From drafting the plan document all the way to recovering subrogation claims, health plans (and the TPAs, brokers, stop-loss carriers, and other vendors that service them) need to be creative, diligent, and vigilant. Network contracts, stop-loss claims, and intricate medical claim determinations are just a few of the complications that self-funded health plans and their partners need to be able to successfully navigate. Join The Phia Group’s legal team for an hour as they discuss some common snafus that health plans and TPAs face, and propose some creative solutions for managing them.
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Check out these highlight snippets from our August 14 Webinar:
July 2018 PGC FAQs (11 minutes into Webinar)
Jennifer McCormick: Continuation of coverage versus a leave of absence are completely different concepts. ADA leave, specifically, is granted to an individual as a reasonable accommodation. Employers began adding these provisions to their plans due to the UPS case in which there was an individual who was pregnant and unable to continue delivering packages for UPS and there was no other function that she could perform. Thus, the reasonable accommodation for her was a leave of absence under the ADA. This is separate from short-term disability or long-term disability in that the leave under the ADA is an accommodation, as opposed to a designated leave granted through a specific employer policy.
Network Contracts (28 minutes into Webinar)
Jon Jablon: First, plans can terminate network contracts. Obviously, you should not do this before notifying the parties involved. However, in terminating the contracts, there are many reference-based pricing (RBP) vendors out there that can help you achieve your payment goals. Every RBP vendor has their own style and techniques, so we recommend you vet each one prior to making a decision. RBP also includes carve-out options, and some popular ones associated with high-dollar claims are dialysis carve-outs and air ambulance carve-outs. If are seeing claims that you can carve out of your plan, chances are there is some way to address it. It is also possible to carve out all out-of-network claims – so not just dialysis or air ambulance. This would be anything not covered by the preferred provider organization (PPO) contract.
Brady Bizarro: We have seen a lot more new disputes lately. Many have to do with soft gaps, which may not catch your eye if you are reviewing a stop-loss policy on its own. For example, there may only be four exclusions and it may say that it otherwise mirrors the plan document, but you may not always be good to go. First, the treatment of Pharmacy Benefit Manager (PBM) rebates, which can be an issue if you have a high volume of drug claims. A plan, in theory, gets rebates from drug manufacturers, but in reality, it is the PBM who is getting those rebates. One plan’s stop-loss carrier somehow found out about these rebates through an audit and was then reducing the reimbursement amounts by the rebate figures, even if it was the PBM and not the plan getting money. The key was interpreting the wording, as some carriers may use “refund” instead of “rebate”. Another issue relates to billing protocols, as some stop-loss policies will reimburse claims in accordance with “standardized billing protocols”. Some carriers even cite Centers for Medicare & Medicaid Services (CMS) billing protocols even though CMS is not the payer and this is a private payer. Medicare reimbursement rates are not the issue here, it is the way Medicare itself pays claims.