CANTON, MA – January 9, 2025 – In its ongoing efforts to be a trailblazer in the healthcare cost containment field, The Phia Group has promoted John Blaney to Executive Vice President of Transformation and Recovery Services. In his new role, Mr. Blaney will spearhead all recovery functions, including subrogation, overpayment, and other cost containment opportunities. Mr. Blaney will leverage his decades of experience serving as an executive in the healthcare field toward streamlining operations as well as automating department-wide processes, all of which will help optimize services offered to Phia’s clients. The Phia Group’s successful growth initiatives and major investments in technology have enabled us to identify more recovery opportunities and deliver higher recoveries to our clients than any other recovery vendor in the market.
“In the short time that John has been at Phia, he has automated more processes and identified more opportunities for driving forward innovation than we previously had,” remarked Phia CEO Adam V. Russo. “He is a true partner in Phia’s mission to lower the overall cost of healthcare.”
“Whereas many companies claim to be making meaningful improvements to the healthcare system, Phia has been invested in this pursuit for 25 years and continues to do so with its innovative products and services,” said Blaney. “It is an honor to be a part of this great organization and to contribute to its continued growth and success.”
Before joining Phia in March 2024, John served as HealthComp’s Vice President Transformation and Automation. In reporting to the CEO of HealthComp, John was instrumental in driving forward process and automation enhancements. Prior to HealthComp, John served as the President of Strategy & Transformation for Equian, a post that eventually segued into Director of Payment Integrity when the company was rebranded as Optum.
A true visionary who found his niche developing claims processing software for healthcare, John was previously the president and founder of Advanced System Applications, Inc., a healthcare application software company, and Primax Recoveries, Inc., a healthcare subrogation and payment integrity company. In serving as the president of the latter company, John implemented transformative strategies that are still being utilized by some of the country’s most renowned recovery firms.
To learn more about The Phia Group and how it empowers plans, please contact Garrick Hunt by email at [email protected] or by phone at 781-535-5644.
About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.
By: David Ostrowsky
Was it a standard administrative cost or a true “phantom tax” allegedly stifling competition?
Back in November, Wesco, a 55-year-old privately-held gas station chain, and the benefits fund for the Utility Workers Union of America filed a class action lawsuit, alleging that Blue Cross Blue Shield of Michigan (BCBSM), an insurance carrier serving over six million Midwesterners, engaged in an anticompetitive practice by charging an additional PEPM (“per-employee, per-month”) fee to any group that opted to use a stop-loss carrier other than BCBS. For BCBS of Michigan, the fee represents a fairly standard industry practice for charging a plan extra if it opts to use a non-preferred stop-loss carrier; conversely, for the aforementioned plaintiffs, the constantly escalating PEPM fee represents a means for inflating costs for the already cash-strapped covered groups as well as driving smaller stop-loss carriers out of the market. Looking ahead, how this case plays out in federal court in Michigan will have a monumental impact on not just the stop-loss marketplace but also the self-funding industry in its entirety.
Though it is fairly common for Third Party Administrators (TPAs) to have contractual arrangements with preferred stop-loss carriers, the argument here, according to Wesco, is that the extra fee proved to be so prohibitively expensive that the company had no choice but to use BCBS of Michigan, already its TPA, as its stop-loss carrier. Subsequently, if smaller stop-loss carriers cannot compete – which would amount to a violation of the Sherman Antitrust Act as well as state antitrust laws – there is no limit to which BCBS could charge self-funded employers.
According to court filings, Michigan’s largest health insurer implemented the fee years ago “to serve as a deterrent and discourage BCBSM’s self-funded customers from buying stop-loss coverage from other carriers while simultaneously weakening its rivals competitively by effectively raising the prices of their stop-loss products.”
Consequently, the “effective prices of stop-loss insurance for self-funded accounts are significantly higher than they otherwise would be in Michigan,” according to the lawsuit that opines the fee is “substantively no different than a price-fixing scheme explicitly designed and employed to raise its rivals’ costs in violation of federal and state antitrust laws.”
