On this episode of the Empowering Plans podcast series, attorneys Corey Crigger and Cindy Merrell discuss the murder of UnitedHealthcare’s CEO, which fueled public outcry over denied claims. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
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. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
By: David Ostrowsky
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.
In the immediate aftermath of Helene, thousands of residents whose cars were buried under their collapsed homes found themselves bereft of medication refills, IV fluid bags (there’s been a lot of publicity about this in particular), insulin supplies, and dialysis equipment among so many other life-saving resources. In addition to the scarcity of options for reliable transportation to medical appointments – or the inability to walk safely along public roads laced with downed trees and electrical wires – survivors have faced the heightened risk of exposure to sewage, toxic industrial waste, and mosquito-borne illnesses stemming from the raging, out-of-control floodwaters. Meanwhile, the blunt force of the storm’s impact has caused a bevy of short-term injuries that, because they have not received immediate medical attention, could mushroom into chronic, far more severe issues. This is to say nothing of the severe mental health problems many residents are surely experiencing in the wake of losing loved ones and having their lives uprooted. To put it another way, instead of shopping for holiday gifts in the coming weeks, many will be busy filing insurance claims.
As North Carolinians whose lives have been upended continue to endure such apocalyptic circumstances, nearby healthcare facilities (or those that are accessible) have faced their own mounting problems. While the physical infrastructure of nearly all community health centers in Western North Carolina remained unscathed, there has been a universal struggle for facilities to obtain clean potable water for sanitizing equipment, cleaning wounds, washing hands properly, or even making an adequate amount of coffee for providers to stay alert. For over a month now, it has been an endeavor of colossal proportions for Asheville’s Mission Hospital, the only designated trauma center in Western North Carolina, to obtain clean, usable water while other facilities − such as Asheville's Planned Parenthood clinic and local birthing centers – were relegated to slashing critical health services due to the lack of running water. By all accounts, the dearth of potable water has been the chief culprit behind the systemic woes bedeviling the region’s healthcare landscape. (It also bears mentioning that there were some North Carolina nursing homes still without an adequate supply of running water for several weeks after Hurricane Helene made landfall.)
In addition to clean water, another all-important resource in drastically short supply for such healthcare facilities is that of adequate manpower. For an area of the country that was already struggling mightily to recruit and retain medical staff, Helene dealt a devastating blow. Truthfully, many of the healthcare workers in Western North Carolina themselves were personally affected by Helene. Some tragically lost their lives while many others have struggled to help victims as they and their families have been experiencing unimaginable distress. Certainly, volunteer doctors, nurses, and psychologists have descended on the region to help hospital patients – as well as those who are housebound often without internet, reliable phone service, electricity, and running water – but a severe staffing shortage, one that may portend a wave of hospital closures, still looms large in the storm-ravaged region.
“How do we attract someone to come into the area at this moment?” Kim Wagenaar, the chief executive of Western North Carolina Community Health Services, which serves 13 counties in the region, shared with the New York Times in an October 28 piece. “It’s just going to take a long time to really mitigate the effects of this disaster.”
Though hurricane season may be winding down, we can’t lose sight of the legions of victims of Helene who want nothing more than adequate healthcare services this holiday season.
By: Kendall Jackson, Esq.
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. The final rules generally apply to group health plans, including self-funded non-Federal governmental health plans that, prior to the issuance of these rules, were able to opt out of MHPAEA compliance. The extension of MHPAEA’s application to self-funded non-Federal governmental health plans is beneficial to ensure that no plan may impose an NQTL with respect to mental health or substance use disorder (“MH/SUD”) benefits in any classification that is more restrictive, as written or in operation, than the predominant NQTL that applies to substantially all medical/surgical (“M/S”) benefits in the same classification. Of the newly outlined rules, most apply to group health plans on the first day of the first plan year beginning on or after January 1, 2025.
The final rules codify that health plans must perform a comparative analysis, which must include an evaluation of NQTLs for network composition, out-of-network reimbursement rates, medical management standards, and prior authorization, as well as six additional elements, such as a description of the NQTL, identification of and definitions for the factors and evidentiary standards used to design or apply the NQTL, and a description of how factors are used in the design or application of the NQTL. The final rules also outline certain responsibilities for plan fiduciaries. The final rules require certification confirming the plan fiduciary’s engagement in a prudent process to select one or more qualified service providers to perform and document a comparative analysis in connection with the imposition of any NQTLs that apply to MH/SUD benefits under the plan in accordance with MHPAEA and its implementing regulations, as well as satisfaction of the duty to monitor those service providers. At a minimum, the Department of Labor expects that the plan fiduciary will review the comparative analysis, ask questions about the results, discuss the results with those who drafted it, if necessary, and ensure that the service provider conducted the comparative analysis in compliance with MHPAEA.
