LOUISVILLE – May 23, 2024 -- The Phia Group LLC is very proud to announce that it was recently named one of the 50 “Best Places to Work in Greater Louisville” by Louisville Business First. The Phia Group was one of the 50 honorees in the 2024 Best Places to Work program based strictly on employee survey results. Earning this distinction reflects a company’s unwavering commitment to fostering an inclusive and overall exceptional workplace environment. This marks the fourth consecutive year in which The Phia Group has received this prestigious honor. The Louisville Business First Best Places to Work program is managed by Quantum Workplace, an Omaha-based company that surveys employees about their companies’ internal policies, adherence to companywide goals, and management styles among other factors. Businesses across a wide swath of industries, including healthcare, technology, and financial services, as well as non-profit organizations, with a minimum of 10 full-time or part-time permanent employees (excluding owners or partners) that have an office in the Greater Louisville area region (Jefferson, Bullitt, Oldham, Shelby counties in Kentucky and Floyd, Clark and Harrison counties in Indiana), were invited to participate. In the August 2, 2024, edition of Louisville Business First, there will be further information about the award winners as well as numerical rankings for each category. For more information about The Phia Group and its commitment to care and plan empowerment, please contact Garrick Hunt at [email protected] or 781-535-5644. About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, is a leading provider of health care cost containment solutions. With offices across the United States, The Phia Group offers comprehensive claims recovery, plan document, and consulting services designed to contain health care costs and protect plan assets. By delivering industry-leading consultation and cost containment solutions, The Phia Group empowers plans to achieve their goals. Learn more at phiagroup.com. About Louisville Business First: Louisville Business First serves as the preeminent source of local business news for the Louisville, Kentucky, region. In addition to featuring business news items pertaining to the Louisville community, the publication also provides tools to help local businesses develop, network, and hire.
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 services. Specifically, the Final Rule does the following:
The main goal here is to protect access to reproductive healthcare by shielding this information from requesters who would be using it to conduct criminal, civil, or administrative investigations into a person for the act of receiving or providing reproductive health care or to impose penalties for doing so. Covered entities must now secure an attestation that a requester of such information is not seeking it for one of these impermissible purposes. Covered entities will also have to revise their notices of privacy practices (NPP) to explain this new prohibition and attestation requirement and provide an example of each. The Final Rule itself is effective June 25, 2024, which means plans must comply with the majority of its requirements within 180 days of that date. The exception is the updated notice of privacy practices (NPP) requirements, which must be complied with by February 16, 2026. The departments are releasing a model attestation but have not noted whether they will release an updated model Notice of Privacy Practices. However, we would expect they will do so prior to the effective date of the new NPP requirements. Otherwise, the materials provided by HHS and CMS online will be non-compliant, a situation we would not expect the Departments to allow to persist for long. In general, we do expect that self-funded plan sponsors will rely on their TPAs for compliance with all of these requirements, as they currently do with preparing NPPs and compliant Business Associate Agreements.
In this installment of The Phia Group’s Empowering Plans podcast series, attorneys Jon Jablon and Cindy Merrell discuss a health plan that lost its ERISA protections because of a pre-cert snafu. Specifically, the provider was quoted benefits at U&C, but that’s not quite what the SPD said – so the court called it a promise outside the SPD, and the security blanket of federal law flew right out the window! Tune in for the full details, and advice on how to not let this happen to you!
Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
During the COVID 19 pandemic, experts anticipated that we would see a surge in undiagnosed cancers. That prediction proved to be accurate. Driven by this ongoing issue, on March 8 the Biden Administration announced updates to its “Cancer Moonshot.” Combining efforts to address navigation, research, treatment, costs and coverage – for health benefit plans, this new focus on cancer represents both an opportunity and risk. Cancer and oncology claims have always been one of the most expensive items health plans encounter. Only those who are aware of ongoing developments and plan ahead will minimize risks and maximize beneficial outcomes. Join The Phia Group as they delve into this and other new regulatory and legal developments, including the aforementioned “Moonshot,” the effect of the Dobbs decision on cancer care, specialty drugs, high cost threats – both present and forthcoming, and a very important personal message from Ron Peck.
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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 tale about the potential issues stemming from private equity firms (otherwise known as “PE firms”) establishing a prominent foothold in the healthcare space. While this trend has cooled of late due to the current high interest rate environment and pervasive staffing shortages, the pre-COVID numbers are undeniable: per the Institute for New Economic Thinking, private equity investment in health care skyrocketed twenty-fold from 2000 (less than $5 billion per year) to 2018 ($100 billion per year). During that time span, private equity firms closed approximately 7,300 healthcare-related deals, amounting to $833 billion.