In other words, the allegation here is that other stop-loss carriers that want to provide more reasonably priced coverage are going to be compelled to offer substantially better deals that hurt their bottom line in order to compensate for the added burden of BCBS’ fees.
But BCBS of Michigan may have a compelling counterargument – aside from buffing up their coffers amidst the ambiguous landscape of anti-trust laws. For self-funded groups, it is naturally easier to work with an entity with which they are familiar as there is less likelihood for administrative snafus to surface; after all, the TPA is the same entity as the stop-loss carrier. In more layperson terms, everyone is already on the same page.
On a grander scale, however, it is important to remember that the relationship involving a benefit plan, TPA, and stop-loss carrier transcends premiums and coffers from which claims can be paid. TPAs charge a fee when a non-preferred carrier is selected for multiple reasons. Indeed, there are more inherent inefficiencies and resources needed for engaging with a carrier with whom an existing process is not yet ironed out. TPAs and their preferred carriers have established processes and system-based tools that facilitate a more streamlined transmission of needed materials; their systems are literally built to integrate with each other. Meanwhile, other carriers would require the TPA to implement and utilize completely new processes outside their usual system.
Furthermore, it bears mentioning that stop-loss carriers that charge less are sometimes able to do so because the scope of their coverage is more limited, their policies contain more exclusions, and they may tend to delay or deny payments. Though the TPA’s only responsibility is to administer the plan in accordance with its terms and applicable law – irrespective of what stop-loss will or will not pay – TPAs, such as BCBS, are often blamed for a stop-loss carrier's failure to reimburse, and are accused of having made some administrative error by allowing the plan to pay claims that would not be reimbursed. Accordingly, TPAs may argue that they institute these fees to safeguard themselves – and their respective plans –from getting in a relationship with cut-rate carriers that will cost them more in the long run. At the very least, the fees arguably buffer the TPA against costs incurred when defending themselves against claims of negligence when a carrier may eventually refuse to reimburse the plan.
Though this case is still in its infancy at this time, new developments can quickly surface as the federal court is being asked to issue an injunction to hinder Blue Cross from assessing this fee.
By: Kelly Dempsey, Esq.
It’s not the news any of us wanted to hear, but 2025 has arrived with no extension to the telehealth services safe harbor for high deductible health plans that are HSA-qualified. As such, the safe harbor officially expires for plan years starting on or after January 1, 2025. There were numerous reports that an extension was included in early drafts of the bill to keep the government funded in December, but the bill passed and signed by President Biden on December 21, 2024, did not include this extension.
This safe harbor was originally created by the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) passed way back in 2020 and additional legislation enacted throughout 2022 extended the safe harbor for plan years starting before January 1, 2025.
Plan sponsors who have offered HDHPs in conjunction with HSAs will no longer be allowed to cover telehealth services before the deductible is met. Should a plan allow reimbursement for telehealth services prior to the deductible being met, the HDHP would not be HSA-qualified; consequently, participants could not contribute to an HSA for that plan year. Plans that violate IRS HSA-qualified HDHP rules can expose both the plan and plan participants to tax consequences.
What’s a plan to do now? Unfortunately, the answer is to update (via amendment or restatement) plan provisions. Plans will need to update their SPD/PDs accordingly at the first plan renewal beginning on or after January 1, 2025. HSA-qualified HDHPs will need to ensure that telehealth services under an HDHP apply to the deductible at the first plan year beginning after January 1, 2025, unless the service is for an ACA-mandated preventive benefit (i.e., a telehealth visit to obtain a prescription for a preventive service).
We know there is a lot of bipartisan support for making this a permanent rule, thus this issue may be taken up in the next Congress, but only time will tell.
