By: Andrew Silverio, Esq.
Anyone who works in health benefits is familiar with surprise billing – the specific kind of balance billing which occurs when a patient visits an in-network physician or hospital, and receives an unexpected balance bill from an out-of-network provider that they didn’t have an opportunity to select, and in many cases, didn’t even know they had utilized. Common culprits are anesthesiologists, assistant surgeons, and outside lab work.
We often think of this as primarily a problem for emergency claims. This makes a great deal of sense, since when someone presents at an ER or is brought there via ambulance, they likely won’t have an opportunity to ask questions about network participation or request specific providers. However, according to surprising data released in the Journal of the American Medical Association on February 11, 2020 entitled “Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities (available at jamanetwork.com/journals/jama/fullarticle/2760735?guestAccessKey=9774a0bf-c1e7-45a4-b2a0-32f41c6fde66&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=021120), these bills don’t actually seem to be more likely to arise from emergencies or other hospital stays where patients have less of an opportunity to “shop around.”
The study looked at 347,356 patients undergoing elective surgeries, at in-network facilities with in-network surgeons. These are patients who had ample opportunity to select their providers, and indeed did select in-network providers for both the surgeon performing their procedure and the facility in which it would occur. Shockingly, over 20% of these encounters resulted in a surprise out of network bill (“Among 347 356 patients who had undergone elective surgery with in-network primary surgeons at in-network facilities . . . an out-of-network bill was present in 20.5% of episodes...”) The instances that involved surprise bills also corresponded to higher total charges - $48,383.00 in surprise billing situations versus $34,300.00 in non-surprise billing situations.
The most common culprits were surgical assistants, with an average surprise bill of $3,633.00, and anesthesiologists, with an average bill of $1,219.00. In the context of previous research indicating that “20 percent of hospital admissions that originated in the emergency department . . . likely led to a surprise medical bill,” it seems that even when patients are able to do their homework and select in-network facilities and surgeons, they are just as susceptible to surprise billing. (See Garmon C, Chartock B., One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills. Health Affairs, available at healthaffairs.org/doi/10.1377/hlthaff.2016.0970.)
Many states have enacted protections against balance billing and surprise billing, with Washington and Texas both recently enacting comprehensive legislation. However, these state-based laws have limited applicability, and there are to date no meaningful federal protections for patients in these situations. Until such protections are enacted, patients are left vulnerable to sometimes predatory billing practices, and plans are left to choose between absorbing that financial blow or leaving patients out in the cold.
Last month, we discussed some disturbing trends surrounding prescription drugs, and what they mean for self-funding. The overwhelming feedback we received after last month’s webinar was that you, our viewers, want more information on this particular topic – so we’re back with a sequel!
Join The Phia Group’s legal team as they take a deeper dive on the topic of Rx drugs, tackle the difficult questions asked in last month’s webinar, and help plans protect themselves while staying ahead of the curve.
Click Here to View Our Full Webinar on YouTube
To obtain a copy of our webinar slides, please reach out to email@example.com.
By: Kevin Brady, Esq.
Every week, we seem some variation of the question: Will this program impact our HSA-Qualified HDHP status? The programs in question often include direct primary care, telemedicine, managed care, or some combination thereof. The answer, often to the disappointment of groups hoping to provide more value to their participants, is that these types of programs can often run afoul with the Internal Revenue Service’s strict requirements on High Deductible Health Plans (HDHP).
An HDHP must meet certain criteria to allow individuals enrolled to contribute to Health Savings Accounts (HSA). The problem arises when an HDHP no longer meets that criteria and therefore loses is qualified status.
For purposes of utilizing a HDHP with an HSA, the HDHP must comply with IRC § 223(c)(2). This section of the code provides the minimum deductible and the maximum out-of-pocket expenses required for a plan to be considered an HDHP. For example, in 2020, the minimum deductible was set at $1,400 for self-only coverage and $2,800 for family coverage. Further, a Plan considered an HDHP cannot contribute to the costs of non-preventive services until an individual’s deductible is met, and the participants cannot be enrolled in other health coverage as defined by the IRS. (See here for more information: Pub. 969)
So, when a client asks us the inevitable question, “will this program impact our HSA-Qualified HDHP status?” We typically look to determine two things; 1. Does the program inherently require the Plan to contribute to the cost of non-preventive services pre-deductible; and 2. does the program constitute other health coverage?
While it certainly requires a full and complete understanding of the proposed program, it has been our experience that the answer to at least one of these questions is often yes.
When these types of programs are included as benefits within the Plan, it often opens the door for the Plan to pay for non-preventive services before an individual’s deductible has been satisfied. Conversely, when the program is offered outside of the Plan, it often constitutes “impermissible other coverage” which renders individuals who are enrolled in both the program and the HDHP ineligible to contribute to their HSA.
If an individual makes contributions to their HSA during a period in which they are not eligible to do so, it could result in massive tax consequences for that individual and could also cause tax consequences on employers who contribute that individual’s HSA as well.
With the current guidance in place, it is difficult for groups to implement these types of alongside or within their HDHPs. This is unfortunate because the programs can often add enormous value for participants and also result in significant savings for Plans.
Luckily, in June of 2019, an Executive Order directed the Secretary of the Treasury to issue regulations to clarify the issue as to whether these types of programs can be offered within or alongside HDHPs without jeopardizing a participant’s ability to contribute to their HSA.