One of the core elements of this high-debt, for-profit financial model of hospital ownership in which PE firms primarily use debt to finance acquisitions is that significant cost-cutting measures ensue whereby some of the longest-tenured, most capable (in other words, most highly compensated) employees see their jobs vanish. Not coincidentally, patients receive lower quality care (not to mention, often higher costs) and underserved populations face even greater barriers to accessing adequate services. Just this past December, researchers at Harvard Medical School revealed results from a study that indicated patients are more prone to fall, get new infections, or experience other forms of harm during their stay in a hospital after it is acquired by a private equity firm.
Unfortunately, the honest to God truth is that this problem isn’t going away. Certainly not anytime soon. Purely from a dollars-and-cents perspective, it is in the best interest of PE firms to cut costs quickly after acquiring a hospital or healthcare system because they make the majority of their profits when they sell and often look to do so several years after the acquisition. With their acute short-term focus, PE firms can rake in substantial profits even when their target healthcare organization goes belly up. For a recent example, one needs look no further than the above-mentioned Steward case: from 2010-2020, as the health care system was drowning in debt, Cerberus Capital Management, the New York-based private equity firm that owned Steward at the time, made nearly $800 million off its investment.
How Steward Health Care System fares in bankruptcy court remains to be seen, but the larger, systemic issue, that being the impact of PE-owned health care facilities on patient welfare, warrants a closer look. Naturally, when staffing levels and adherence to patient safety protocols start to wane, trouble looms. But ultimately, from a macro perspective, there are seemingly two irreconcilable dynamics coming into play with the financialization of healthcare: the PE firms’ incentive to rapidly extract a profit and the health care industry’s vested interest in taking care of patients and keeping them healthy.
Tragically, society’s most vulnerable members are so often caught in the middle.
In this concluding episode of our special two-part series on the Empowering Plans Podcast, Adam Russo and Corey Crigger return to unpack more significant developments in the self-funded space. This episode focuses on Walmart’s surprising withdrawal from the healthcare arena—a sector it heavily invested in just a year ago. Listen as they analyze the impact of this move on rural markets and what it signifies for the industry's future. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
Join us for a captivating two-part episode of the Empowering Plans Podcast. Adam Russo, CEO and Founder of The Phia Group, is back alongside Corey Crigger to delve into the exhilarating 150th Kentucky Derby and share why Corey’s insights are indispensable. This episode also addresses pressing concerns in the self-funded sector that are crucial for our clients. Packed with valuable information, we had to split the discussion into two parts! Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
The Empowering Plans podcast gets a southern infusion in this very Kentucky-centric podcast! Cindy Merrell and Corey Crigger get together to discuss the 150th running of the Kentucky Derby. Before you hear about all things Derby, Cindy and Corey review two impactful Supreme Court cases that were argued in the last session and discuss the implications of presidential immunity as well as the role EMTALA can play in state regulations. No other podcast in the country will break down SCOTUS cases and Derby winners like the Empowering Plans Podcast! Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
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, take a flu test, or even get X-rays done, all for a very reasonable fee. As many of these shoppers/patients either lacked health insurance or had high deductible plans with imposing out-of-pocket costs, these clinics represented their only viable option for obtaining any semblance of proper healthcare. Surely, some had not been to a doctor of any type for years.
Now, the not-so-good news that recently dropped: last month, the Bentonville, Arkansas-based retailer announced that it will soon cease operations in all 51 of its healthcare centers as well as cut off virtual healthcare services. In a company-released statement, Walmart noted that this was a “difficult decision,” but its healthcare push was not profitable for the company because of the “challenging reimbursement environment and escalating operating costs.”
Walmart remains the country’s most profitable retail corporation – its stock price is hovering around an all-time high – yet because this healthcare endeavor was not deemed financially viable, thousands of low-income Americans who have benefited from affordable and convenient primary and urgent care – not to mention dental work as well – are now left in the dark. (It should be noted that Walmart plans to continue operating 4,600 pharmacies and over 3,000 optical centers nationwide.) Walmart has not yet provided specific dates for when its health centers will shutter but said that it will divulge that information when it’s available. However, two people familiar with the situation who were interviewed (anonymously) by CNBC, said that the clinics will close over the next 45 to 90 days. Either way, it seems safe to say that the masses of underserved Americans who have reaped the benefits of Walmart clinics now need to scramble to find another option or go without healthcare.