On today’s episode of the Empowering Plans podcast series, attorneys Kendall Jackson and Brian O’Hara discuss the Biden administration’s decision to withdraw proposed rules that would have expanded the birth control benefits mandate. Join us in our discussion of the mandate and how it has evolved throughout the Obama, Trump, and Biden administrations. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
Earlier this month, as the healthcare industry was receiving an inordinate amount of unwanted public attention and scrutiny, there was actually a positive development stemming from one of the country’s largest health insurers. Indeed, lost in the shuffle amidst the chaotic aftermath of the murder of UnitedHealthcare CEO Brian Thompson was Anthem Blue Cross Blue Shield’s reversal of its initial decision to stop paying for anesthesia care in certain states if the surgery or procedure extends beyond a particular time limit. Had such a titan of the health insurance industry proceeded in not paying for medically necessary anesthesia services, tens of thousands of Americans – many of whom are of limited financial means -- would have been at risk of getting cut off from a life-saving service.
On November 1, Elevance Health, which recently rebranded from Anthem Blue Cross Blue Shield, issued a news release detailing its proposed billing guidelines changes for Connecticut, New York, and Missouri whereby starting this February, time limits pre-set by the insurer would have dictated the amount of anesthesia care to be covered. It also appears that a similar note had been issued to providers in Colorado, with a March start date.
More specifically, Anthem had said that beginning in February it would use metrics — known as Physician Work Time values — from the Centers for Medicare and Medicaid Services (CMS) to “target the number of minutes reported for anesthesia services.” Claims for anesthesia care stretching beyond that set number of minutes would be denied. In more layperson terms, if a patient’s procedure ran longer than anticipated, well, there would be a no-pun-intended rude awakening as they’d be left to foot the unexpected bill.
In fairness, Anthem declared it would exempt maternity-related care and patients under the age of 22 from this new rule and that providers could have recourse to dispute claims if they disagreed with a reimbursement decision. Meanwhile, there was a belief among some that Anthem’s intention was not to create an undue financial burden for patients but rather to hold providers accountable by standardizing anesthesiologists’ pay at a set rate.
“Anthem’s policy would not have increased costs for their enrollees,” opined Eric Levitz, a senior correspondent at Vox in a December 6 article. “Rather, it would have reduced payments for some of the most overpaid physicians in America. And when millionaire doctors beat back cost controls — as they have here — patients pay the price through higher premiums.
“Anesthesia services are billed partially on the basis of how long a procedure takes. This creates an incentive for anesthesiologists to err on the side of exaggerating how long their services were required during an operation. And a few studies have found that a small portion of anesthesiologists may engage in overbilling by overstating the length of a procedure, or the degree of risk a patient faces in undergoing anesthesia.”
But regardless of the actual motive, the optics were not favorable and the public backlash to Anthem’s announcement was, as expected, intense. In addition to the American Society of Anesthesiologists (ASA), many politicians articulated strong frustration over some commercial health insurers seeking to boost their profits at the expense of patients’ welfare – a sentiment that many Americans surely feel at this hour. New York governor Kathy Hochul was not shy about expressing her outrage at the proposal. Meanwhile, in Connecticut (where Anthem is the provider of the state employee health plan) multiple public officials lobbied the insurance carrier to alter its decision. While US Senator Chris Murphy called on Anthem to take swift action and reverse course, State Senator Jeff Gordon, a practicing oncologist and hematologist who knows full well that a surgery or procedure can face unforeseen challenges and take longer than originally planned for, sent a letter to Connecticut Anthem Blue Cross and Blue Shield urging them to follow suit, claiming “people's healthcare and lives depend on it.” Though it’s hard to fathom that a surgeon and anesthesiologist would ever contemplate truncating a surgery prematurely, the prospect of an unsuspecting patient being saddled with a mountain of medical debt – which is after all, the leading driver of homelessness in America -- is unnerving.
But now, thanks to Anthem doing an about-face, that situation is no longer an impending reality.