Given the Executive Order, and similar legislation making its way through Congress, we are hopeful that there will be new guidance to allow the expanded use of these types of programs with HDHPs in the new future. Until then, it is best to err on the side of caution and confirm that a proposed program doesn’t conflict with the IRS rules before implementing it into your benefits offerings.
In this episode, Adam and Ron interview industry legend, Ernie Clevenger, regarding CareHere, LLC, the future of consumer-centric medicine, technology – and most importantly – the MyHealthGuide newsletter!
Click here to check out the podcast! (Make sure you subscribe to our YouTube and iTunes Channels!)
By: Jon Jablon, Esq.
You may have read the blog post that my colleague Andrew Silverio wrote about this case just a few days ago. (If you haven’t, check it out!)
After doing a deep dive into this case, there are a few specific things I want to bring up – and to do so, I’ll do some quoting from the complaint. The plaintiffs – certain medical providers that feel they have been victimized by Cigna – have made many allegations, some very specific, and some more sweeping in nature. While we have no basis to question the facts presented by the plaintiffs, it does seem that the logic employed in the arguments leaves something to be desired. Here are a few paragraphs from the complaint that I find most noteworthy from a self-funding point of view:
13. Plaintiffs’ incurred charges for the Cigna Claims total approximately $72,757,456.28, reflecting Plaintiffs’ usual and customary rates for the particular medical services provided. But Cigna has paid only a small fraction of this amount,—$16,937,637.50, which represents only 23% of its legal responsibility.
The plaintiffs are alleging that the 23% of the total billed charges paid to them by Cigna was “only 23% of [Cigna]’s legal responsibility.”
I’ll pause to let that ridiculousness set in.
These plaintiffs are actually alleging that Cigna’s legal responsibility is to pay 100% of billed charges, across numerous claims. Not surprisingly, the complaint doesn’t support that assertion with any plan language, law, or logic, and I can’t help but wonder what the drafter of this complaint was thinking.
20. In this example, Cigna has told the provider that the unlucky Cigna Subscriber owes it $60,316.07 as the amount not covered under the Subscriber’s Plan, but has told the Subscriber that he/she owes the provider only $895.25 because Cigna negotiated a 98% discount with the provider. In doing this, Cigna misrepresents to Cigna Subscribers that the amounts improperly adjusted by Cigna are “discounts.” This misrepresentation appears on most Cigna Claim Patient EOBs.
Here, the plaintiffs allege that the EOBs provided to them identify that the amount Cigna claims to be above its allowable amount is a discount. This is a common folly and one we strongly caution against making! RBP plans often fall into this trap, since their payments are always at an allowable amount lower than the provider’s billed charges; characterizing the disallowed or excess amount as a “discount,” when it is not, is misleading to providers (causing confusion and frustration, and ultimately hurting outcomes when combating balance-billing) and a misrepresentation to members.
121& 122. For emergency services, the ACA Greatest of Three regulation and New Jersey law require Cigna to reimburse Plaintiffs at least at the in-network rate at which Cigna would reimburse contracted providers for the same services. … Plaintiffs are therefore entitled to the total incurred charges for the elective and emergency claims at issue, less Patient Responsibility Amounts not waived by Cigna.
This is not quite accurate for two reasons. First, the plaintiffs misquote the “Greatest of Three” rule; the amount that must be paid is at least the median in-network rate that each individual plan would pay for the same services, rather than the blundering mischaracterization of “the in-network rate at which Cigna would reimburse contracted providers.” Those are important differences, and, frankly, the attorney should have known better.
Second, even if this premise were accurate as written, the conclusion drawn is still nonsensical. The plaintiffs have indicated that since the payment must be at least the in-network rate paid to the same provider, then the payment must be “total incurred charges” minus patient responsibility. In other words, these providers are suggesting that the in-network rate, across thousands of claims with multiple providers, is 100%. It’s true that 0% discounts exist, but they’re somewhat rare, and it is certainly not the case here that every single relevant discount, accessed by any of the relevant health plans, is 0%.
155. Exhaustion is therefore deemed futile pursuant to 29 C.F.R. § 2560.503-1(l) because Cigna failed to provide a clear basis for its denials and has refused to produce the requested documents necessary for Plaintiffs to evaluate the Cigna Claims denials. Cigna thus offered no meaningful administrative process for challenging its denials of the Cigna Claims.
This last example is another one where many self-funded plans run into unexpected issues. Called “futility,” this doctrine holds that appeals are not necessary, and a claimant can jump straight to a civil suit, if the plan renders appeals futile in any of various ways.
Here, if Cigna has truly issued insufficient EOBs, refused to provide substantiating documentation, and generally didn’t follow the applicable regulations, the providers have a very good argument that appeals are futile. What’s more, though, is that these actions constitute a breach of the Plan Administrator’s fiduciary duties to abide by applicable law and the terms of the Plan Document, which could subject the Plan Administrator to penalties as well as work against the payor in court.
We’re excited to see how this suit unfolds, and we’ll give you more updates when we can!
In this episode, Ron Peck and Brady Bizarro discuss the first Democratic debate of 2020 and the latest ruling from a federal appeals court on Obamacare. Time could be running out, both for the ACA and for the candidates for president. You do not want to miss our take on these issues and more!