Separate from those requirements listed above, the implementation of several other requirements is delayed until January 1, 2026. This includes the meaningful benefits standard, which requires that if a plan provides any benefits for an MH/SUD condition in any of the six benefit classifications, it must provide “meaningful benefits” for that condition or disorder in every classification in which meaningful M/S benefits are provided. Also delayed are the regulations requiring plans to satisfy the design and application requirements, which include the prohibition on discriminatory factors and evidentiary standards, and the relevant data evaluation requirements, which involve collecting and evaluating relevant data to assess the impact of NQTLs on access to MH/SUD benefits and M/S benefits. Any requirements for the provisions of the comparative analyses related to the delayed requirements are also deferred until January 1, 2026.
While several of these new requirements are not applicable for quite some time, plans that cover both M/S benefits and MH/SUD benefits and impose NQTLs on MH/SUD benefits should be sure to perform and document a comparative analysis of the design and application of each applicable NQTL in a manner consistent with the new final rules. The Departments have yet to provide how often these comparative analyses should be performed, but rather state that they should be kept current. We generally interpret this to mean that they should be performed annually based on the fact that the plan is updated annually.
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.
Click Here to View Our Full Webinar
To obtain a copy of our webinar slides, please reach out to [email protected].
By: Scott Bennett and David Ostrowsky
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.
Addressing the Challenges of RBP Programs and NSA Requirements
RBP programs use reference points such as Medicare rates to create more predictable and transparent pricing. While this can reduce healthcare costs and broaden provider options, it also exposes plan participants to potential balance billing when providers reject the RBP payment as full settlement and bill the patient for the remaining balance. This creates financial stress for both patients and employers.
The introduction of the NSA further shifts the focus of payment disputes from patients to employers. Open Negotiations and IDR processes require a deep understanding of regulations, adherence to strict timelines, and awareness of critical benchmarks necessary to successfully argue, negotiate, and defend cases. TPAs and self-funded employers must navigate these processes carefully to mitigate risk and manage potential exposure.
How Comprehensive RBP Solutions and NSA Expertise Mitigate Risks
1. Effective Balance Bill Resolution
Choosing an RBP solution that offers strong balance bill resolution is critical. Programs that include direct intervention and independent legal support can prevent unexpected financial burdens on employees and reduce the administrative load on employers and TPAs. Care Empowered Pricing, for instance, includes this type of support, leveraging years of experience in resolving balance billing issues effectively and adapting to the evolving regulatory landscape under the NSA.
2. Expertise in NSA Open Negotiations and IDR
Handling Open Negotiations and IDR requires more than basic dispute resolution skills. Employers need an informed and experienced team that understands the regulations, adheres to strict timelines, and recognizes the important benchmarks necessary to advocate successfully. Solutions that provide this level of expertise ensure that employers are prepared to navigate these complex processes and defend their positions effectively, minimizing exposure and ensuring compliance.
3. Empowered Provider Selection
The use of advanced provider data and selection tools can greatly enhance the success of an RBP program. By using technology-enabled repricing engines, TPAs can glean insights into provider practices and payment acceptance, thereby steering employees toward providers more likely to accept reference-based payments without triggering balance bills. This also helps reduce the frequency of disputes requiring NSA Open Negotiations or IDR processes.
4. Member Education and Support
Educating employees about how their RBP plan functions and how to identify compliant providers is essential. Solutions that offer real-time support and guidance ensure that members are confident and well-prepared when navigating healthcare services. Additionally, having a well-informed and experienced team capable of reacting swiftly, reaching out, and using technology based on practical experience to track and resolve cases is vital. Care Empowered Pricing emphasizes member education and continuous access to resources in order to bolster awareness of the NSA processes.
Best Practices for Preventing and Resolving Balance Bills and Navigating NSA Processes
Preventing and addressing balance billing and post-payment disputes is essential for the success of any RBP program. Key practices include:
Why Enhanced RBP and NSA Solutions Matter
For TPAs and self-funded employers, selecting an RBP solution that encompasses customizable pricing, experienced advocacy, and continuous member support—while also incorporating expertise in NSA regulations and dispute resolution—is essential. Solutions like Care Empowered Pricing deliver comprehensive approaches, ensuring that participants are informed, supported, and protected from balance billing challenges and that employers are well-equipped to handle post-payment disputes. This creates a more sustainable, efficient, and fair approach to healthcare pricing and compliance that benefits all stakeholders.