This development is in equal parts discouraging and surprising. It was just over a year ago, in March 2023, that Walmart revealed its plans to incorporate over two dozen health centers into its superstores located in Dallas, Houston, Phoenix, and Kansas City among other locales. But, on the other hand, perhaps it’s not so shocking, considering the dire state of the healthcare industry, specifically the dearth of primary care providers in America, which, according to the Association of American Medical Colleges, could exceed 55,000 in the next decade. Also, in fairness, it was a tall order for a corporation selling retail products like shampoo and oatmeal to have the expertise and managerial resources to pivot to a vastly different line of work. But, for a while anyways, it all seemed to work.
While Walmart made a commendable effort in leveraging its massive financial scale and brick-and-mortar presence to provide convenient, reasonably priced healthcare services to patients in rural outposts, ultimately the multi-trillion-dollar American healthcare system, one rife with systemic inefficiencies and complications, proved immune to undergoing radical change.
Attorneys Brady Bizarro and Andrew Silverio discuss the pending case of Lewandowski v. Johnson & Johnson, a lawsuit brought against plan fiduciaries for violating their fiduciary duties under ERISA. How did they violate those duties? By failing to negotiate drug prices and sufficiently oversee their PBM or investigate alternatives. No matter who wins, this case highlights the importance of ERISA’s fiduciary duties and the gravity of the decisions fiduciaries are (or should be) making.
On Dec. 27, 2020, the No Surprises Act (NSA) was signed into law, with an eye towards protecting patients against so-called “surprise” balance bills. The law leaned heavily on “good faith” negotiations between payers and providers, as well as “objective” decision making via independent dispute resolution. Three years later, The Brookings Institution reported that you are paying nearly four-times what Medicare pays (an average of 390%) and are spending at least 50% MORE than an average PPO network. The bottom line? Providers are winning and you are paying MORE now than you did before the NSA’s passage.
The Phia Group can help you formalize a process that ensures timely triaging of disputes, insert an objective third party for correspondence with providers and IDR, utilize intelligent out-of-network pricing methodologies, implement multifaceted benchmarking for objective yet aggressive defense, and utilize a tiered program to ensure continuous advocacy on behalf of your plan. Want to join the winning team?
Canton, MA – April 24, 2024 – The Phia Group’s CEO, Adam V. Russo, was presented with the Be A Beacon Award at the Free Market Medical Association (FMMA) Annual Conference in recognition of his outstanding leadership and achievements in transforming healthcare.
The award represents those who have gone above and beyond in their support and promotion of the free market movement with award recipients chosen by the FMMA Founders. FMMA said of this year’s recipients, “We are grateful for your leadership and vision, and this award is a well-deserved recognition of your invaluable contributions!”
Adam Russo commented, “I was proud and honored to receive the Be A Beacon award this year, especially from an organization that has so many innovative leaders. This award is a reflection of The Phia Group's continual innovation and commitment to excellence in every aspect of our organization.”
For more information about The Phia Group and its commitment to care and plan empowerment, please contact Garrick Hunt at [email protected] or 781-535-5644.
About The Phia Group: The Phia Group, LLC, headquartered in Canton, Massachusetts, is a leading provider of health care cost containment solutions. With offices across the United States, The Phia Group offers comprehensive claims recovery, plan document, and consulting services designed to contain health care costs and protect plan assets. By delivering industry-leading consultation and cost containment solutions, The Phia Group empowers plans to achieve their goals. Learn more at phiagroup.com.
About Free Market Medical Association: Free Market Medical Association headquartered in Oklahoma City, OK is a free market movement in healthcare promoting transparency. Founded in 2014 by Jay Kempton and Dr. Keith Smith, their goal is to bring together buyers and sellers of healthcare goods and services – reducing costs and increasing quality. For more information visit fmma.org.
Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo:
It's conference season yet again, and like Johnny Cash, I’ve been everywhere – Arizona, California, Florida, Oklahoma City, the Caribbean, and every place in-between … and in all places, I am spreading the message to the masses. Your message, my message, Phia’s message. A message of optimism and hope. A belief that together we can improve the quality of healthcare, reduce the costs we pay for it, improve access, and put the “benefit” back in “benefit plan.” I am honored to be educating brokers and employers on better ways to fund their health plans, and am witnessing a new level of interest from those entities unlike any I’ve seen before.
