves to protect access to this care in the wake of the Supreme Court’s Dobbs v. Jackson Women’s Health Organization (Dobbs) decision. This decision, overturning the constitutional right to abortion, led to renewed efforts by many states to more heavily restrict and criminalize certain types of reproductive health care, particularly abortion ...
• The Stewardship of Hospitals
  
  May 16, 2024
  By: David Ostrowsky Hospitals, ambulatory surgery centers, long-term care facilities, primary care physician practices, nursing homes, hospice care. They are the most indispensable institutions of any functioning society, but unlike a Fortune 500 company or professional sports franchise, the identity of their respective owners often remains an afterthought. That is, unless you work for or are served by a financially distressed health care system, such as for example Steward Health Care, the massive private-for-profit healthcare conglomerate that recently filed for Chapter 11 bankruptcy protection. Steward’s sad demise, one of the most impactful health care stories this spring, serves as a cautionary ...
• The End of a (Brief) Era
  
  May 2, 2024
  By: David Ostrowsky It was a nice feel-good story of corporate America helping the commonfolk. Five years ago, Walmart, the multi-billion-dollar retail behemoth, opened its first-ever health clinic in Georgia. Soon, dozens more Walmart-sponsored clinics started opening their doors across not just Georgia, but also Arkansas, Florida, Illinois, Missouri, and Texas. Most of these pop-up clinics operated in rural communities where chronic diseases were rampant and (affordable) primary care options were scarce. Irrespective of the pandemic soon unfolding, they served their purpose: customers shopping for microwaveable dinners and bath supplies could stop by for a doctor’s appointment, get stitched up, ...
• IDR: The Confusion Never Ends!
  
  April 8, 2024
  By: Jon Jablon, Esq. It seems like every day that The Phia Group's consulting team is presented with an IDR-related issue brought up by either a provider in an appeal or simply a TPA trying to iron out or streamline its processes. Sometimes the question centers around the specifics of the IDR process, but sometimes the question instead focuses on the very concept of IDR itself and when it becomes applicable to begin with. By definition, the IDR process, as prescribed by the No Surprises Act, is intended specifically and only to choose between two competing offers. For IDR ...
• Reimbursing . . . Medicaid?
  
  April 3, 2024
  By: David Ostrowsky It is the most nightmarish version of a wolf at the door. Imagine that you have recently lost a loved one, are still in the midst of grieving, feeling sleep deprived, dealing with a bevy of uncomfortable logistical issues, and then told . . . that you may have to forfeit your house. Such a dire predicament befalls tens of thousands of Americans whose recently deceased relatives were Medicaid beneficiaries who received long-term care services (i.e., nursing home care or in-home healthcare) and never reimbursed their respective state of residence. (Although it should be noted that ...
• Lenmeldy: The World’s New Most Expensive Drug
  
  April 1, 2024
  By: Kendall Jackson, Esq. The U.S. Food and Drug Administration (FDA) stoked the fire that is the ever-present discussion surrounding gene therapy when it approved Lenmeldy on March 18, 2024. Lenmeldy is the first FDA- approved gene therapy to treat metachromatic leukodystrophy (MLD), a rare disease that affects the brains and nervous systems of children in their late infantile and early juvenile years. Lenmeldy is just one of several gene and cell therapies that, due to their high cost, lead plans to consider implementing plan exclusions for these therapies. While a self-funded plan has broad discretion as to what ...
• Wegovy: Not Just a Weight Loss Drug
  
  March 20, 2024
  By: David Ostrowsky As if there weren’t enough buzz surrounding Wegovy. Earlier this month, the wildly popular weight loss medication was approved in the US to help prevent life-jeopardizing cardiovascular events in people who are overweight, obese, and/or have a history of cardiovascular disease. The FDA’s stamp of approval for drugmaker Novo Nordisk to include cardiovascular benefits to Wegovy’s label meant it was the first weight loss drug to market itself in this manner. Now the million-dollar question (no pun, intended) becomes, will this label expansion make insurers feel more inclined to provide coverage? For good measure, will Medicare, currently ...
• The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Plans
  
  March 11, 2024
  By: Andrew Silverio, Esq. It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”  At stake were over 14 billion yearly transactions and this attack has seriously disrupted provider billing, interfering with patient care, and even preventing some providers from paying their employees. On top of that, a massive amount of patient information, protected under HIPAA, ...
• How the Recent Industry Cyberattack Impacts You
  