By integrating these strategies into their RBP programs, TPAs and employers can enhance participant experiences, reduce financial risks, and build a healthcare framework centered on transparency, fairness, and robust regulatory compliance.
On this episode of the Empowering Plans Podcast, attorneys Ron Peck and Nick Bonds talk through a recent Florida case addressing judicial review of IDR determinations and highlight some of the key insights and takeaways for any entity subject to the No Surprises Act. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
The Independent Dispute Resolution (“IDR”) process was designed to be a cornerstone of the No Surprises Act (“NSA”), a means for resolving claims for payment for out-of-network items and services and a vital mechanism for buttressing the NSA’s protection for plan members against potentially devastating balance billing expenses. Unfortunately, since the NSA took effect on January 1, 2022, things have gone awry on many fronts.
The case volume has overloaded the IDR process; courts have been split over whether and how parties can enforce arbitration awards; payers, including group health plans, have paid close to four times as much for services as CMS rates. Ultimately, the confluence of these troubling dynamics threatens to undermine the original intent of the NSA and elevate costs for all.
In fact, in the most recent edition of JAMA Internal Medicine, a prominent monthly peer-reviewed medical journal published by the American Medical Association, authors Kevin A. Schulman, MD and Barak Richman, JD, PhD, provided indisputable evidence that prices stemming from IDR decisions closely align with what providers – many of whom belong to private equity-backed practices -- have requested, vastly exceeding Medicare rates and prior in-network commercial market prices. As just one example, Schulman and Richman report median IDR decisions (from Q1 and Q2 2023) for three categories of services – emergency care, imaging, and neonatal/pediatric critical care – that surpass Medicare prices by a factor of 3.7 or more for all three service types. Clearly, the NSA has not curtailed exploitive business practices and at this time, there still aren’t any implementing rules in force, as arbitrators continue to operate with minimal substantive guidance in trying to resolve price disputes.
Subsequently, now, more than ever, it is of paramount importance to understand how such developments will impact your self-funded health plan. Handling NSA claims is, after all, still a relatively new process, one largely bereft of transparency, and many plans are understandably struggling to manage open negotiations and subsequent IDR procedures. In this regard, The Phia Group, with its battle-tested processes for deftly handling NSA claims and appeals and utilization of intelligent out-of-network pricing methodologies, benchmarking and cutting-edge appeal review software, can provide immeasurable value.
“Unlike the rest of the organizations in this industry that provide NSA services, our reputation was built on ensuring that all regulatory, compliance and plan design needs are focused on first,” explains Phia CEO Adam V. Russo. “This includes understanding the processes and tools that administrators have in dealing with the vastly different deadline and notification aspects of the NSA. We know it, we built our software around it and our extensive team of experts ensures that we meet every set of standards needed for a successful NSA program, including coordination of stop loss carriers.
“There is no other firm with repricing capabilities that can match our reputation and outcomes when it comes to navigating the legal complexities that this service requires.”
Some of the core reasons why Phia’s IDR support service achieves optimal results:
“With a powerhouse team of seasoned attorneys, certified medical coders, data-savvy analysts, and skilled negotiators, Phia is uniquely equipped to handle straightforward NSA claims with precision and seamlessly scale to expert-level solutions for the most complex cases,” added Scott Bennett, Phia’s Senior Vice President of Provider Relations.
Undeniably, the IDR process continues to be riddled with significant ambiguity and opacity but The Phia Group, for the aforementioned reasons along with many others, has the resources to help you navigate the chaos.
Since the US Supreme Court decided to undo nationwide abortion rights in summer 2022, women’s reproductive rights has arguably been the most pressing topic in healthcare. Naturally, as we enter the final stretch of election season – as well as the Biden administration – the all-important, polarizing matter has resurfaced.
Earlier this month, the departments of Health and Human Services, Labor and Treasury proposed to broaden a federal mandate (under the Affordable Care Act) obligating private health insurers to cover condoms, birth control pills, and “morning after” pills for women on private health insurance plans – even without a prescription. Currently, health insurers are mandated to cover only the cost of prescribed contraception; should the new rule become law next year, over 50 million more American women on private health insurance plans would be able to go to their local drugstores and pharmacies and purchase these items, irrespective of whether or not they were prescribed. Accordingly, private health plans would also be required to disclose to women that those contraceptives are covered without cost-sharing.
Taking a deeper dive into the proposed rule, it’s apparent that there’s more than just the matter of whether or not a pill is prescribed. Under the Biden administration’s plan, insurers would have to cover all FDA-approved drugs and drug-led combination products, unless the plans also cover a therapeutic equivalent. Therapeutic equivalents, per the FDA, are drugs that have an identical amount of the same active ingredient. At this hour, insurers only need to cover one drug per category of contraception — which could be birth control pills, implants or IUDs — causing some women to have difficulty accessing the precise combination of drugs in the type of prescription contraceptive they so desire.