I am explaining to technologists and software developers the various compliance rules and regs, and all the other “tough stuff” that we must deal with every day in the self funded industry. The audience has grown – in size and composition. It is a great time to be on the road! Yet, I see those familiar faces in the crowd as well. I love getting to see old friends and meet new ones, but it’s not all positive. The horrible part of hitting the road is saying goodbye each week to my family. You know the feeling… but I know the cause is worth it. I humble myself, knowing that it could be a lot worse. I could be in the military overseas, fighting for our freedom, not seeing my family for months or even years. I could be any one of our plan participants, in-patient at a hospital for weeks or months… missing my family just as much, but gazing at my own mortality instead of your shining faces. Yeah – I think about those who have got it worse, and it gives me the jolt I need to work even harder, on their behalf.
As you know, at The Phia Group our mission is to ensure that every American has access to high-quality, low cost care. It's a tough battle, but I know we are winning. The tools we have rolled out, and those that we are developing now, will make the difference. Whether it's our Ignite software, our A/I powered compliance and appeals software, or the vast algorithms we have created to identify recovery trends and ways for you to lower your costs, the best will keep getting better. Yet, the challenges aren’t getting any simpler either. There is no better example right now than what is happening with the No Surprises Act (“NSA”). I urge all of you to read the article provided here, about the Brookings Institute findings. Let this one example show you just how much you and your plans are overpaying for these out-of-network facilities. We know that with the right processes, the right education, and the right compliance team, you can cut those NSA expenses by almost 50%. You owe it to your clients to take a look at your current process… and we can help.
Additionally, on a personal note, this May will mark 11 years since one of my best friends was killed by cancer. Robert "Staga" Pokorski was not only like a brother to me, he was also a loving husband and father to two beautiful young children. Then, a few years later, I lost my father-in-law to cancer. Jack Sheehan was a legend, and so many of my stories feature this larger-than-life character. I know I am not alone. For too many of us, it’s not a matter of “if” but “when” cancer will impact you or someone you love. Only by investing in research can we reduce the chances that cancer will win. At the same time, more effective, efficient diagnoses and treatments reduce the cost we pay to fight cancer. It’s a win-win. Join me as I fight alongside my friend and Phia Group CLO – Ron E. Peck – in our fundraising effort, on behalf of the renowned Leukemia and Lymphoma Society (“LLS”). Take a minute to click this link, for supporting the fund or use the QR code below, and donate. Every dollar counts, and every donor has my eternal gratitude. I don’t want to lose another person I love to cancer, and I don’t want you to lose someone you love either.
Thank you for believing in The Phia Group and happy reading.
Service Focuses of the Quarter Phia Fit to Print From the Blogosphere Webinars Podcasts The Phia Group’s 2024 Charity Employee of the Quarter Phia News
Service Focus of the Quarter: No Surprises Act & IDR Support
As you probably know, the No Surprises Act has created what seems like a never-ending set of hoops for health plans to jump through. In the course of providing our Phia Unwrapped and Independent Dispute Resolution (IDR) support services, we have discovered that not only are there more and more hoops all the time, but that the hoops actually seem to be getting smaller and smaller.
According to a recent Brookings study (https://www.brookings.edu/articles/a-first-look-at-outcomes-under-the-no-surprises-act-arbitration-process), the mean IDR decision is actually 50% higher than the mean in-network commercial payer’s cost, coming in around 370% of Medicare (including an average of 401% of Medicare for emergency claims and a whopping 511% of Medicare for neonatal/pediatric care). Somewhat ironically, that pricing is far higher than what CMS seems to have expected, and is actually closer to historical non-network prices, likely frustrating the very purpose of the IDR process in many cases. Though the NSA was created specifically to increase the burden on health plans, we’re not confident that the regulators intended the added burden to be quite this large.
In response, Phia’s services have evolved as well, with an increased focus on a multi-benchmark system to develop settlement offers that are reasonable not only to providers, but (far more importantly, in our view) for health plans as well. Our relationships are becoming deeper and our cadence is quickening, leading to increased efficiency and unprecedented settlement leverage. In our experience, quick response times and bona fide settlement efforts prior to IDR will almost always be more favorable to a health plan, which is where Phia really shines. The benefit of accessing Phia’s NSA-related services is attaining favorable settlements with a focus on avoiding IDR whenever possible, since IDR is unpredictable and more often than not lands in favor of higher payments. Even if a claim progresses to IDR, however, Phia has an arsenal of data and logic to promote more favorable outcomes.