On this episode of the Empowering Plans podcast series, attorneys Corey Crigger and Cindy Merrell discuss the murder of UnitedHealthcare’s CEO, which fueled public outcry over denied claims. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
In this episode of the Empowering Plans podcast, attorneys Jon Jablon and Brady Bizarro delve into the details of a recent lawsuit where BCBS of Michigan, in its capacity as a TPA, is alleged to have engaged in anticompetitive practices for charging a fee to a group that chose a stop-loss carrier other than BCBS. This case is in its infancy as of December 2024, but we expect it to have noticeable effects on the stop-loss marketplace regardless of outcome. In this episode, Jon and Brady discuss those potential effects and how a holding either way could impact self-funding as a whole. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
Well before Hurricane Helene, one of the deadliest storms in modern American history, ripped through Western North Carolina earlier this autumn, decimating scores of residences and businesses and washing away entire neighborhoods, the largely impoverished Appalachian region was grappling with a precarious healthcare infrastructure. To this day, Asheville, North Carolina, and its surrounding mountainous communities have never fully recovered from the devastation of the Great Recession of 2008, resulting in a grave health disparity among other societal ills. And, yes, the recent ferocious tempest of which Western North Carolina bore the brunt has only exacerbated the region’s already fragile healthcare system.
In the immediate aftermath of Helene, thousands of residents whose cars were buried under their collapsed homes found themselves bereft of medication refills, IV fluid bags (there’s been a lot of publicity about this in particular), insulin supplies, and dialysis equipment among so many other life-saving resources. In addition to the scarcity of options for reliable transportation to medical appointments – or the inability to walk safely along public roads laced with downed trees and electrical wires – survivors have faced the heightened risk of exposure to sewage, toxic industrial waste, and mosquito-borne illnesses stemming from the raging, out-of-control floodwaters. Meanwhile, the blunt force of the storm’s impact has caused a bevy of short-term injuries that, because they have not received immediate medical attention, could mushroom into chronic, far more severe issues. This is to say nothing of the severe mental health problems many residents are surely experiencing in the wake of losing loved ones and having their lives uprooted. To put it another way, instead of shopping for holiday gifts in the coming weeks, many will be busy filing insurance claims.
As North Carolinians whose lives have been upended continue to endure such apocalyptic circumstances, nearby healthcare facilities (or those that are accessible) have faced their own mounting problems. While the physical infrastructure of nearly all community health centers in Western North Carolina remained unscathed, there has been a universal struggle for facilities to obtain clean potable water for sanitizing equipment, cleaning wounds, washing hands properly, or even making an adequate amount of coffee for providers to stay alert. For over a month now, it has been an endeavor of colossal proportions for Asheville’s Mission Hospital, the only designated trauma center in Western North Carolina, to obtain clean, usable water while other facilities − such as Asheville's Planned Parenthood clinic and local birthing centers – were relegated to slashing critical health services due to the lack of running water. By all accounts, the dearth of potable water has been the chief culprit behind the systemic woes bedeviling the region’s healthcare landscape. (It also bears mentioning that there were some North Carolina nursing homes still without an adequate supply of running water for several weeks after Hurricane Helene made landfall.)
In addition to clean water, another all-important resource in drastically short supply for such healthcare facilities is that of adequate manpower. For an area of the country that was already struggling mightily to recruit and retain medical staff, Helene dealt a devastating blow. Truthfully, many of the healthcare workers in Western North Carolina themselves were personally affected by Helene. Some tragically lost their lives while many others have struggled to help victims as they and their families have been experiencing unimaginable distress. Certainly, volunteer doctors, nurses, and psychologists have descended on the region to help hospital patients – as well as those who are housebound often without internet, reliable phone service, electricity, and running water – but a severe staffing shortage, one that may portend a wave of hospital closures, still looms large in the storm-ravaged region.
“How do we attract someone to come into the area at this moment?” Kim Wagenaar, the chief executive of Western North Carolina Community Health Services, which serves 13 counties in the region, shared with the New York Times in an October 28 piece. “It’s just going to take a long time to really mitigate the effects of this disaster.”
Though hurricane season may be winding down, we can’t lose sight of the legions of victims of Helene who want nothing more than adequate healthcare services this holiday season.
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 plans that, prior to the issuance of these rules, were able to opt out of MHPAEA compliance. The extension of MHPAEA’s application to self-funded non-Federal governmental health plans is beneficial to ensure that no plan may impose an NQTL with respect to mental health or substance use disorder (“MH/SUD”) benefits in any classification that is more restrictive, as written or in operation, than the predominant NQTL that applies to substantially all medical/surgical (“M/S”) benefits in the same classification. Of the newly outlined rules, most apply to group health plans on the first day of the first plan year beginning on or after January 1, 2025.