Practically speaking, the Biden administration’s proposal could have life-changing consequences for large swaths of the female population in this country. The emergency contraceptives that women on private insurance plans would be able to access without cost – and prescription – most notably include levonorgestrel, more commonly known by the brand name “Plan B,” which is a pill that must be taken immediately after intercourse to prevent pregnancy. As it currently stands, when women don’t have a doctor’s prescription, they may pay as much as $50 for a pack of the pills. Thus, women who may feel inclined to delay purchasing the medication until they get a doctor’s prescription could be compromising the efficacy of the pill – perhaps without even being aware. Moreover, if this new rule is in fact implemented, insurers would have to assume the full cost of Opill, a new OTC birth control pill that the FDA approved last year. A one-month supply of Opill costs $20, perhaps not an extravagant price but nonetheless one that may be prohibitively expensive for some.
Vice President Kamala Harris, who has affixed her presidential campaign to a pledge to embolden women’s healthcare rights, trumpeted her administration’s proposal, declaring in an official statement:
“Every woman in every state must have reproductive freedom and access to the health care they need. That is why I have fought to lower health care costs and protect the ability of every woman to make her own decisions about her own body."
“Today, our Administration is proposing the largest expansion of contraception coverage in more than a decade. This new proposed rule will build on our Administration’s work to protect reproductive freedom by providing millions of women with more options for the affordable contraception they need and deserve.”
Since the passage of the Affordable Care Act, women have saved billions of dollars that they would otherwise have spent on contraception. But now, for the first time in the history of the United States there is strong potential for universal coverage for no-cost, over-the-counter, no-prescription-necessary contraception, which would save even more billions.
Join Attorneys Corey Crigger and Kendall Jackson on this Halloween edition of the Empowering Plans Podcast. Corey and Kendall take a look at topics that send shivers down the spine of the self-funded industry. How do you protect your plan from the scary cost of gene therapies? What will the rapidly advancing AI sector mean for you and your clients? What is the best trick or treat candy? Tune in to find the answers to these questions and many more on the Empowering Plans Podcast. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
Although healthcare hasn’t stolen the limelight as it did in past elections, those “in the know” know that the results of this historic election will have a major impact on healthcare and health benefit plans alike. Between soaring drug costs, increased fiduciary litigation, the impact of A/I, and growing popularity of weight-loss drugs (which is likely to escalate as the year ends), to thrive in 2025 and beyond industry insiders must understand the current state of the market as well as predict what is to come. Join us as we discuss these and other pressing issues. Also, speaking of A/I, our team will present a live demonstration of SoPhia, our very own chatbot, which will engage with audience questions. Click Here to View Our Full Webinar To obtain a copy of our webinar slides, please reach out to [email protected].
Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo:
Halloween is my favorite holiday of the year, though my reasoning has evolved over time. Back in the day, I used to love wearing a cool costume and going trick or treating in my neighborhood. Could anything beat the combination of free candy, time with friends, and fresh air? Today, however, Halloween is no longer about serving myself, and rather, is about bringing joy to my own children and our neighborhood kids. That passion to serve others drives me to – according to my wife – go a little too far. Each year I basically build a haunted house in my front yard, for the entertainment of the hundreds - yes I said hundreds - of kids that stop by and care to be spooked by my many scary decorations and animatronics…
It's gotten to the point that people from other neighborhoods come to mine just to see what I have in store that year. At this point, you may be asking what this has to do with The Phia Group, health insurance, benefit plans, or any of the other pressing topics and innovative services that Phia has to offer. I mean, election day is upon us, laws are changing, litigation is pending, regulations are evolving… At first blush, you’ll say my story is unrelated… but you’d be wrong. Watching hard work translate into joy; investing time and effort into serving others; it all boils down to one important thing – passion.
Just as my passion for Halloween has expanded and grown to include a larger community, so too has my passion for this industry expanded and evolved. Moreover, a passion for serving others is paired with a passion to compete! I'm out there trying to outdo the neighbors. I need to have the coolest set up in town with the latest items and features. The same can be said for The Phia Group as well. Yes; we are focused on reducing the cost of care while improving quality outcomes, but we also want to be the best at what we do. We are passionate about every service, every feature, every new piece of technology and we want to share it – both our services and our passion – with the industry. Just like I want to share my love of Halloween with my neighborhood. What a treat!!! Well I hope you have lots of children dressed up and ringing your doorbell this October 31st. I can't wait to see the creativity in some of the costumes just like you all enjoy the creativity of our plan documents.