To learn more, contact [email protected].
Enhancement of the Quarter: NQTL Report Cards
Users of Phia’s Independent Consultation and Evaluation (ICE) service will now have access to a benefit specifically geared toward the federal Mental Health Parity law! For groups that aren’t sure what MHP is all about, or that are hesitant to do a full non-quantitative treatment limitations (NQTL) analysis until the Department of Labor gives more guidance, or who want to know how their plan language stacks up compliance-wise, our team of experts can now provide a “report card” of parity-related information from a given SPD.
Whether it is a group’s finalized plan document or a template, our team will review the provisions and provide a high-level summary of MHP-related compliance issues. This is included within the ICE service, so your groups can rest assured knowing that we’ve got their backs.
Federal law still requires health plans to generate full NQTL comparative analyses, but this is a way to find out where the health plan is bleeding, and bandage up the wounds, as soon as possible.
Phia Case Study: The Unusually Narrow Hazardous Activities Exclusion
A TPA recently presented Phia’s consulting team with a stop-loss denial and asked if we could help opine on the merits of the denial. Specifically, the claim involved a bull-riding accident; the health plan excluded hazardous activities, but only in connection with professional or semi-professional sporting activities, which – the plan determined – did not apply here; and so, the plan paid this claim. The claims exceeded the plan’s specific deductible, and thus were submitted to stop-loss for reimbursement. The carrier subsequently denied the claim for reimbursement, citing the SPD’s hazardous activities exclusion, though it’s not clear whether the carrier misinterpreted the exclusion or simply saw the word “hazardous” and decided that it applied.
Phia analyzed the claim and language and provided a thorough written analysis, concluding that not only did the plan’s hazardous activities exclusion not apply here, since this had nothing to do with semi-professional or professional sporting activities, but the No Surprises Act in fact wouldn’t even allow this exclusion to be used in this case since it is a “general plan exclusion” that has been rendered inapplicable to emergency claims pursuant to federal guidance.
Since the stop-loss policy did not contain its own hazardous activities exclusion but rather the carrier relied on the plan’s exclusion, and since the plan did not need to exercise any discretion to allow this claim, Phia’s review also concluded that the carrier’s denial did not appear to be substantiated by any limitation found within the policy.
The TPA went back to the carrier, armed with Phia’s review, and we were thrilled when three weeks later the TPA updated us to let us know that the carrier reversed its denial and paid the claim.
Fiduciary Burden of the Quarter: Considering All the Evidence
As you probably know, the law allows health plans a great deal of discretion in interpreting facts and plan document provisions and administering benefits based on those interpretations. But what happens when the facts underlying a claim aren’t clear, or when there is conflicting information in the record?
With some exceptions, judicial review of benefit determinations will defer to the plan administrator’s interpretations of facts and the SPD unless they are deemed “arbitrary and capricious”. To illustrate that and differentiate between the two terms, picture flipping a coin. An example of a decision that is arbitrary would be flipping the coin, and making the decision based on however the coin landed. In contrast, a decision that is capricious would be flipping the coin, checking the result, and then deciding on a whim that you want to choose the other one instead. Benefit interpretations are rarely that simple, of course, but it’s important to realize that while arbitrariness involves a degree of randomness, capriciousness involves applying inconsistent logic rather than choosing randomly – and it’s not always so obvious when a decision rises to the level of capriciousness.
A great example that happens somewhat often is when a health plan receives conflicting information regarding, say, the medical necessity of a given claim. If a plan is in receipt of two conflicting medical reviews – one confirming medical necessity and the other denying it – courts in many jurisdictions would consider it capricious for the plan to simply choose the review most favorable to itself, unless the plan can articulate a reasoned basis for valuing one medical opinion over the other. In many cases, seeking a neutral third opinion to resolve the discrepancy can be a prudent strategy to sidestep that capriciousness – but in the absence of that third opinion, when faced with a “he said, she said” scenario, opting for the review that benefits the plan without a compelling and articulable rationale may well be considered capricious, potentially compromising the plan’s decision-making authority.
Webinars:
• On February 21, 2024, The Phia Group presented “The Skinny on Weight Loss Drugs,” in which we discussed off-label drug usage, international drug importation, defining medical necessity, plan drafting and exclusions.