By: Nick Bonds, Esq.
With the Legislature moving at a glacial pace, the Trump administration has doubled down on its policy objective to reduce health care costs through executive action and administrative rulemaking. A key part of their strategy involves a push to increase transparency in the health care industry – taking special aim at hospitals and drug manufacturers. The apparent logic being that if hospitals and drug makers have to share their actual prices, patient reaction will be strong enough to drag prices down. Experts disagree as to how effective these strategies would be in theory, but we may never have the opportunity to see their impact in practice.
High-profile initiatives to emerge from this approach have run in to a number of difficulties. The administration’s proposed rule requiring drug manufacturers to disclose their drugs’ list prices in their television ads has not been largely repulsed by the pharmaceutical industry, who have had a fair amount of success thus far blocking this rule in court. The pharmaceutical industry argued that this disclosure rule lacked authority and violated their free speech. Last summer, a federal judge in Washington, D.C. ruled that HHS exceeded its authority by compelling them to disclose their prices. HHS appealed, but this past week the U.S. Court of Appeals for the D.C. Circuit appeared unsympathetic. The appeals court agreed that HHS had not been granted the requisite authority by Congress to implement this drug pricing rule, and remained unconvinced that this pricing disclosure requirement would in fact help achieve the administration’s goal of bringing down drug costs. WE expect the administration to appeal yet again.
Announced last November, another transparency-minded federal rule requires hospital systems to disclose the price discounts they have negotiated with insurers for a wide swath of procedures. This disclosure is intended to inform patients of their prospective costs before they are incurred, empowering patients to shop around for the best prices. Here again, debate swirls as to whether this tactic would be effective. Meanwhile, hospital groups have implored the D.C. District Court to block these rules from taking effect echoing the arguments of the pharmaceutical companies before them: that the administration lacks the authority to implement its rule, and that the proposed rule violates their First Amendment rights. Time will tell if the courts come down on the administration’s side this time around.
Other Trump administration efforts have seen fewer setbacks: they have slashed regulations on short terms plans and association health plans (“AHPs”), more generic drugs have been approved, and they are plowing ahead with a notice of proposed rulemaking to allow importation of prescription drugs from Canada. Nonetheless, the number of Americans without health insurance continues to rise, as do marketplace premiums and the actual costs of care. The goal of reducing healthcare costs is an admirable one, we will see how effective the administration’s attempts will be.
Whether you are a fan of politics, profits, or identifying savings, you are likely keeping a close eye on pharmaceuticals. From life-preserving medications that have been around for decades (and whose price increases continue to outpace the national GDP) to specialty drugs that are inches away from FDA approval (and bankrupting most benefit plans), the cost tied to drugs is a hot topic. While congressional efforts to curb rising costs have stalled, pharmaceutical companies, pharmacy benefit managers (PBMs), and politicians continue to look for someone else to blame. Join The Phia Group as they discuss the Rx trends to watch for, the biggest threats to health plans, cost-containment strategies to implement, political efforts underway, and an injection of information you can’t do without.
In the final hours of 2019, a coalition of New Jersey medical providers filed a voluminous, 150-page complaint against CIGNA in federal court in New Jersey. The providers, in general, are challenging the validity of CIGNA’s reference-based pricing (“RBP”) program, which guides the payments of numerous self-funded plans in and around New Jersey. As would be expected with such a lengthy and thorough complaint, there are various causes of action being pursued – some allege criminal activities like “embezzlement, theft, and unlawful conversion,” and “a pattern of racketeering activity” under RICO. Others strike more directly at basic and common aspects of any RBP program, while others allege practices that, if the allegations are true, would certainly be reasonably classified as problematic.
In the coming weeks and months, we will be monitoring this case closely and providing in-depth analysis and commentary in our upcoming webinars and other releases, but for now, we wanted to highlight some key allegations being made. If the case progresses to any sort of substantive holdings, it could have significant effects on RBP as a whole, depending on which causes of action ended up “sticking.”
A key element of many of the complaint’s allegations is that CIGNA and its vendors, in repricing and processing non-contracted claims, fraudulently represent that the amounts paid are in fact agreed-to, contracted amounts which the providers have agreed to accept as payment in full. The providers state that there is in fact no agreement, which is almost certainly true, but also allege that the amounts actually paid are less than is required under the individual plans. For this second element, the complaint cites to no evidence. This issue would certainly be a matter of plan document language, which is not touched on in the complaint.
In support of these allegations that CIGNA fraudulently represents a nonexistent contractual agreement, the providers allege that the EOBs CIGNA sends to plan participants differ from those it sends to providers. Specifically, the patient EOB allegedly describes the portion of charges disallowed after repricing as a contracted discount, stating that the patient has saved money, while the provider EOB describes this same amount as an “amount not covered,” instructing providers not to balance bill the patient, but to contact CIGNA’s repricing company instead with any disputes. The providers give several examples of such claims paid at 1-3% of billed charges and describe a negotiation and dispute process which they allege is a “war of attrition,” aimed at creating delay, expense, and frustration rather than a good faith procedure truly aimed at resolution.