It's a great time of year - 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: Phia Unwrapped (featuring Phia Ignite)
Wrap networks? More like Cr-- well, they’re not great, anyway. Instead of that antiquated and widely despised fallback for OON claims, Phia Unwrapped is a better, smarter, more cost-conscious way to manage those claims.
Powered by the expertly crafted Phia Ignite Repricing Engine, Phia Unwrapped boasts best-in-class claims repricing and comprehensive patient-centric balance billing support with the full weight and skillset of The Phia Group behind it.
If you haven’t used, seen a demo of, or heard great things about Phia Unwrapped, we urge you to email [email protected] today. (Your bank account will thank you.)
Enhancement of the Quarter: SoPhia
The Phia Group’s great consulting and technology minds have continued to refine our artificial intelligence (AI) tool, SoPhia, which is expertly trained using documentation curated explicitly for SoPhia. This is unique in that SoPhia is trained exclusively with Phia’s own consulting expertise and carefully curated third-party sources in order to maximize the quality of SoPhia’s responses.
We're excited to announce that two of our clients are now participating in the beta testing phase, exploring how SoPhia can streamline tasks and disseminate information in a helpful way.
We’ve engineered SoPhia to help improve the ICE service for all users, whether directly or indirectly, and the beta testing program is a step toward broader usage. We look forward to expanding SoPhia’s capabilities and we’re eager to eventually roll it out to all our ICE clients!
Phia Case Study: Third Opinions
Note: this is not one single case study, but a conglomeration of many similar ones.
Medical reviews have become an integral part of claims and appeals adjudication, and with good reason: employers are not clinicians (. . . unless the group is literally a group of clinicians). But what happens when a medical review is performed on an initial claim and yields one result, and then a different medical review is performed on appeal and yields the opposite result? Does the plan necessarily have to trust the second opinion? If it differs from the first opinion, who’s to say that the second one is more correct than the first?
The answer depends on the circumstances, but like so many things, the plan has to make sure that it’s being reasonable in its administration of this type of issue. For instance, some plans continue to rely on an initial medical review (which supports the benefit exclusion) through the entire appeals process, but that’s likely a violation of the appeals regulations that require a new review on appeal. Other plans seek a second medical review on appeal, and operate based on the second, more recent medical review. Other plans still look for a “tiebreaker” medical review when the initial two conflict; the process has to end somewhere, after all.
Though we are generally of the opinion that either of the second two options is compliant (that is, rely on the later medical review on appeal, or rely on the “tiebreaker” when the initial two conflict), we can say with confidence that relying on a single medical review that supports the claim denial throughout the entire appeals process is not compliant.
This is one of the draws of The Phia Group’s Plan Appointed Claim Evaluator (PACE) service: whenever there’s a clinical question, we have a new medical review performed, so you never need to worry that you’ve relied on the same review the whole way through the process!
Fiduciary Burden of the Quarter: Aligning the SPD with Network Contracts
Too many times, Phia’s consulting team has encountered Plan Documents that say in no uncertain terms that all claims payments will be limited to some sort of U&C-based amount. That’s fine, of course, but only if it’s accurate! Unfortunately, if a claim is subject to a network contract, that U&C limitation can’t be applied, and the SPD language becomes accidentally incorrect.
Though it’s unlikely that anyone will complain about a technical SPD violation when the provider and patient are both happy because a claim is paid at the network rate instead of the lower rate specified in the SPD, it’s nonetheless a breach of the fiduciary’s duty to fail to not administer the plan strictly in accordance with the SPD – not to mention that stop-loss carriers generally don’t reimburse claims paid at amounts higher than the SPD allows, regardless of the fact that the employer has separately agreed to make the higher payment via its network contract.
Luckily, there’s a simple fix for this: to make sure the SPD remains accurate with respect to contracted claims payments while keeping its strong cost containment for non-contracted claims. Our preference is something simple, such as defining the payable rate as “a negotiated rate, if one exists,” and then falling back to the other cost containment methods if there’s no negotiated rate.
It’s very important for a fiduciary to do exactly what the SPD says – so we urge employers and those who service them to be diligent about making sure the SPD language is accurate with respect to claims payments.
Webinars:
• On August 19, 2024, The Phia Group presented “Don't Be Surprised - Phia's Keys to Success with The No Surprises Act and Appeals Management,” in which we discussed our unique, battle-tested processes for handling NSA claims and appeals.