  March 7, 2024
  By: David Ostrowsky Late last month, an apparent massive cybersecurity incident involving the potential theft of patient data – this could entail personally identifiable information, sensitive health information, and financial information -- and encrypted company files seemingly paralyzed one of the nation’s largest pipelines for healthcare payments and prior authorization processing. Impacting a substantial percent of Americans’ medical claims (billions of claims totaling over a trillion dollars per year), millions have been affected. But perhaps the worst part is that many don’t even know it – and won’t be aware until they need to visit their physician or refill a ...
• Millions Saying Good-Bye to Medicaid
  
  February 22, 2024
  By: David Ostrowsky That millions of Americans have been losing Medicaid coverage over the past year may be unsurprising, but it doesn’t make it any less heartbreaking. Some historical context: Normally, Medicaid recipients who receive federally funded health insurance due to disabilities or low incomes undergo eligibility reviews every year to see if they are eligible for renewed coverage. But, of course, March 2020 was far from a normal time and the feds froze the checks due to it being a public health emergency. Subsequently, Medicaid recipients would retain their enrollment for the following three years . . . until ...
• Welcome to the Subrogation Sphere
  
  February 9, 2024
  By: Cindy Merrell, Esq. The Subrogation Sphere Is a Place Where Opponents Become Allies   Las Vegas does not have the only sphere that can provide an extraordinary experience for its participants. Let me introduce you to the subrogation sphere where participants may first appear to have conflicting interests but can become allies. When a health plan member is injured because of a third-party action it sets into motion a dance involving many players, potentially including the plan participant, at-fault party, medical providers, stop loss carrier, and the health plan. Each player is trying to determine which player is the ...
• Are Measles Making a Comeback?
  
  January 31, 2024
  By: David Ostrowsky When Dr. Michael Osterholm speaks, people listen – even if many do so begrudgingly. The ever-serious epidemiologist out of Minnesota, who forewarned of a global pandemic years ago and has garnered the not-so-flattering nickname “Bad News Mike,” has a new dire message about the recent measles outbreak, one to which children are most susceptible, that has started to trickle through pockets of Europe and, more recently, the US: “We're going to start seeing more and more of these outbreaks,” Osterholm told USA TODAY last month. “We're going to see more kids seriously ill, hospitalized and even die. And ...
• A New Year Brings New (Higher) Prescription Drug Prices
  
  January 18, 2024
  By: David Ostrowsky It must be January. W-2 forms are hitting the mail. Fitness centers are packed to the brim. The NFL playoffs are in full force. And, yes, pharmaceutical companies are hiking prices on their drugs. This time of year, when insurance plans turnover, Big Pharma unveils its list of new (aka elevated) prices for drugs, which, particularly concerning newly launched ones, sparks sticker shock for consumers. Certainly, January 2024 does not appear to be an exception to this unpleasant trend. On December 29 -- as many were making last-minute New Year’s Eve plans – the unsettling news dropped: ...
• Considerations Regarding the Exclusion of Gender-Affirming Care
  
  January 16, 2024
  By: Kendall Jackson, Esq. Gender-affirming care was a particularly popular topic throughout 2023. As we enter the new year, the prevalent discussion concerning plan coverage of such care will certainly continue. For self-funded health plans, the decision of whether to cover or exclude gender-affirming care is quite multilayered. Specifically for plans that exclude gender-affirming care within their plan documents, there are several potential discrimination concerns. An important element when evaluating these concerns is what law applies to the plan. For instance, certain state laws may not apply to a self-funded plan governed by the Employee Retirement Income Security Act ...
• Is the Department of Labor Offsetting a Major Problem?
  
  January 3, 2024
  By: David Ostrowsky As if Americans on employer-based health plans didn’t face enough obstacles in trying to obtain reasonably priced healthcare. The inconvenient truth is that many participants on ERISA self-funded health plans, ones who are often already paying high premiums and deductibles, have unknowingly fallen victim to the ethically questionable – although not technically outlawed -- practice of cross-plan offsetting over the years. In fact, only very recently, as in the past several months, has there been heightened awareness of the adverse effects of cross-plan offsetting on unsuspecting American plan participants. First, a quick primer on cross-plan offsetting: There ...
• Time’s Up! It’s Gag Clause Attestation Season
  
  December 26, 2023
  By: Andrew Silverio, Esq. As the year wraps up and plans and TPAs around the country are scrambling to handle renewals, another challenge looms large in 2023 – the first annual gag clause attestation.  As a reminder, the Consolidated Appropriations Act, 2021 (CAA) prohibits plans from entering into any contracts with providers and certain other entities that contain “gag clauses” – and requires them to attest annually that their contracts are free of them. The first attestation is due at the end of 2023, and it will cover the period of December 27, 2021 through December 31, 2023. The goal ...
• For Sickle Cell Disease Patients, Hope Has Arrived – but at What Cost?
  