An allegation key to the RICO/racketeering causes of action stems from CIGNA’s billing practices, which the providers describe as a fraudulent scheme to convert plan assets. The complaint claims that CIGNA and its vendors retain a flat percentage of savings fee based on the initial repricing, and importantly, retain that full fee even when, after a negotiation/dispute process, the plans end up paying additional amounts, sometimes up to a full billed charge, negating any actual savings. For illustration, the complaint describes a situation in which a plan pays 1% of a billed charge, a 30% percentage of “savings” fee to CIGNA, then ends up paying the full billed charge after a provider dispute. The end result is the plan paying 130% of a billed charge, with the extra 30% going to CIGNA.
At the complaint stage, it’s important to remember that all the allegations described here are just that – allegations. Some take aim at practices which, if they are actually being engaged in, are objectively problematic, while others strike at core elements of RBP itself. We will be closely monitoring the case as it develops and providing commentary and analysis on an ongoing basis.
Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo:
From the Desk of the CEO
Happy New Year everyone! 2020 marks the 20th anniversary of The Phia Group and it made me realize just how much we have accomplished and how far we have come. I am not going to sit here and tell you that this was the dream - to have a leading cost containment firm in the self-funding industry with over 200 employees. I just wanted to create something, anything that would change the status quo. I had no concept of the size of Phia, the revenues, the expertise, the reputation, the services, or the technology we have created.
I just had a passion to offer more than what was being offered at that time. I was 26, living in my mother’s basement, and basically had nothing to lose. We never got a loan, never had investors, never hired top talent - we couldn’t afford anyone! What we had was a determination to have fun, disrupt and innovate. What we created after 20 years still boggles my mind. I want all of you to know how much I appreciate the friendships, the loyalty and the collaboration we have built together. I will never forget where I came from or how I got here - thank you. Happy reading and I hope you all have an amazing 2020. I know we will.
Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)
Phia Group Case Study
Phia Fit to Print
From the Blogosphere
The Phia Group’s 2020 Charity
Phia’s Speaking Events
Employees of the Quarter & Year
We Are Proud to Announce: Free Health Benefits for Phia Employees & Their Families
The Phia Group, LLC is pleased to announce that with the ringing in of the new year, it will be offering FREE HEALTH BENEFITS to employees and their families. Specifically, plan participants that have been enrolled in the plan for five or more years will be enrolled in January of 2020 and have zero contribution or premium; 100% of the cost of their and their families’ membership is paid for by The Phia Group. Further, no plan participant’s contribution rate will increase in 2020.
This remarkable achievement is made possible thanks to the application and utilization of cost containment measures developed and provided by The Phia Group to the self-funded health benefits community, and proactive efforts on the part of its own plan membership to be educated, and cost-conscious “consumers” of healthcare.
Adam V. Russo, remarked – in response to those that believe cost-shifting the burden of rising healthcare costs onto employees is inevitable – that, with the right tactics in place, health benefits can be affordable and employees do not need to bear the burden of an inefficient health plan. “If our approach to health benefits didn’t work,” Adam continued,“… could we afford to maintain our contribution levels, year after year? Could we continue to offer benefits with no co-pays or deductible? The answer is no.”
Ron E. Peck, explained, “Our mission is to ensure health benefits are robust and affordable for hard-working Americans. Very few people work as hard as our own employees, so providing them with the best, most affordable benefits is us living our mission.”
“We are very proud to be able to offer our employees and their families the types of benefits they’d only see at a very small number of businesses, nationwide;” Adam concluded.
Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)
Some years ago, in response to growing industry concerns over fiduciary duties and appeals, The Phia Group created its Plan Appointed Claim Evaluator (PACE) service. PACE is a risk-sharing service for final-level internal appeals. It is designed to help ensure Plans and their TPAs made correct determinations in response to appeals, thereby insulating the health plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations.
• Plan Document and stop-loss policy “Gap Reviews” ensure compliance, eliminate coverage gaps, and ensure PACE readiness;
• Advanced-level webinars exclusively for PACE clients;
• Assessment of eligible final internal appeals resulting in a written directive; and,
• Unsurpassed legal analysis, clinical review, and access to URAC-accredited IROs (and PACE covers all external review costs).
We also now offer complimentary PACE Certification – with which your organization can enhance your PACE business, improve your internal appeals processes, ensure regulatory compliance, and improve your operation as a whole.
Chapter One of PACE Certification explores the ins and outs of self-funding; Chapter Two takes a deeper dive into the laws and regulations applicable to self-funded health plans; Chapter Three explains what PACE is, how it works, and how it can best be utilized.
To learn more, contact Michael Vaz at firstname.lastname@example.org or 781-884-4971.
Phia Case Study: Claim Negotiation & Signoff (CNS)
The Phia Group was asked to negotiate a high-dollar claim on behalf of a self-funded health plan sponsored by a non-profit religious order. The charges totaled just over $100,000.00, and repricing yielded a Medicare rate of only $7,500.00 (a mark-up of over 1300% over Medicare). To compound the situation, the plan document had not been updated since the early 1990s, and had very weak language governing payment for out-of-network claims.
One of The Phia Group’s negotiators noted that the hospital bore the same name of the religious order of which the patient was an ordained member. After some investigation, Phia learned that this religious order was the very same that founded the hospital nearly a century ago.