• On July 16, 2024, The Phia Group presented “The Impact of Provider Trends on Stop-Loss and Plans,” in which we discussed how to counterbalance rising prices as well as navigate increasingly complex interactions with stop-loss.
Be sure to check out all of our past webinars!
Podcasts:
Empowering Plans
• On September 27, 2024, The Phia Group presented “Senator Sanders: “Stop ripping us off,” in which our hosts, Brady Bizarro and Andrew Silverio, discussed senate committee hearing on GLP-1 drug pricing and strategies that self-funded employers are using to manage the extreme costs of these drugs while we wait and hope for congressional action.
• On September 12, 2024, The Phia Group presented “Diving Into the Parity Pool: MHPAEA’s Latest Updates,” in which our hosts, Jennifer McCormick and Bryan Dunton, discussed several critical considerations for plans as renewal season approaches.
• On September 5, 2024, The Phia Group presented “Recognizing Our Blind Spots” in which our host, Adam V. Russo, was joined by our special guest, Dr. Marty Makary. Listen in as they discuss his new book, Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health.
• On August 29, 2024, The Phia Group presented “Summer Regulation Rundown,” in which our hosts, Kelly Dempsey and Nick Bonds, discussed some of the big rules we’re looking forward to as the clock gradually runs out on the Biden administration and the challenges they may face.
• On August 15, 2024, The Phia Group presented “Healthcare on the Ballot,” in which our hosts, Nick Bonds and Corey Crigger, discussed the impact that each administration could have on the self-funded industry and the country.
• On August 1, 2024, The Phia Group presented “The Concerns About PBMs and the Demand for Reform,” in which our hosts, Jon Jablon and Kendall Jackson, broke down the consequences of PBM steerage.
• On July 18, 2024, The Phia Group presented “Exploring Claims Processing Models,” in which our hosts, Andrew Silverio and Cindy Merrell, delved into the pros and cons of the pay and chase versus pend and pay models of claims processing.
• On July 2, 2024, The Phia Group presented “SCOTUS Decisions: Harrington and Loper's Impact on Healthcare,” in which our hosts, Brady Bizarro and Corey Crigger, broke down two of the most significant Supreme Court cases just decided this term – the Harrington case and the Loper case.
Be sure to check out all of our latest podcasts!
Back to top ^
Phia Fit to Print:
• Worklife News – From ‘Tinder Leave’ to Pet Insurance, Employers Get Creative with Benefits – September 2024
• Medium – Driving Disruption: Adam V Russo Of The Phia Group On The Innovative Approaches They Are Taking To Disrupt Their Industry – September 2024
• Dorchester Reporter – ‘Dot kid done-good’ funds a scholarship at Suffolk – August 2024
From the Blogoshpere:
• What the Overturning of Chevron Means for Healthcare. Learn about the Supreme Court’s 1984 decision in Chevron U.S.A., Inc. v. Natural Resources Defense Council.
• Health Over Wealth. It has become fairly common practice for PE firms to acquire a struggling healthcare facility or physician practice, one desperately in need of capital and management expertise.
• Healthcare in Rural America. Healthcare inequality is a glaring problem across our nation, but the issue is particularly acute in rural America where folks grapple with a perfect storm of factors restricting access to medical facilities.
• Section 1557 Final Rule: Where Do We Stand? The implications of the Section 1557 Final Rule are currently in flux since the Final Rule was issued on April 26, 2024.
• The First Ten: Medicare Unveils Inaugural List of Negotiated Drug Prices. Will drug prices be coming down in the near future?
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.
Silent Auctions at SIIA National
At this year’s SIIA National event, Phia auctioned off a stunning painting by Rich Hunt, our Facilities Manager. The auction saw competitive bidding over two days, and Heather Schiappacasse emerged as the final winner. Additionally, Kelly Russo’s painting was auctioned off at our cocktail party, which was won by Danny Schwarz. The paintings raised over $1,300, with all proceeds going to support the Boys & Girls Clubs of Metro South. A big thank you to everyone who participated!
2024 Volunteer Day
The Phia Group had the opportunity to visit the Boys & Girls Clubs of Metro South to participate in some fun activities for the kids! With over 100 kids to entertain all day, we had plenty for people to do. Temporary tattoos, tie-dye, face painting, hiking, and so many more activities filled the day with so much joy and left us with so many memories. We are looking forward to next year’s Volunteer Day!
2024 Louisville Volunteer Day
Our Louisville team was out and about this past summer, volunteering at The Boys & Girls Club of Kentuckiana. They hosted a Water Wonderland event for the kids that included face painting, a water slide, sprinklers, water balloon/cannon games, and more. We hope you all had a great time and can’t wait to do it all again next year!