• On January 16, 2024, The Phia Group presented “Navigating 2024: The Latest, Most Innovative Plan Design Features & Stop-Loss Policy Updates,” in which we discussed a rundown of 2024’s biggest plan document and stop-loss updates, including matters about which our team has been asked the most.
Be sure to check out all of our past webinars!
Podcasts:
Empowering Plans
• On March 29, 2024, The Phia Group presented “Xenotransplantation: A Potential Game Changer for Self-Funded Plans” in which our hosts, Nick Bonds and Jen McCormick, discussed the groundbreaking development of the world's first successful genetically engineered pig kidney transplant at MGH in Boston.
• On March 14, 2024, The Phia Group presented “Weighing the Options” in which our hosts, Ron Peck and Corey Crigger, discussed the impact the surge in demand for weight loss drugs has had on health plans and consumers.
• On March 8, 2024, The Phia Group presented “State of the Union, 2024” in which our hosts, Brady Bizarro and Nick Bonds, discussed some key healthcare initiatives that we’ll be keeping a close eye on in the coming months.
• On February 29, 2024, The Phia Group presented “The Therapeutic Equivalence Approach: A New “Pill”ar of Contraceptive Coverage,” in which our hosts, Kendall Jackson and Jon Jablon, discussed the “therapeutic equivalence” approach to compliance, what it means for consumers, and what it means for health plans.
• On February 15, 2024, The Phia Group presented “Navigating Post-Settlement Fund Pursuits,” in which our hosts, Andrew Silverio and Cindy Merrell, discussed a newly decided case which provides a roadmap for pursuing settlement funds after disbursement.
• On February 1, 2024, The Phia Group presented “Chevron Deference in Peril – What It Could Mean for Healthcare Regulations,” in which our hosts, Brady Bizarro and Brian O’Hara, discussed the legal doctrine involved in two cases now before the Supreme Court – Chevron deference.
• On January 18, 2024, The Phia Group presented “The Continuing Evolution of MHPAEA,” in which our hosts, Jennifer McCormick and Kelly Dempsey, discussed the ever-shifting landscape of the Mental Health Parity and Addiction Equity Act (MHPAEA).
• On January 4, 2024, The Phia Group presented “Higher Healthcare Prices (Made From Concentrate),” in which our hosts, Ron Peck and Nick Bonds, discussed how the trend of provider consolidation is primed to pick up pace in 2024.
Be sure to check out all of our latest podcasts!
Back to top ^
Phia Fit to Print:
• BenefitsPro – Self-funding plan preparation for 2024 – January, 2024
• BenefitsPro – Self-funding plan preparation for 2024 – March, 2024 Back to top ^
From the Blogoshpere:
• How the Recent Industry Cyberattack Impacts You. As this horrific situation has been playing out across pharmacies throughout our country, physicians in both massive hospital networks and small clinics are struggling to obtain prior authorization for exams, medications, and procedures.
• Millions Saying Good-Bye to Medicaid. 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.
• Welcome to the Subrogation Sphere. The subrogation sphere can have a substantial impact on many people.
• Are Measles Making a Comeback? Will we start seeing more and more of these outbreaks?
• A New Year Brings New (Higher) Prescription Drug Prices. Pharmaceutical companies are hiking prices on their drugs
To stay up to date on other industry news, please visit our blog. Back to top ^
The Phia Group's 2024 Charity
At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.
The Phia Group's 2024 charity is the Boys & Girls Club of Metro South.
The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.
The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8 to 18, signed up as club members. In the 30-plus years since then, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.
Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs.
Annie: The Play
The Phia Group invited 30 children from The Boys & Girls Clubs of Metro South to watch Annie at the Inly School. They were accompanied by a large number of Phia employees and had a blast watching Adam and the cast put on a phenomenal show!
Phia News: Candy Heart Contest
As is tradition, Phia held its annual Candy Heart Contest. The Phia Family made some great guesses, but there was one person who came particularly close to guessing the exact number. Congratulations to Regina Cattel on guessing 1076 pieces of candy corn. This was a very close guess, as we had 1089 pieces of candy hearts in the jar!
Get to Know Our Employee of the Quarter: Adam Doherty & Elizabeth Galewski
Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition.
The Phia Explore team unanimously agrees that there are no individuals more deserving than Adam Doherty and Elizabeth Galewski to be recognized as The Phia Group’s Employee of the Quarter for Q1 of 2024.