In the initial outreach to the provider, we explained the claim’s metrics and equivalent Medicare rate; it was our hope that even without strong plan language or unloading our newfound argument regarding the member’s relationship to the hospital, the hospital would recognize the importance of settlement. Unfortunately, the provider was largely unresponsive to our efforts. After over a month of constant persistence in the form of calls, e-mails, and faxes, we finally received an offer from the provider to accept 35% off of billed charges. While not the smallest discount, that payment still would have constituted almost 900% of the applicable Medicare rate, and our client was not inclined to accept the offer.
In crafting a response, we got a little creative, and quoted some language directly from the “history” section of the hospital’s website. This patient, we noted, is a member of the religious order that founded this hospital back in 1922, and which transformed it into a hospital for children in 1936. That the hospital was now seeking almost 900% of the applicable Medicare rate from one of its founders seemed unreasonable and disingenuous. We also quoted a study that found that the average charge for an out-of-network claim in the state was 176% of Medicare; through this figure, we were able to base our client’s counteroffer in a concrete metric, even though the plan’s cost-containment language left much to be desired.
Ultimately, the provider agreed to accept our offer of 176% of the Medicare rate, and close its file. By going the extra mile, The Phia Group was able to save its client over $88,000; since the Plan Document didn’t have strong cost-containment language, the Plan would have legally been on the hook for the vast majority of it, had this settlement not been achieved.
Fiduciary Burden of the Quarter: New Denial Reasons on Appeal
It’s not uncommon for health plans to realize, while adjudicating a claimant’s appeal, that the initial denial reason was incorrect or incomplete. That’s one major function of appeals – to let a claimant identify that the denial reason is inapplicable. For instance, if the initial Adverse Benefit Determination denies a claim on the basis that the service is experimental, the claimant may appeal and present evidence that the claim is not in fact experimental. The fiduciary, when reviewing the appeal, may realize “whoops – this claim should have been denied for lack of medical necessity, but we used an experimental code by mistake!”
The result is generally that the fiduciary will still deny the appeal, but write that the claim is denied for medical necessity, rather than being experimental. The appeal is a request for additional benefits, but if additional benefits are not payable for some other reason that was not written in the initial denial, then the appeal should still be denied. Health plans often do not consider this to be a “separate” or “new” denial – but legally, it is.
Considering appeals to have been exhausted despite having provided a new denial reason effectively leaves the claimant with no opportunity to appeal that new denial for medical necessity. Courts have iterated that this is contrary to the intent and requirements of ERISA, which are designed to ensure that claimants are afforded the opportunity to appeal an adverse benefit determination. An appeal denial with a reason not previously given for that particular claim’s denial is therefore considered to be an initial adverse benefit determination all over again, even if given as part of a second-level appeal.
In short, any time a new denial reason is given for an existing claim, the claimant has the right to appeal that denial reason.
This could in theory create an absurd situation where the plan must accept many different appeals for the same claim – but to avoid that, we would suggest that the plan list all its denial reasons in the initial denial, when possible. That way, the plan can ensure that it does not need to respond to multiple unnecessary appeals, and also that a claimant is not strung along with the undue burden to appeal multiple times to try to get a straight answer out of her health plan.
Success Story of the Quarter: Balance-Billing at its Best!
The Phia Group was presented with a balance-billing claim from a client of Payer Compass’ INNOVATE360 service, for which The Phia Group provides back-end balance-billing support. This particular claim was billed at $1.57 million; the health plan allowed 150% of Medicare, which was about $289,000. The balance, billed in full to the patient, was nearly $1.3 million.
The TPA had been told prior to The Phia Group’s involvement that the maximum “discount” the provider would allow was 15%. Understandably, this payor would not accept that, and instead engaged The Phia Group to try to resolve this claim to alleviate the balance-billing. The payor was potentially willing to pay additional money to settle the claim, but certainly not the amount the provider was demanding.
The Phia Group engaged the provider, and right off the bat, attorney Rob Martinez unloaded all the arguments he had in his arsenal. They included arguments based on the ID card, the plan document, the hospital’s financial assistance policy, detrimental reliance, and more – and on a more personal note, the fact that this hospital was sending bills to its supposedly valued patient for $1.3 million.
Amazingly, the hospital conceded that Rob’s arguments were sufficient to extinguish the balance. The account was awarded a zero balance, and poof – just like that – Rob “the Magician” Martinez made a $1.3 million balance-bill disappear.
New Service Offered by Phia: Patient Defender
The Phia Group is proud to introduce its “Patient Defender” program. For a small PEPM fee, every plan participant has access to legal representation against lawsuits targeting patients, or crippling balances being sent to collections, when efforts to amicably resolve these disputes fail, Patient Defender is the ultimate weapon in the battle against abusive balance billing tactics. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by these increasingly aggressive tactics, Patient Defender will be there.
Patient Defender finally plugs the gap that has existed across the industry in relation to reference-based pricing programs and balance billing concerns. With Patient Defender, a small PEPM rate ensures that a trusted law firm is placed on retainer, ready and willing to assist the patient when balance-billing occurs. Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.
To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or email@example.com.