Backpack & School Supply Drive
We just wrapped up our annual backpack & school supply drive with The Boys & Girls Club of Metro South. Our staff collectively donated items and/or money to purchase supplies for 150 kids (ages 5-18). In total, we donated over 3,000 items . . . 3,304 to be exact.
Leukemia & Lymphoma Society
As a tireless supporter of the Leukemia & Lymphoma Society, The Phia Group, behind Chief Legal Officer, Ron E. Peck (Mission Award Winner – Research), was extremely proud to be a leading sponsor of this year's Boston Metro Visionary of the Year campaign. We are also thrilled to report that Ron's efforts placed him in the top five all-time fundraisers for this campaign and were a major reason why this turned out to be a record-breaking year. We look forward to continuing this wonderful partnership for many years to come.
Phia News:
Phia On Fire at SIIA National
The Phia Group brought incredible energy to this year’s SIIA National event! If you were there, you likely heard the buzz of cowbells coming from our booth. We had it all: hot sauce tastings, live painting sessions, and live demos of our new software. It was an exciting, interactive experience, and we can’t wait to do it all again in 2025!
Phia’s New Software
The Phia Group was proud to showcase four innovative software demos at the SIIA National Conference in Phoenix, AZ. These demos highlighted the latest tools designed to optimize healthcare cost containment and plan management:
• Care Empowered Pricing (CEP): Revolutionizing cost savings through smarter pricing strategies.
• Phia Appeals Management System (PAMS): Streamlining the appeals process for better efficiency.
• SoPhia: A sophisticated platform for actionable insights and automation.
• Phia Unwrapped: A cutting-edge service for unbundling and identifying hidden costs. These tools demonstrate Phia’s commitment to leading innovation in the industry. Check out our new demos, here: https://vimeo.com/1018445477/91a84ffba1
Phia on the News
The Phia Group’s CEO, Adam V. Russo, appeared on Boston 25 News to discuss the incredible partnership with The Boys & Girls Club of Metro South. He shared his personal story of his involvement with the club as a child and expressed how meaningful it is to give back to the organization that helped him in his youth.
Get to Know Our Employee of the Quarter: Alex Houle
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 is no one more deserving than Alex Houle to be recognized as The Phia Group’s Employee of the Quarter for Q3 of 2024.
Congratulations, Alex, and thank you for your ongoing and future contributions.
Job Opportunities:
• Sr. Claims Recovery Specialist
• Office Assistant (Accounting)
• Claims Recovery Specialist – Mass Tort
• Case Investigator
See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers
Promotions
• Bill Parlee has been promoted from Claims Recovery Specialist IV to Sr. Claims Recovery Specialist.
• Nicholas Walsh has been promoted from Case Investigator to Sr. Claims Recovery Specialist
• Jessica Grande has been promoted from Team Lead, Project Coordinator to Manager, Projects & Operations
New Hires
• Kendall Felici was hired as a Project Coordinator
• Brad Hall was hired as a Sr. Claims Recovery Specialist
• Bradley Lynch was hired as a Case Investigator
• Ben Chute was hired as a Salesforce Consultant
• Samantha Canestraro was hired as a Claims Recovery Specialist
• Hannah Coffey was hired as a Case Investigator
• Immanuel Allen was hired as a P/T Office Administrator
• Lakshmi Sreenevasan was hired as a VP, Data Services, Analytics and Automation
• Justin Forton was hired as a Client Success Account Executive
• Tamika Virgil was hired as a Customer Service Rep
• Keri Potter was hired as a Customer Service Rep
• Julie Wisch was hired as a Customer Service Rep
• Tabyrius Baldwin was hired as a Sr. Claims Recovery Specialist
• Brianna Sullivan was hired as a Customer Service Rep
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.
On this episode of the Empowering Plans Podcast, attorneys Jon Jablon and Cindy Merrell explore the changing landscape of several state and federal laws that affect coverage of gender-affirming care. Click here to check out the podcast! (Make sure you subscribe to our YouTube and Apple Podcasts Channels!)
As you’re reading this blog, millions worldwide are suffering from the horrors of schizophrenia, one of the most complex, debilitating, and stigmatized mental disorders inflicted on humanity, the symptoms of which typically manifest themselves in early adulthood, though they are not always so easy to detect. Those afflicted by this condition are desperately trying to manage an array of frightening symptoms (hearing voices, delusions, memory lapses to name a few) while carrying on with their lives. In this country alone there are approximately 2.8 million Americans living with schizophrenia; tragically, many of those 2.8 million Americans won’t be living much longer as there is a particularly acute rate of suicide among people battling schizophrenia. Meanwhile, so many others suffering often experience prolonged bouts of homelessness and/or run afoul of the law. And for decades, pharmacological innovation has moved at such a glacial pace that treatment has largely yielded inadequate improvement in symptoms and/or intolerable side effects during therapy that many have felt inclined to discontinue usage.