The final rules codify that health plans must perform a comparative analysis, which must include an evaluation of NQTLs for network composition, out-of-network reimbursement rates, medical management standards, and prior authorization, as well as six additional elements, such as a description of the NQTL, identification of and definitions for the factors and evidentiary standards used to design or apply the NQTL, and a description of how factors are used in the design or application of the NQTL. The final rules also outline certain responsibilities for plan fiduciaries. The final rules require certification confirming the plan fiduciary’s engagement in a prudent process to select one or more qualified service providers to perform and document a comparative analysis in connection with the imposition of any NQTLs that apply to MH/SUD benefits under the plan in accordance with MHPAEA and its implementing regulations, as well as satisfaction of the duty to monitor those service providers. At a minimum, the Department of Labor expects that the plan fiduciary will review the comparative analysis, ask questions about the results, discuss the results with those who drafted it, if necessary, and ensure that the service provider conducted the comparative analysis in compliance with MHPAEA.
Separate from those requirements listed above, the implementation of several other requirements is delayed until January 1, 2026. This includes the meaningful benefits standard, which requires that if a plan provides any benefits for an MH/SUD condition in any of the six benefit classifications, it must provide “meaningful benefits” for that condition or disorder in every classification in which meaningful M/S benefits are provided. Also delayed are the regulations requiring plans to satisfy the design and application requirements, which include the prohibition on discriminatory factors and evidentiary standards, and the relevant data evaluation requirements, which involve collecting and evaluating relevant data to assess the impact of NQTLs on access to MH/SUD benefits and M/S benefits. Any requirements for the provisions of the comparative analyses related to the delayed requirements are also deferred until January 1, 2026.
While several of these new requirements are not applicable for quite some time, plans that cover both M/S benefits and MH/SUD benefits and impose NQTLs on MH/SUD benefits should be sure to perform and document a comparative analysis of the design and application of each applicable NQTL in a manner consistent with the new final rules. The Departments have yet to provide how often these comparative analyses should be performed, but rather state that they should be kept current. We generally interpret this to mean that they should be performed annually based on the fact that the plan is updated annually.
On Friday, November 1, millions of Americans awoke from their Halloween slumber only to be further spooked by a New York Times report that employers expect the costs of health benefits to surge as much as 9 percent on average in 2025. How much will the outcome of this month’s elections – held during many companies’ open enrollment period -- impact this now decades-long industry trend? What does this all mean for plans interested in covering big-ticket items like weight loss drugs and next-generation gene therapies in the new year? As 2024 soon merges into 2025, join The Phia Group’s webinar as its panel of experts break down how election results will impact the industry and look ahead to what compliance changes are afoot in just over a month ahead. Indeed, this is a crucible moment for the healthcare industry – and Phia’s Independent Consultation & Evaluation (ICE) team looks forward to lending its expertise.
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To obtain a copy of our webinar slides, please reach out to [email protected].
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 of RBP Programs and NSA Requirements
RBP programs use reference points such as Medicare rates to create more predictable and transparent pricing. While this can reduce healthcare costs and broaden provider options, it also exposes plan participants to potential balance billing when providers reject the RBP payment as full settlement and bill the patient for the remaining balance. This creates financial stress for both patients and employers.
The introduction of the NSA further shifts the focus of payment disputes from patients to employers. Open Negotiations and IDR processes require a deep understanding of regulations, adherence to strict timelines, and awareness of critical benchmarks necessary to successfully argue, negotiate, and defend cases. TPAs and self-funded employers must navigate these processes carefully to mitigate risk and manage potential exposure.
How Comprehensive RBP Solutions and NSA Expertise Mitigate Risks
1. Effective Balance Bill Resolution
Choosing an RBP solution that offers strong balance bill resolution is critical. Programs that include direct intervention and independent legal support can prevent unexpected financial burdens on employees and reduce the administrative load on employers and TPAs. Care Empowered Pricing, for instance, includes this type of support, leveraging years of experience in resolving balance billing issues effectively and adapting to the evolving regulatory landscape under the NSA.
