The Phia Group Blog Posts

First to Market

On January 13, 2025
Unfortunately, there has long been a widely held perception that the healthcare industry is largely antiquated and riddled with inefficient processes. Perhaps that can explain why last week’s announcement – that Machinify, a provider of artificial intelligence (AI)-powered software for streamlining the healthcare claims lifecycle, will become an integral part of the company recently formed through the merger of The Rawlings Group (“Rawlings”), Apixio’s Payment Integrity business (“Apixio PI”), and VARIS – was deemed particularly newsworthy. That this new conglomerate, to be named Machinify, will be leveraging next generation technology and a wealth of data to further automate and enhance healthcare administration processes has apparently captured the imagination of healthcare stakeholders worldwide, and struck a chord with those that believe the healthcare industry must do more to leverage new technologies and catch up to other innovative industries.

An App for What Ails You

On January 13, 2025
This is the future presaged by “PDURS” (Prescription Drug Use-Related Software). One of the sillier acronyms to grace the healthcare industry in recent memory, PDURS are defined by the FSDA as “software disseminated by or on behalf of a drug sponsor that accompanies one or more of the sponsor’s prescription drugs, including biological drug products.” Essentially, most patients will encounter this software as an app, paired with marquee prescription drugs, that is designed to “assist” patients and healthcare providers in the prescription and use of the medication.

The Phia Group Announces the Promotion of John Blaney to Executive Vice President of Transformation and Recovery Services

On January 9, 2025
In its ongoing efforts to be a trailblazer in the healthcare cost containment field, The Phia Group has promoted John Blaney to Executive Vice President of Transformation and Recovery Services. In his new role, Mr. Blaney will spearhead all recovery functions, including subrogation, overpayment, and other cost containment opportunities. Mr. Blaney will leverage his decades of experience serving as an executive in the healthcare field toward streamlining operations as well as automating department-wide processes, all of which will help optimize services offered to Phia’s clients. The Phia Group’s successful growth initiatives and major investments in technology have enabled us to identify more recovery opportunities and deliver higher recoveries to our clients than any other recovery vendor in the market.

Why Wesco v. BCBSM Matters (A Lot)

On January 8, 2025
Back in November, Wesco, a 55-year-old privately-held gas station chain, and the benefits fund for the Utility Workers Union of America filed a class action lawsuit, alleging that Blue Cross Blue Shield of Michigan (BCBSM), an insurance carrier serving over six million Midwesterners, engaged in an anticompetitive practice by charging an additional PEPM (“per-employee, per-month”) fee to any group that opted to use a stop-loss carrier other than BCBS. For BCBS of Michigan, the fee represents a fairly standard industry practice for charging a plan extra if it opts to use a non-preferred stop-loss carrier; conversely, for the aforementioned plaintiffs, the constantly escalating PEPM fee represents a means for inflating costs for the already cash-strapped covered groups as well as driving smaller stop-loss carriers out of the market. Looking ahead, how this case plays out in federal court in Michigan will have a monumental impact on not just the stop-loss marketplace but also the self-funding industry in its entirety.

No Extension for HDHPs and Telehealth

On January 6, 2025
It’s not the news any of us wanted to hear, but 2025 has arrived with no extension to the telehealth services safe harbor for high deductible health plans that are HSA-qualified. As such, the safe harbor officially expires for plan years starting on or after January 1, 2025. There were numerous reports that an extension was included in early drafts of the bill to keep the government funded in December, but the bill passed and signed by President Biden on December 21, 2024, did not include this extension.

Empowering Plans: P208 – The Evolution of the Birth Control Benefits Mandate

On January 2, 2025
On today’s episode of the Empowering Plans podcast series, attorneys Kendall Jackson and Brian O’Hara discuss the Biden administration’s decision to withdraw proposed rules that would have expanded the birth control benefits mandate. Join us in our discussion of the mandate and how it has evolved throughout the Obama, Trump, and Biden administrations.