  December 21, 2023
  By: Kelly E. Dempsey, Esq. For generations of sickle cell disease (SCD) patients, the suffering has been unbearable – with no end in sight. SCD, an inherited genetic red blood cell disorder that affects hemoglobin, the protein that carries oxygen throughout the body, torments nearly 100,000 Americans (20 million people worldwide), a disproportionate number of whom are African-American. Among other symptoms, SCD often triggers chronic bouts of excruciating pain that require regular hospitalization, organ failure, strokes, and shortened life expectancy. Meanwhile, the only known cure for the insidious disease has been a bone marrow transplant. Until last month, that is. ...
• Is Artificial Intelligence the New Frontier for Healthcare?
  
  December 12, 2023
  By: David Ostrowsky The ills of the American healthcare system, namely an undue administrative burden on healthcare providers and a labor supply not keeping pace with the demand for services, have been well documented. But now, as we grind through the 2020s, relief may be on the way with the booming popularity (or in some cases, acceptance) of artificial intelligence (AI). Many healthcare experts believe that AI – a mechanism grounded in the simulation of human intelligence by computerized systems and one that has already changed how many humans learn and work – could revolutionize the field. But as enticing ...
• MAHP 2023 Annual Health Care Conference: Health Care Affordability, Quality and Equity in a Post Pandemic World
  
  November 28, 2023
  By: David Ostrowsky A year later … and how (relatively) little has changed in the state of Massachusetts healthcare. Last November, the Massachusetts Association of Health Plans (MAHP) Annual Conference focused on healthcare challenges and opportunities – both from a regional and national perspective -- amidst a receding pandemic. The 2022 conference, headlined by then-Governor Charlie Baker, homed in on two topics: a.) healthcare equity and b.) regulation of provider prices. Twelve months later, on November 17, 2023, the MAHP 2023 Annual Conference, held once again at the Seaport Hotel in downtown Boston, had an eerily familiar theme: “Health ...
• Minor Members and Third Party Settlements
  
  November 27, 2023
  By: Cindy Merrell, Esq. Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? The answer is yes. However, there are various factors that can influence the Plan’s recovery in these circumstances. Federal courts across the country have recently considered a few challenges to a health plan’s right of recovery and clarified an ERISA plan’s right of recovery through reimbursement. What is abundantly clear is good plan language is vital to a health plan’s recovery. Who? What? When? Where? Any subrogation professional is aware that good plan language is important to a plan’s successful ...
• Being Mindful of Telemedicine Access
  
  November 9, 2023
  By Jen McCormick, Esq. and David Ostrowsky From a healthcare standpoint, two of the most significant byproducts of the COVID-19 pandemic have been the exploding popularity of Telemedicine, the practice of providing medical and mental health services remotely, and a heightened awareness of many Americans’ longstanding mental health issues. Due to a confluence of prolonged extenuating circumstances, it became readily apparent to healthcare providers, politicians, social workers, employers, teachers, and parents on both sides of the Mississippi that a.) the inimitable convenience of virtual healthcare does not compromise quality (at least for some patients and practitioners) and b.) many Americans ...
• Update on the Federal IDR Process
  
  October 27, 2023
  By: Kendall Jackson, Esq. Recently there has been significant discussion about the federal IDR process. The IDR process is an important tool of the No Surprises Act (“NSA”) as it resolves claims for payment for out-of-network items and services. It not only provides a procedure for settling disputed claims but is also an integral mechanism for supporting the NSA’s protection for plan members against potentially crippling expenses from balance billing for high-cost out-of-network claims. In Texas Medical Association v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK (TMA IV), the U.S. District Court for the Eastern District of ...
• Empowering the 2023 SIIA National Conference
  
  October 26, 2023
  By: David Ostrowsky Earlier this month, the self-insurance industry’s most prominent thought-leaders, innovative service providers, and esteemed subject matter experts convened at the 2023 Self-Insurance Institute of America (SIIA) National Conference at the JW Marriott Phoenix Desert Ridge Resort & Spa. The SIIA National Conference, which this year covered such pressing topics as artificial intelligence, surprise billing, emerging trends impacting the employer stop-loss market, and recent legislative and regulatory updates, is widely considered to be the self-insurance industry’s annual marquee event, bringing together hundreds of industry professionals including TPAs, vendors (there were over 950 booths representing industry vendors stationed in ...
• District Court Strikes a Blow to Copay Accumulator Programs
  