2. Expertise in NSA Open Negotiations and IDR
Handling Open Negotiations and IDR requires more than basic dispute resolution skills. Employers need an informed and experienced team that understands the regulations, adheres to strict timelines, and recognizes the important benchmarks necessary to advocate successfully. Solutions that provide this level of expertise ensure that employers are prepared to navigate these complex processes and defend their positions effectively, minimizing exposure and ensuring compliance.
3. Empowered Provider Selection
The use of advanced provider data and selection tools can greatly enhance the success of an RBP program. By using technology-enabled repricing engines, TPAs can glean insights into provider practices and payment acceptance, thereby steering employees toward providers more likely to accept reference-based payments without triggering balance bills. This also helps reduce the frequency of disputes requiring NSA Open Negotiations or IDR processes.
4. Member Education and Support
Educating employees about how their RBP plan functions and how to identify compliant providers is essential. Solutions that offer real-time support and guidance ensure that members are confident and well-prepared when navigating healthcare services. Additionally, having a well-informed and experienced team capable of reacting swiftly, reaching out, and using technology based on practical experience to track and resolve cases is vital. Care Empowered Pricing emphasizes member education and continuous access to resources in order to bolster awareness of the NSA processes.
Best Practices for Preventing and Resolving Balance Bills and Navigating NSA Processes
Preventing and addressing balance billing and post-payment disputes is essential for the success of any RBP program. Key practices include:
Why Enhanced RBP and NSA Solutions Matter
For TPAs and self-funded employers, selecting an RBP solution that encompasses customizable pricing, experienced advocacy, and continuous member support—while also incorporating expertise in NSA regulations and dispute resolution—is essential. Solutions like Care Empowered Pricing deliver comprehensive approaches, ensuring that participants are informed, supported, and protected from balance billing challenges and that employers are well-equipped to handle post-payment disputes. This creates a more sustainable, efficient, and fair approach to healthcare pricing and compliance that benefits all stakeholders.
By integrating these strategies into their RBP programs, TPAs and employers can enhance participant experiences, reduce financial risks, and build a healthcare framework centered on transparency, fairness, and robust regulatory compliance.
On this episode of the Empowering Plans Podcast, attorneys Ron Peck and Nick Bonds talk through a recent Florida case addressing judicial review of IDR determinations and highlight some of the key insights and takeaways for any entity subject to the No Surprises Act. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
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 as much for services as CMS rates. Ultimately, the confluence of these troubling dynamics threatens to undermine the original intent of the NSA and elevate costs for all.
In fact, in the most recent edition of JAMA Internal Medicine, a prominent monthly peer-reviewed medical journal published by the American Medical Association, authors Kevin A. Schulman, MD and Barak Richman, JD, PhD, provided indisputable evidence that prices stemming from IDR decisions closely align with what providers – many of whom belong to private equity-backed practices -- have requested, vastly exceeding Medicare rates and prior in-network commercial market prices. As just one example, Schulman and Richman report median IDR decisions (from Q1 and Q2 2023) for three categories of services – emergency care, imaging, and neonatal/pediatric critical care – that surpass Medicare prices by a factor of 3.7 or more for all three service types. Clearly, the NSA has not curtailed exploitive business practices and at this time, there still aren’t any implementing rules in force, as arbitrators continue to operate with minimal substantive guidance in trying to resolve price disputes.
Subsequently, now, more than ever, it is of paramount importance to understand how such developments will impact your self-funded health plan. Handling NSA claims is, after all, still a relatively new process, one largely bereft of transparency, and many plans are understandably struggling to manage open negotiations and subsequent IDR procedures. In this regard, The Phia Group, with its battle-tested processes for deftly handling NSA claims and appeals and utilization of intelligent out-of-network pricing methodologies, benchmarking and cutting-edge appeal review software, can provide immeasurable value.