Congratulations, Adam and Elizabeth, and thank you for your ongoing and future contributions.
Phia Attending the SIIA National Conference
Several of Phia’s industry experts will attend SIIA’s 2024 National Conference in Phoenix, Arizona, from September 22nd – 24th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website:
Get more details: SIIa's 2024 Index
Job Opportunities:
• Case Investigator
• Claim and Case Support Analyst
• Director, IT Infrastructure
• Case Analyst
See the latest job opportunities, here: Our Careers Page
Promotions
• Jackie Andrews has been promoted from Sr. Director, Provider Relations to Vice President, Provider Relations.
• Alex Houle has been promoted from Director, Provider Relations to Sr. Director, Provider Relations.
• Brady Bizarro has been promoted from Sr. Director, PGC to Vice President, PGC.
• Andrew Silverio has been promoted from Compliance and Oversight Counsel to Director, PGC.
• Daiana Williams has been promoted from Director, Recovery Services to Senior Director, Recovery Services.
• Ekta Gupta has been promoted from Manager Data Services Group to Director Data Services Group.
• Zach John has been promoted from Sr. Manager, Applications Development to Director, Applications Development.
• Andrew Mead has been promoted from IT Helpdesk Coordinator to Systems Administrator.
• Sneh Gaonshindhe has been promoted from Sr. Software Developer to Manager, Applications Development.
• Angela Grande has been promoted from Team Lead to Manager, Provider Relations.
• David Ostrowsky has been promoted from Content Specialist to Manager, Corporate Communications.
• Trina Garcia has been promoted from PACE Specialist II to Health Benefit Plan Consultant III.
• Michelle Rowland has been promoted from Health Benefit Plan Consultant to Health Benefit Plan Consultant III.
• Tara Otoka has been promoted from Health Benefit Plan Consultant to Health Benefit Plan Consultant III.
• Diana Newburg has been promoted from PACE Specialist II to Health Benefit Plan Consultant III.
• Maghen Keefe has been promoted from PACE Specialist I to Health Benefit Plan Consultant II.
• LaTrisha Keierleber has been promoted from PACE Specialist I to Health Benefit Plan Consultant II.
• Michelle Haga has been promoted from PACE Specialist I to Health Benefit Plan Consultant II.
• Corrie Cripps has been promoted from Health Benefit Plan Consultant III to Health Benefit Plan Consultant IV.
• Olesya Avramenko has been promoted from Health Benefit Plan Consultant III to Health Benefit Plan Consultant IV.
• Emily Rodriguez has been promoted from NQTL Consultant I to Consultant I, MHPAEA.
• Bryan Dunton has been promoted from Consulting Attorney I to Consulting Attorney II.
• Nick Bonds has been promoted from Consulting Attorney II to Consulting Attorney III.
• Morganne Samuelson has been promoted from Project Manager to Senior Project Manager.
• Desmond Campbell has been promoted from Accounting Administrator I to Accounting Administrator II.
• Saheed Yussuff has been promoted from Accounting Administrator I to Staff Accountant.
• Deonte Small has been promoted from Accounting Assistant to Accounting Administrator I.
• Richard Harrison has been promoted from Sr. Accountant to Accounting Manager.
• Liz Pels has been promoted from Manager, Recovery Service Onboard & Support to Sr. Manager, Case Evaluation & Customer Service.
• Jen Marsh has been promoted from Recovery Service Onboard & Support Specialist to Senior Team Lead, Customer Service.
• Skyla Mrosk has been promoted from Sr. Claims Analyst to Sr. Claims Analyst, Trainer & Auditor.
• Malcolm Rymer has been promoted from Claims Analyst, Outreach Specialist to Claims Analyst, Client Outreach Specialist.
• Lindsey Stewart has been promoted from Customer Care Representative to Case Analyst.
• Dennis Ferzoco has been promoted from Claims Analyst to Sr. Claims Analyst.
• Tomasz Olszewski has been promoted from Sr. Claim & Case Support Analyst to Team Lead, Claim & Case Support.
• Haley McBroom has been promoted from Senior Claims Recovery Specialist to Team Lead, Recovery Services.
• Ethan Forrest has been promoted from Claim Recovery Specialist III to Senior Claims Recovery Specialist.
• Nicole Capozzoli has been promoted from Claim Recovery Specialist III to Trainer.
• Bridget Binda has been promoted from Case Investigator to Claims Recovery Specialist III.
• Richard Hunt has been promoted from Facilities Coordinator to Facilities Manager.