  October 11, 2023
  By: Andrew Silverio, Esq. Many of our clients are aware of, or even utilize, “copay accumulator” programs – these programs create plan savings by not counting amounts received by patients from manufacturer assistance programs toward annual deductibles and out-of-pocket maximums.  Some programs go a step further by actually increasing the applicable copayment for certain drugs to maximize the amount a patient may be eligible to receive from manufacturers.  The Trump Administration’s Notice of Benefit and Payment Parameters for 2021 (“NBPP”) facilitated these programs by explicitly permitting plans to not count manufacturer assistance amounts toward annual deductibles or out of pocket maximums.  ...
• Fall Is Here & So Are the Cold-Weather Germs – New CDC Recommendations
  
  September 26, 2023
  By: Kelly Dempsey, Esq. Fall is officially here as the fall equinox has passed and with fall comes the impending “flu season” which also brings a bunch of other germs – new strains of COVID-19 and a rise in RSV cases. If you have children who have headed back to school (even college kids), you’ve probably noticed an uptick in stuffy noses and tummy aches already. In anticipation of the upcoming turn in weather that brings an increase in viral illnesses, the Centers for Disease Control and Prevention (CDC) has been busy issuing new recommendations related to RSV – formally known ...
• Three Shots for Autumn
  
  September 18, 2023
  By: David Ostrowsky It’s a daunting Venn diagram – the interplay of three potentially fatal diseases: Respiratory Syncytial Virus (“RSV”), COVID-19, and influenza. And with summer slipping into fall, this triple-headed monster is (once again) threatening to rear its ugly head. But, thanks to modern medicine, could this cold-weather season have a less devastating toll on humanity than what transpired a year ago? As has been well publicized this past week, there is in fact reason for optimism as updated COVID-19 vaccines from Pfizer and Moderna targeting the devilish Omicron variant XBB.1.5 will soon hit the market. It’s a promising development ...
• The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiations
  
  August 30, 2023
  By: David Ostrowsky Traditionally, August is a slow news month. Congress is on recess; dignitaries have ensconced themselves in their summer homes; many reporters are on vacation. Invariably, the waning days of summer don’t appear conducive to delivering breaking news. Not this year, however. Indeed, August 2023 will go down as a momentous period of time in American history. A month that was dominated by headlines involving criminal charges brought against former President Donald Trump ended with a healthcare development that will surely impact an untold number of Americans for the foreseeable future. On August 29, President Biden unveiled the first ten ...
• Protecting the Most Vulnerable
  
  August 24, 2023
  By: Corey Crigger, Esq. In February 2022, we received a balance bill referral that was truly exceptional, but for all the wrong reasons. Our client received a staggering bill of over $675,000.00 after a premature delivery with major complications resulted in a two-month stay in the NICU. It was an unjust financial burden exacerbating an already challenging situation. Our Efforts to Help: We immediately sprang into action, aiming to halt collection efforts while devising a strategy to achieve desired results. While the provider was unwavering in their stance, our #PatientDefenseProgram Partner Firm came to our aid. After over a year ...
• Wegovy: The Heart of the Matter
  
  August 18, 2023
  By: David Ostrowsky Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment? On August 8, Novo Nordisk, the Danish pharmaceutical juggernaut, unveiled the intriguing results of a large-scale clinical study documenting the efficacy of its obesity drug called Wegovy: of ...
• The Power Dynamics of Gag Clauses
  
  August 14, 2023
  By: Jon Jablon, Esq. In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights ...
• Expanding Protections for Breastfeeding Mothers
  
  August 3, 2023
  By: Kendall Jackson So far this year, we have seen two notable advancements in protections for breastfeeding mothers in the workplace. The first of which includes the expansion of women’s preventive services under the Affordable Care Act (ACA). Based on new recommendations by the Health Resources and Services Administration (HRSA), breastfeeding mothers will no longer have to pay out-of-pocket costs for particular breast pumps and related supplies. The HRSA specifically noted that access to double electric breast pumps should be prioritized and should not be treated as a secondary step if manual pumps are unsuccessful. In addition to the ...
• Diapers & Wipes Reflection
  