Phia Fit to Print:
• BenefitsPro – COBRA can be complicated: What to watch for – December 4, 2019
• Self-Insurers Publishing Corp. – ACA Enrollment By The Numbers! Administration's Attempts To Stall The ACA At Work? – December 1, 2019
• BenefitsPro – Trending therapy options: Gene and stem cell therapy for self-funded plans – November 22, 2019
• Self-Insurers Publishing Corp. – ACA Round-Up for 2020: Items Affecting Employer-Sponsored Group Health Plans – November 5, 2019
• Self-Insurers Publishing Corp. – The Tower of Babel-Talking Heads Talking Past Each Other – October 4, 2019
Back to top ^
From the Blogosphere:
• Washington’s “Surprise” Billing Law Goes Into Effect – January 2020. One less surprise you’ll have to worry about.
• New Transparency Rules Released, But Will They Last? A proposed rule to bring transparency to hospitals near you.
• Theories v. Practicality: The Simplest Answer is Often the Best! The easiest path to third party recovery.
• Happy (Almost) New Plan Year! Preparing your plan documents for 2020!
• Battle Lines Drawn over Medicare for All in the Latest Democratic Debate. Is there truly a cure for our healthcare system?
To stay up to date on other industry news, please visit our blog.
• On December 17, 2019, The Phia Group presented, “A Perfect Vision for 2020,” where we review the issues, topics, and innovations of 2019 that we believe will impact 2020, as well as the strategies you need to implement now to conquer the coming year.
• On November 13, 2019, The Phia Group presented, “Plan Language, Rx, and Lawsuits to Watch (and File): Innovation for a Changing Industry,” where we discuss innovative programs to manage vendor fees, balance-bill litigation, Rx manufacturer assistance, and other ideas being proposed by players in the industry.
• On October 17, 2019, The Phia Group presented, “2020 Forecast - Storm Clouds, Clear Skies, and the Issues that will Dominate Next Year,” where we discuss the issues that impacted 2019, and are poised to dominate 2020, including (but not limited to) Mental Health Parity, Paid Leave, Health Insurance Taxes, Drug Prices, Regulations, and Coupons.
Be sure to check out all of our past webinars!
• On December 19, 2019, The Phia Group presented, “Medicare Podcast for All” where our hosts, Ron Peck and Brady Bizarro, pick apart Elizabeth Warren’s Medicare-for-All proposal, and the concept as a whole; the good, the bad, and the really bad.
• On December 11, 2019, The Phia Group presented, “Preparing Your Plan Document for 2020,” where The Phia Group’s Executive Vice President and General Counsel, Ron E. Peck, and Senior Vice President of Consulting, Jen McCormick, sit down to discuss the top-rated topic chosen by Phia’s webinar listeners. Make sure you tune in to find out what Ron and Jen have to say about plan documents and learn the do’s and don’ts when it comes to reviewing and updating your plan document in 2020!
• On November 21, 2019, The Phia Group presented, “The Young & The Restless,” where our hosts, Adam Russo and Brady Bizarro sit down with Craig Clemente, Chief Operations Officer at Specialty Care Management and outgoing Chairman of the SIIA Future Leaders Committee, to discuss the future of the committee and the many ways they intend on engaging the younger generation.
Face of Phia
• On November 15, 2019, The Phia Group presented, “Shauna Makes a Comeback,” where our hosts, Adam Russo and Ron Peck, sits down with Shauna Mackey, The Phia Group’s Associate General Counsel. Tune in to learn more about Shauna and her experience with both public and private healthcare throughout her pregnancy and delivery.
• On November 4, 2019, The Phia Group presented, “Battling Balance-Billing,” where our hosts, Adam and Ron, interview Lyneka Hubbert, a Medical Claim Negotiator here at The Phia Group.
• On October 16, 2019, The Phia Group presented, “Reminiscing on Memories with Mrs. Marsh,” where our hosts, Adam and Ron, interview Jen Marsh, our Client Satisfaction & Quality Control Manager.
Tales From the Plan
• On October 24, 2019, The Phia Group presented, “Translating Phia’s Benefit Plan,” where our hosts, Adam Russo and Ron Peck, interview The Phia Group’s Human Resources Manager, Linda Pestana. Learn how Linda was able to navigate our health plan and negotiate with a provider to make her son’s hearing aids affordable.
Be sure to check out all of our latest podcasts!
The Phia Group’s 2020 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 2020 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 8-18, signed up as club members. In the 25 years since, 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 Brockton 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 programming.
Each year employees of The Phia Group pick nametags from the Angel Tree that sits in our main lobby. On those tags are names, ages and the wish lists of children from The Salvation Army. This year we had over 130 nametags! The Phia family loves to give back to the community; our greatest joy is providing these children with all of their holiday wishes.
Christmas Came Early
The Phia Group had the pleasure of bringing Christmas joy to the Boys & Girls Club of Metro South. Adam Russo and his helpers passed out hundreds of gifts to over 130 children. We hope these children enjoy their new toys as much as they enjoyed spending time with Santa!
2019 Kennedy Service Award
Adam and Kelly Russo were honored with the 2019 Kennedy Service Award last week at the 2019 Great Futures Gala hosted by The Boys & Girls Clubs of Metro South. Check out the link below to see highlights from this unforgettable night! To learn more about this award, please visit
Thanksgiving Dinner Delivery
The Phia Family was out and about the week of Thanksgiving, delivering Thanksgiving dinners to the families of The Boys and Girls Club of Metro South! Additionally, our Phia Family in Idaho was out and about spreading the same cheer to five families in the Boise area. Check out the great picture we were able to get from that special night! We hope everyone had a wonderful Thanksgiving!