“Unlike the rest of the organizations in this industry that provide NSA services, our reputation was built on ensuring that all regulatory, compliance and plan design needs are focused on first,” explains Phia CEO Adam V. Russo. “This includes understanding the processes and tools that administrators have in dealing with the vastly different deadline and notification aspects of the NSA. We know it, we built our software around it and our extensive team of experts ensures that we meet every set of standards needed for a successful NSA program, including coordination of stop loss carriers.
“There is no other firm with repricing capabilities that can match our reputation and outcomes when it comes to navigating the legal complexities that this service requires.”
Some of the core reasons why Phia’s IDR support service achieves optimal results:
“With a powerhouse team of seasoned attorneys, certified medical coders, data-savvy analysts, and skilled negotiators, Phia is uniquely equipped to handle straightforward NSA claims with precision and seamlessly scale to expert-level solutions for the most complex cases,” added Scott Bennett, Phia’s Senior Vice President of Provider Relations.
Undeniably, the IDR process continues to be riddled with significant ambiguity and opacity but The Phia Group, for the aforementioned reasons along with many others, has the resources to help you navigate the chaos.
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 without a prescription. Currently, health insurers are mandated to cover only the cost of prescribed contraception; should the new rule become law next year, over 50 million more American women on private health insurance plans would be able to go to their local drugstores and pharmacies and purchase these items, irrespective of whether or not they were prescribed. Accordingly, private health plans would also be required to disclose to women that those contraceptives are covered without cost-sharing.
Taking a deeper dive into the proposed rule, it’s apparent that there’s more than just the matter of whether or not a pill is prescribed. Under the Biden administration’s plan, insurers would have to cover all FDA-approved drugs and drug-led combination products, unless the plans also cover a therapeutic equivalent. Therapeutic equivalents, per the FDA, are drugs that have an identical amount of the same active ingredient. At this hour, insurers only need to cover one drug per category of contraception — which could be birth control pills, implants or IUDs — causing some women to have difficulty accessing the precise combination of drugs in the type of prescription contraceptive they so desire.
Practically speaking, the Biden administration’s proposal could have life-changing consequences for large swaths of the female population in this country. The emergency contraceptives that women on private insurance plans would be able to access without cost – and prescription – most notably include levonorgestrel, more commonly known by the brand name “Plan B,” which is a pill that must be taken immediately after intercourse to prevent pregnancy. As it currently stands, when women don’t have a doctor’s prescription, they may pay as much as $50 for a pack of the pills. Thus, women who may feel inclined to delay purchasing the medication until they get a doctor’s prescription could be compromising the efficacy of the pill – perhaps without even being aware. Moreover, if this new rule is in fact implemented, insurers would have to assume the full cost of Opill, a new OTC birth control pill that the FDA approved last year. A one-month supply of Opill costs $20, perhaps not an extravagant price but nonetheless one that may be prohibitively expensive for some.
Vice President Kamala Harris, who has affixed her presidential campaign to a pledge to embolden women’s healthcare rights, trumpeted her administration’s proposal, declaring in an official statement:
“Every woman in every state must have reproductive freedom and access to the health care they need. That is why I have fought to lower health care costs and protect the ability of every woman to make her own decisions about her own body."
“Today, our Administration is proposing the largest expansion of contraception coverage in more than a decade. This new proposed rule will build on our Administration’s work to protect reproductive freedom by providing millions of women with more options for the affordable contraception they need and deserve.”
Since the passage of the Affordable Care Act, women have saved billions of dollars that they would otherwise have spent on contraception. But now, for the first time in the history of the United States there is strong potential for universal coverage for no-cost, over-the-counter, no-prescription-necessary contraception, which would save even more billions.
Join Attorneys Corey Crigger and Kendall Jackson on this Halloween edition of the Empowering Plans Podcast. Corey and Kendall take a look at topics that send shivers down the spine of the self-funded industry. How do you protect your plan from the scary cost of gene therapies? What will the rapidly advancing AI sector mean for you and your clients? What is the best trick or treat candy? Tune in to find the answers to these questions and many more on the Empowering Plans Podcast. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)