  August 3, 2023
  By: Desireé Erskine My name is Desireé Erskine and I have been at The Phia Group for the past 17 years, the last 10 of which I have spent as an Overpayment Recovery Specialist in the Provider Relations Department. As my family and I look forward to celebrating our daughter Kinsley’s first birthday this Sunday, we have revisited some of our fond memories and challenges in our first year as a family of five. In doing so, we have discussed how helpful Phia’s “Diapers and Wipes” program has been to our family. The “Diapers and Wipes” program, per The Phia ...
• Benefest 2023: Talking Costs and Laws with Carriers
  
  July 31, 2023
  By: Jessie Boyle and David Ostrowsky By March, amidst the snowbanks contracting and days growing incrementally longer, conference season – at least for the healthcare industry -- is in full bloom. One of the marquee Massachusetts-based healthcare conferences, Benefest 2023, focused on “shaping the future of healthcare” in the commonwealth, was held earlier this summer at Worcester’s Polar Park -- during the peak of conference season. On June 15, the Massachusetts Chapter of the National Association of Benefits and Insurance Professionals (NABIP), which represents over 100,000 licensed health insurance agents, brokers, general agents, consultants, and benefit professionals and has over ...
• IDR Entities Still Struggling with Volume – Highlights from the Q4 2022 Report
  
  July 17, 2023
  By: Andrew Silverio IDR Entities Still Struggling with Volume – Highlights from the Q4 2022 Report Under the No Surprises Act (NSA), the Departments of Health and Human Services, Labor, and Treasury are required to post quarterly data on the Federal Independent Dispute Resolution (IDR) process.  In response to the federal court decision in Texas Medical Association, et al. v. United States Department of Health and Human Services, portions of the governing regulations were vacated, resulting in a February 10, 2023 order for IDR entities to cease issuing new payment determinations (see CMS payment disputes between providers and health plans).  This ...
• One Year Post-Dobbs Decision
  
  July 5, 2023
  By: Kelly Dempsey June 27, 2023 marked one year since the Supreme Court of the United States (SCOTUS) overturned the constitutional right to abortion in the case of Dobbs v. Jackson Women’s Health Organization. Over the last 12 months, half of the states have passed some type of abortion restriction or complete ban and many more are in the process of creating legislation. Some of these laws include the possibility for civil or criminal penalties against women who obtain abortions, doctors who perform abortions, or even individuals who, broadly, facilitate abortions. It may be a year old now, ...
• Merck vs. Biden
  
  June 23, 2023
  By: David Ostrowsky and Jessie Boyle The globally recognized, multi-billion-dollar pharmaceutical company Merck & Co. sued the U.S. government on June 6th in an effort to halt the Medicare drug price negotiation program contained in the Inflation Reduction Act. The drug negotiation program aims to form agreements with drugmakers to lower costs on their most expensive drugs, which will save billions of dollars for Americans, particularly those on Medicare, while sapping Big Pharma of billions in potential revenue. In the first attempt by a drugmaker to challenge the law, Merck is pushing to be declared exempt from the drug price ...
• What Happens When Auto and Health Insurance Collide?
  
  June 20, 2023
  By: Cindy Merrell, Esq.   I remember when I graduated college, I was in the early stages of adulthood and my parents told me that I needed to get my own car insurance. Beyond knowing that my monthly bills were going up, I had little understanding about car insurance other than it was required and it provided protection in the event of an accident. After over a decade of practicing, law I have found that most adults (not just recent college graduates) do not actually know or understand their own auto coverage. Even fewer adults know how auto insurance and ...
• A Weight Off My Chest
  
  June 6, 2023
  By: Ron E. Peck, Esq. Insurance is supposed to be something you purchase to protect yourself against unforeseen – but costly – losses.  You don’t “expect” to be involved in a motor-vehicle accident, but you purchase automobile insurance to protect yourself against the costs incurred in an accident.  You don’t expect your home to flood or burn down, but you purchase homeowner’s insurance to protect yourself against the costs incurred in such incidents.  Automobile insurance does not pay to fill your car’s gas tank or change the oil.  These are foreseen, planned costs of automobile ownership and maintenance.  Homeowner’s insurance ...
• Autism Benefits: DOL Enforcement for Sufficient Coverage
  
  May 22, 2023
  By: Kaitlyn Malkin, Esq. About 1 in 36 children in the United States has autism spectrum disorder, which is a lifelong condition that can affect a person’s behavior, communication, interactions, and ability to learn. The Department of Labor (DOL) continues strongly advocating for more comprehensive autism coverage under group health plans and Employee Benefits Security Administration (EBSA) has been working to ensure individuals who need treatment are able to access it. The Phia Group is also working hard to ensure plans are offering robust benefits while remaining compliant with mental health parity laws.   The main mechanism that EBSA is ...