ACA Enrollment By The Numbers! Administration's Attempts To Stall The ACA At Work?
By: Chris Aguiar, Esq. – December 2019 – Self-Insurers Publishing Corp.
With headlines focused on collusion, corruption, impeachment, and a wall being erected in Colorado, much of the political discourse in 2019 has avoided Healthcare Reform. In contrast, 2017 and 2018 featured many headlines with the current Administration doing everything within Its power to make good on a touchstone of Its 2016 campaign platform; President Trump and the Republican Party pushed for repeal and replacement of Barak Obama’s crowning achievement, the Affordable Care Act. When they were unable to garner the votes, the President utilized powers outside the control of Congress to weaken key parts of the Law designed to ensure the viability of the Insurance Marketplace, as well as keeping the American public in the dark regarding enrollment by virtually defunding marketing efforts. Many feared these tactics would encourage disengagement of the young and healthy, demographics crucial to maintaining a balanced risk pool covered by the Marketplace. Did it work?
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ACA Round-Up for 2020: Items Affecting Employer-Sponsored Group Health Plans
By: Corrie Cripps – November 2019 – Self-Insurers Publishing Corp.
During this open enrollment season, plan sponsors of group health plans should be aware of any Affordable Care Act (ACA) changes that may affect the design and administration of their plans.
The case Texas v. United States is the ongoing litigation challenging the constitutionality of the ACA. A decision on this case is expected at any time from the Fifth Circuit Court of Appeals (“Fifth Circuit”). Any decision appears likely to be appealed to the Supreme Court. Whether or not the Supreme Court will take the case depends on how the Fifth Circuit rules. If the Supreme Court does not take the case, the Fifth Circuit’s decision will remain the law; however, the agencies will most likely need to issue regulatory guidance on how they interpret the decision.
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The Tower of Babel-Talking Heads Talking Past Each Other
By: Ron E. Peck, Esq. – October 2019 – Self-Insurers Publishing Corp.
As the 2020 Presidential Election draws closer, the topic of healthcare continues to dominate the airwaves. Be it media or debate, this is one of the (if not the) issue about which everyone is talking; but pay close attention and you’ll notice they aren’t all speaking the same language.
One word everyone can agree upon is “affordability.” The issue, however, is that depending upon whom you ask, what it is that ought to be “affordable” differs. Some people throw the term “access” around, while others seek affordable “care,” whilst still others focus (candidly) on affordable insurance.
To stay up to date on other industry news, please visit our blog.
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Phia’s 2019 Speaking Engagements:
• 1/9/2019 – FMMA Conference – Austin, TX
• 2/27/2019 – Sunlife 2019 MVP Academy – Denver, CO
• 3/8/2019 – UnitedAg Conference – Anaheim, CA
• 3/19/2019 – SIIA Self-Insured Health Plan Executive Forum – Charlotte, NC
• 3/21/2019 – CGI Business Solutions Seminar – Woburn, MA
• 3/26/2019 – HFTPA Broker Meeting – Tyler, TX
• 4/3/2019 – BenefitsPRO Broker Expo – Miami, FL
• 4/5/2019 – Pareto Conference – Nashville, TN
• 4/7/2019 – Captive Symposium – Cayman Islands
• 4/8/2019 – National Beer Wholesalers Association Legislative Conference – Washington DC
• 4/12/2019 – FMMA 2019 Annual Conference – Dallas, TX
• 4/23/2019 – Johns Hopkins Industry Education Series – Baltimore, MD
• 4/24/2019 – Sunlife 2019 MVP Academy – Kansas City, MO
• 4/25/2019 – BevCap’s Best Practices Workshop – Orlando, FL
• 4/26/2019 – Society of Professional Benefit Administrators Annual Conference – Washington, D.C.
• 5/2/2019 – MassAHU Benefest 2019 Conference – Westborough, MA
• 5/14/2019 – Cypress Unversity – Las Vegas, NV
• 5/30/2019 – Contrarian Captive – Austin, TX
• 6/11/2019 – Leavitt Conference – Big Sky, MT
• 7/16/2019 – HCAA TPA Summit – Dallas, TX
• 7/31/2019 – 2019 MVP Academy – Wellesley, MA
• 8/20/2019 – Pritchard & Jerden Employee Benefits Forum – Brookhaven, GA
• 9/17/2019 – WebTPA Annual Confernece – Dallas, TX
• 9/19/2019 – Employee Benefits Planning Association Conerence – Seattle, WA
• 9/30/2019 – SIIA National Educational Conference & Expo – San Francisco, CA
• 10/27/2019 – 2019 Annual NASP Conference – Washington DC
Phia’s 2020 Speaking Engagements:
• 1/30/2020 – SunLife MVP Academy – San Diego, CA
• 1/31/2020 – 2020 Kairos Risk Management Summit – Phoenix, AZ
• 2/13/2020 – Artex Risk Solutions Conference – Orlando, FL
• 2/18/2020 – HMIG Producer Advisory Counsil – Amelia Island, FL
• 3/9/2020 – CICA Captive Conference – Palm Springs, CA
• 3/12/2020 – SunLife MVP Academy – Kansas City, MO
• 3/26/2020 – TABA Spring Conference – Woodlands, TX
• 4/26/2020 – Berkley Captive Symposium – Caymen Islands
• 6/10/2020 – Leavitt Conference – Big Sky, MT
• 6/18/2020 – SunLife MVP Academy – Kansas City, MO
• 7/14/2020 – HCAA TPA Summit – St. Louis, MO
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Get to Know Our Employees of the Quarter:
Igor Senic & Desireé Erskine
Desireé is always going above & beyond to help everyone in the company. From trying to fix the fax machines & printers, sending out all of the mail when we are short-staffed at the front desk, to setting up a computer at a coworker’s home & driving them to and from work. She does all of these extra things while being the main component of the OP department. Desireé is an extremely hard worker who has passion and truly cares about this company.
