To Pay or Not To Pay - Examining Exclusions, Definitions, and Other Things That Really Matter

On February 12, 2014

4th Quarter Newsletter 2013

On January 13, 2014

A Look Behind, A Look Ahead, Lessons Learned in 2013, and Predictions for the Coming Year

On January 8, 2014

Supreme Court upholds ERISA plan document statute of limitations

On December 20, 2013
By Andrea DavisIn

What can be viewed as a victory for plan sponsors, the Supreme Court ruled on Monday that statute of limitation periods written into plan documents are valid, as long as those periods are “reasonable.” The court, however, declined to define “reasonable.”

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For the Fourth Year in a Row, The Phia Group, LLC has been named to Inc. Magazine's List of America's Fastest Growing Private Companies

On December 14, 2013

The Phia Group's Adam Russo Fires at WSJ Article 'When Insurance Fails...'

On December 14, 2013

Pushing Back Against Prompt Pay Laws

On December 4, 2013
Pushing Back Against Prompt Pay Laws

You may be aware of recent growing efforts by providers and vendors to leverage prompt pay laws as they seek to obtain additional funds from you and benefit plans across the nation. In particular, we are aware of providers in Texas working hand-in-hand with aggressive local law firms to take advantage of the state’s prompt pay laws. One Texas law firm recently boasted that it is pursuing potential damages exceeding $865,000,000 and is now promising to pay a 20% referral fee to parties that refer providers to the firm. While these laws may indeed impact you and your process, we at The Phia Group have analyzed the matter in great detail. We urge you to contact us, so that we may discuss your options further. In the meantime, here is a summary of our recent findings: [click here to read more]

Texas Prompt Pay Legislation

S.B. 418 amended Article 3.70-3C of the Texas Insurance Code to require insurers to make payment determinations within 45 days of receiving clean claims from providers in a non-electronic format, or within 30 days of receiving clean claims submitted electronically. Depending on the insurer’s determination, there are three potential courses of action:

(1) if the entire claim is payable, pay the total amount of the claim;
(2) if a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the provider in writing why the remaining portion will not be paid; or
(3) if the claim is not payable, notify the provider in writing why the claim will not be paid.

As you can see, a key to protecting yourself from these laws and those that seek to take advantage of it, is simply notifying providers within the allocated time frame of factors prohibiting prompt payment of a claim. If a claim is incomplete, or additional information is needed from a third party, simply notifying the provider will stop the clock.

Insurers that fail to abide by the prompt pay deadlines could face a penalty of up to 100% of the difference between the provider’s billed rate and its contracted rate. Insurers may also be required to pay the provider’s reasonable attorney’s fees.

How To Fight Back

First, S.B. 418 provides that an insurer may request additional information from a provider in order to make a proper payment determination. However, the request must be in writing and strict deadlines apply to this allowance.

Second, the Texas Department of Insurance (TDI) has taken the position that the Texas prompt pay statutes do not regulate private self-funded ERISA plans.

Third, the TDI has indicated that in order to be considered a “clean” claim, the submitted claim must be legible, accurate, and complete. Thus, a Plan may argue that a claim was not a “clean” claim, and not incur the obligation to pay promptly, in the event that any information is missing from the claim. We would once again suggest, however, that if a claim is not clean, you notify the provider of that fact within the deadline.

For a more detailed explanation of these and other effective defenses that are available for group health plans, even including ERISA-exempt plans and ERISA plans susceptible to regulation by state law (due to the savings clause of ERISA), make sure to contact The Phia Group and join in our effort. If you would like to ensure that your own plan or your clients’ plans are afforded all essential rights, please contact pgcreferral@phiagroup.com and we will be happy to assist you in any way possible.

Disclaimer — The above article constitutes the opinion of The Phia Group, LLC, only and should not be construed or interpreted as constituting a legal opinion or binding legal advice.

Hospitals facing big divide in pro- and anti-ACA states

On December 2, 2013
By Beth Kutscher

Bradford Regional Medical Center and Olean General Hospital sit just 20 miles apart on opposite sides of the Pennsylvania/New York border. They serve a similar patient population in the rural, forested region. They are both owned by the not-for-profit Upper Allegheny Health System.

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What You Don't Know Can Hurt You!

On November 20, 2013

New York Governor Signs Legislation Prohibiting ERISA Liens on Settlement Proceeds

On November 19, 2013
McGivney & Kluger, P.C.

On November 13, 2013, the Governor of New York signed legislation which clarifies the scope of General Obligations Law (“GOL”) Section 5-335. As a result of this amendment, ERISA plans are prohibited from asserting liens against settlement proceeds in personal injury, medical malpractice and wrongful death actions.

This legislation was motivated by the legislature’s finding that the “settlement of certain types of claims have been impeded as a result of health insurers’ attempts to intervene into pending litigation, as well as similar attempts to institute subrogation and reimbursement actions against litigants. As a result, settlement of claims made by accident victims and others are imperiled and prevented, thus causing undue burdens and pressures upon the court system. In addition, defendants in such actions are being subjected to claims made by health insurers, exposing them to additional liability.”

Amendments to GOL Section 5-335 previously enacted in 2009 were made for the purpose of protecting “parties to the settlement of a tort claim from certain unwarranted lien, reimbursement and subrogation claims.” However, the United States District Court for the Eastern District of New York, in Wurtz v. Rawlings Co., LLC, 2013 WL1248631 (E.D.N.Y), has held that this legislation was preempted to the extent it applies to any insured employee benefit plan covered by the Employee Retirement Income Security Act of 1974 (“ERISA”).

The November 13th amendment to GOL Section 5-335 is intended to define the purpose of the “general obligations law which is to ensure that insurers will not be able to claim or access any monies paid in settlement of a tort claim whether by way of a lien, a reimbursement claim, subrogation, or otherwise so that the burden of payment for health care services, disability payments, lost wage payments or any other benefits for the victims of torts will be borne by the insurer and not any party to a settlement of such a victim’s tort claim.This law is specifically directed toward entities engaged in providing health insurance, thus falling under the ‘savings’ clause contained in ERISA, which reserves to the states the right and the ability to regulate insurance.”

Please do not hesitate to contact Greg Gaines of McGivney & Kluger, PC at ggaines@mklaw.us.com with any questions regarding this important legislation