• Diane McAuley has been promoted from Executive Assistant to Senior Project Manager to the Chief Operating Officer.
• Emily Kewer has been promoted from Case Investigator to Team Lead, Case Investigation.
• Amanda DeRosa has been promoted from Manager, Recovery Services to Senior Manager, Liability Investigation and Claims Recovery.
• Hannah Lane has been promoted from Manager, Contracts Administration to Junior In House Counsel.
New Hires
• Sarah Bracken was hired as a Sr. Claim Recovery Specialist.
• Sean Luckett was hired as a Sr. Claim Recovery Specialist.
• Sara Welch was hired as a Consultant.
• Alianna Feria was hired as a Sr. Claim Recovery Specialist.
• Ben Balke was hired as a Sr. Architect Pricing Engineer.
• Andrew Schulz was hired as a Sr. Subrogation Attorney.
• Luke Harrison was hired as a Sr. Claim Recovery Specialist.
• Angela Norris was hired as a Claims Specialist.
• Brianna Gatto was hired as a Case Investigator.
• Alison Abdikarim was hired as a Customer Service Rep.
• Justin Asher was hired as a Sr. Claim Recovery Specialist.
• Jaime Smith was hired as a Customer Service Rep.
• Alex Morison was hired as a Case Investigator.
• Marilu Flores was hired as a Customer Service Rep.
• Megan Knox was hired as a Customer Service Rep.
• Jessica Williams was hired as a Customer Service Rep.
• Stephen Sockol was hired as an AV Specialist.
• Jason Whitlock was hired as a Sr. Claim Recovery Specialist.
The Phia Group Reaffirms Commitment to Diversity & Inclusion At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.
We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.
The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.
We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.
Listen in as Kelly Dempsey and Brian O'Hara hit it out of the park in this Empowering Plans episode about Essential Health Benefits (EHBs)! The regulating bodies are at it again and issued ACA FAQ #66 on April 2, 2024! Listen in for a quick refresher on EHBs - how they started, where they are now, and where we’re going - and Phia’s interpretation and analysis of FAQ #66.
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 to become applicable, the plan must have first tendered some initial payment (or at least adjudicated the claim as covered). To contrast, a complete denial of a given line item of service based on a plan exclusion does not render the claim eligible to be challenged at IDR. Put bluntly, the IDR Entity is not a clinician, and its job is not to scrutinize or invalidate complete denials. The IDR Entity is much more like an arbitrator than a judge; its job is to choose between two payment amounts, not to decide whether a given denial was appropriate.
To reiterate, if a claim is denied entirely, it does not trigger the NSA’s IDR-related protections at all. The NSA is intended to apply to claims that are payable in some amount.
If a claim is denied in its entirety and that denial is compliant with the NSA, that claim falls outside the NSA's protections and regular plan appeals come into play. As expected, other NSA-interpreting regulations provide that external review – not the NSA's IDR, but the “ordinary” external review established by the ACA so many years ago – “must be available for any adverse benefit determination by a plan or issuer that involves medical judgment, as well as rescissions.” This was apparently meant to underscore that a complete denial of a claim – regardless of whether that claim falls under the NSA’s protections – is subject to regular appeals processes, including IRO review when applicable. That much seems intuitive, since, after all, a claim that does not fall under the NSA is an ordinary claim like any other, subject to ordinary claims and appeals guidelines.
The question then often becomes: what happens when a complete denial is overturned on appeal, and it turns out the claim did fall under the NSA after all? Our interpretation is that once a payment is made, the NSA would kick in if applicable, and that “initial” payment – even though not made "initially" – would be subject to open negotiations and IDR just as if the payment had been made "initially". If a denial is reversed, the NSA process effectively starts from there; after all, it seems like it would be the mother of all loopholes if a health plan was able to deny a claim at first, only to later reverse the denial but avoid the NSA's processes with respect to the payment.
As a final note, when trying to answer questions relating to the No Surprises Act, it's important to look through the lens of consumer (i.e., patient) protection. The Phia Group has been at the forefront of making these NSA process interpretations, and always thinking of Congressional intent – to help American workers avoid exorbitant costs – has proven invaluable in helping Phia and the industry at large navigate the NSA's complexities. As a TPA or broker, whenever you are asked to give your advice regarding the NSA and its application, we urge you to do the same.
As always, if you have any questions, please don't hesitate to reach out to Phia's consulting team!