Igor has worked so diligently over the past year in Accounting and it is well deserved. He has come up with multiple enhancements to improve and benefit the Accounting department.
A few examples:
(1) He has stepped up and has become someone on the team that the others can come to for assistance, ask questions, and resolve issues. (2) He set up training for the new Kentucky claims recovery specialists to make sure they are more comfortable with the Accounting payment process, along with trainings for the other accounting team members. (3) His knowledge of OP has helped make the OP payment processing more efficient & he was part of updating the OP payment process from processing payments individually to being able to process multiple payments at one time.
Congratulations Desireé (pictured above) and Igor, and thank you for your many current and future contributions.
Get to Know Our Employees of the Year:
Megan Colter & Joanna Wilmot
Megan joined our team as a Consultant in 2018. Since that time Megan’s duties have expanded to include final reviews of plan document checklists, assessments and SBC services. Megan has also been very helpful in training and mentoring new employees. Megan always makes sure the client’s expectations and deadlines are met. She has been staying late and/or working from home and her effort is appreciated. Megan is a pleasure to work with and we are happy she is part of our team!
Joanna is an exceptional example of a model employee. Her kindness, loyalty, enthusiasm, and dedication are only a few of the reasons why she deserves an employee of the year title. She is never short of energy which she selflessly offers to the team, her work product, and our clients.
She is dedicated and hardworking. Over the course of this year she reviewed, audited and revised each process to maximize efficiency and productivity. Specifically, our clients continue to ask for customized approaches, reports, and notifications. Most recently a TPA client requested a tailored notification process for when a mutual client was being onboarded by a partner vendor. Joanna not only went out of her way to build a notification process for this TPA but she also immediately implemented this process for all clients. This is an example of the personal touch and consistency she exemplifies every day. Building a sense of community is important to Joanna as well. For Thanksgiving she organized a team-building and community give back opportunity for PACE. This shows she not only cares about her team, but about her community and the team’s contribution to the community.
Congratulations Joanna & Megan, and thank you for your many current and future contributions.
PACE® Certification Is Making Waves
The PACE Certification program will educate you using 3 distinct chapters of information:
Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.
Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.
Explains what PACE is, what PACE does, and how it's obtained, implemented, and utilized. The PACE Certification program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.
Additionally, the PACE Certification program provides education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.
Please see the PACE Certification flyer, as well as this video for more information.
Please contact Michael Vaz (firstname.lastname@example.org) for more information.
Ugly Sweater Contest
The Phia family held its famous ugly sweater contest the week before Christmas, and we had a great turnout this year! With all of the great sweaters, it was a close race for finding the person with the ugliest sweater, but once we tallied up all of the votes, we found a winner. Congratulations to Rob Jolly, who is pictured below in the brown bear getup!
Halloween at Phia
Phia had its annual Halloween costume competition in late October. There were a lot of great costumes on display, but we could only choose one winner. Congrats to Ben Mooney, the homeless man with a passion for healthcare!
Candy Corn Contest
We set up a little contest at the front desk and asked everyone to guess how many candy corn! The winner was Andrew Fine, and the total count was 408. Andrew guessed that there were 402 pieces of candy corn. It’s hard to believe that all of those pieces of candy fit into that tiny jar!
• PACE Specialist
• Administrative Assistant
• Staff Attorney – PGC
• Health Plan Documentation Specialist
• Claims Specialist, Provider Relations
• Manager, Talent Acquisition
• Case Investigator I
• Data / ETL Analyst
• Provider Relations Client Concierge
• Vice President of Client Solutions and Account Management
• Human Resources Compliance Specialist
See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers
• Bethany LaChance has been promoted from Case Investigator to Claim Recovery Specialist III
• Dylan Fry has been promoted from Case Investigator to Senior Claim Recovery Specialist
• Allison Britton has been promoted from Case Investigator to Legal Assistant
• Brenna Jackson has been promoted from Legal Assistant to Senior Claim Recovery Specialist
• Jiyra Martinez has been promoted from Customer Service Representative to Senior Claim Recovery Specialist
• Diane Mcauley was hired as an Executive Assistant
• Arianna Hibbard was hired as an Executive Assistant
• Robert Jolly was hired as a Claim And Case Support Analyst
• Jessica Grande was hired as an Intake Specialist
• Alyssa Campbell was hired as a Case Investigator
• Elizabeth Painten was hired as a Human Resources Assistant
• Corey Crigger was hired as a Provider Relations Attorney
• Joshua Farley was hired as a Provider Relations Attorney
• Cole Wagner was hired as an Accounting Assistant