Anthem Blue Cross Blue Shield’s Major Reversal

On December 26, 2024
Earlier this month, as the healthcare industry was receiving an inordinate amount of unwanted public attention and scrutiny, there was actually a positive development stemming from one of the country’s largest health insurers. Indeed, lost in the shuffle amidst the chaotic aftermath of the murder of UnitedHealthcare CEO Brian Thompson was Anthem Blue Cross Blue Shield’s reversal of its initial decision to stop paying for anesthesia care in certain states if the surgery or procedure extends beyond a particular time limit. Had such a titan of the health insurance industry proceeded in not paying for medically necessary anesthesia services, tens of thousands of Americans – many of whom are of limited financial means -- would have been at risk of getting cut off from a life-saving service.

Empowering Plans: P206 – Non-Preferred Carrier Fees: Incentives or Control?

On December 5, 2024
In this episode of the Empowering Plans podcast, attorneys Jon Jablon and Brady Bizarro delve into the details of a recent lawsuit where BCBS of Michigan, in its capacity as a TPA, is alleged to have engaged in anticompetitive practices for charging a fee to a group that chose a stop-loss carrier other than BCBS. This case is in its infancy as of December 2024, but we expect it to have noticeable effects on the stop-loss marketplace regardless of outcome. In this episode, Jon and Brady discuss those potential effects and how a holding either way could impact self-funding as a whole.

Life After Helene: The Ever-Widening Health Disparity in Appalachia

On December 2, 2024
Well before Hurricane Helene, one of the deadliest storms in modern American history, ripped through Western North Carolina earlier this autumn, decimating scores of residences and businesses and washing away entire neighborhoods, the largely impoverished Appalachian region was grappling with a precarious healthcare infrastructure. To this day, Asheville, North Carolina, and its surrounding mountainous communities have never fully recovered from the devastation of the Great Recession of 2008, resulting in a grave health disparity among other societal ills. And, yes, the recent ferocious tempest of which Western North Carolina bore the brunt has only exacerbated the region’s already fragile healthcare system.

New Requirements Under the Mental Health Parity and Addiction Equity Act (“MHPAEA”)

On November 20, 2024
The deadline to comply with several of the new final rules regarding the Mental Health Parity and Addiction Equity Act (“MHPAEA”) is quickly approaching. On September 9, 2024, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released new final rules that updated existing regulations to provide additional clarity for plans and their vendors on what is required and what will be considered compliant and non-compliant for parity purposes when performing a nonquantitative treatment limitation (NQTL) comparative analysis.

A New Year, a New Administration, but the Same Old Problem?

On November 19, 2024
On Friday, November 1, millions of Americans awoke from their Halloween slumber only to be further spooked by a New York Times report that employers expect the costs of health benefits to surge as much as 9 percent on average in 2025. How much will the outcome of this month’s elections – held during many companies’ open enrollment period -- impact this now decades-long industry trend? What does this all mean for plans interested in covering big-ticket items like weight loss drugs and next-generation gene therapies in the new year? As 2024 soon merges into 2025, join The Phia Group’s webinar as its panel of experts break down how election results will impact the industry and look ahead to what compliance changes are afoot in just over a month ahead. Indeed, this is a crucible moment for the healthcare industry – and Phia’s Independent Consultation & Evaluation (ICE) team looks forward to lending its expertise.

Navigating Balance Billing and Post-Payment Disputes: Solutions for TPAs and Self-Funded Employers

On November 14, 2024
As rising healthcare costs continue to challenge employers and third-party administrators (TPAs), Reference-Based Pricing (RBP) has emerged as a powerful strategy for cost containment. However, RBP, while promising, is not without its pitfalls. Chief among them is balance billing, in which providers charge patients for the difference between their billed charges and the RBP plan’s payment. Additionally, the No Surprises Act (NSA) has introduced Open Negotiations and Independent Dispute Resolution (IDR) processes, which, while protecting patients, expose employers to post-payment disputes. Addressing these concerns effectively requires comprehensive tools, support, and strategic implementation.

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