Starting this month, however, game-changing relief may be forthcoming. After 70 years of incremental progress, the FDA has greenlighted Bristol Myers Squibb’s new drug to treat schizophrenia, Cobenfy, which promises to alleviate said conditions while averting debilitating side effects previously associated with schizophrenia medications such as incontrollable weight gain, involuntary muscle jerking, and heightened risk for diabetes. In contrast to earlier iterations of antipsychotic medications that targeted dopamine receptors, the twice-a-day pill Cobenfy, the active ingredients of which are xanomeline and trospium chloride, works on cholinergic receptors. It’s a scientific breakthrough that could very well have a life-changing impact on this vastly overlooked, vulnerable population that, according to some estimates, exceeds 24 million people around the world.
“There is now an entirely new pharmacological approach for schizophrenia — one that has the potential to change the treatment paradigm,” Chris Boerner, Ph.D., board chair and CEO at Bristol Myers Squibb, remarked following the FDA’s landmark approval. “As we reenter the field of neuropsychiatry, we are dedicated to changing the conversation around serious mental illness, beginning with today’s approval in schizophrenia.”
While Bristol Myers Squibb may be trumpeting the efficacy of Cobenfy, the soon-to-be released medication is not without its own considerable side effects, namely heightened risk for nausea, vomiting, and constipation, as evidenced by clinical trial results. Still, considering that many patients deem medications currently available for schizophrenia to be grossly ineffective, the emergence of Cobenfy as a viable alternative to existing treatments may be grounds for cautious optimism.
Of course, the larger, no-pun-intended million-dollar question is whether or not Cobenfy will be prohibitively expensive for the masses in dire need of relief. Indeed, Cobenfy carries a list price of $22,500 for a year’s supply before accounting for insurer rebates or discounts, which according to a Bristol Myers spokesperson, is priced “in line with the landscape of branded oral antipsychotics.” Apparently, the majority of schizophrenia patients are on Medicare or Medicaid and won’t pay the list price anyways, but what about those who are not on government-sponsored programs and don’t have the wherewithal to pay such imposing out-of-pocket costs? Will private insurers provide coverage for Cobenfy considering that the FDA has already approved over a dozen antipsychotic medications for schizophrenia that are on the market? Will these companies require patients to try their cheaper generic versions first before approving coverage of the far more expensive Cobenfy? (The FDA approved Cobenfy as a monotherapy—meaning it is meant to be taken alone, without other medications.)
“If it's like a lot of the other new medications, insurance is generally going to mandate that people try at least two generic medicines first … before they will pay for it [Cobenfy],” Dr. Jacob Ballon, an associate professor of psychiatry at Stanford University, told the Associated Press.
If such barriers are in place for an antipsychotic prescription, one has to wonder if is it within the realm of possibility that mental health parity violations surface.
But for the time being, there is understandably a groundswell of hopefulness in the scientific and medical communities that the FDA’s recent approval of Cobenfy represents a watershed moment in psychiatric research. Should Cobenfy have the desired salubrious effects, it is quite possible, perhaps even likely that Bristol Myers Squibb will seriously explore other avenues for administering the medication, such as for treating Alzheimer’s-related psychosis, bipolar mania, Alzheimer’s-associated agitation, and Alzheimer’s-associated cognitive impairment.
Of course, though, first there needs to be a large enough sample size of the population to try Cobenfy for treating schizophrenia . . . which, in turn, means there needs to be reasonably priced coverage of the drug.
By: Ron Peck, Esq.
Donald Trump recently stated that while he will never give up on repealing the Affordable Care Act (ACA), he was not running on terminating the ACA. This is likely a smart decision, given that a recent Kaiser Family Foundation (KFF) poll[1] revealed that for Republican voters, repealing Obamacare was an important issue for a very small percentage of respondents. Is this demonstrative of a more widespread loss of interest in healthcare as a political talking point?
As someone whose day-to-day career is centered around health benefit plans, cost containment, and the attempt to ensure plan participants enjoy maximum care for minimal cost, understanding the rules and regulations that dictate and control what payers pay and providers of health care can and cannot do, is – for me – always top of mind. As an American, however, I cannot help but notice how little “airtime” healthcare seems to be getting during the ongoing presidential campaigns. Compared to the 2020 and 2016 elections, during which healthcare was one of the top issues (including but not limited to the repeal and replacement of Obamacare), for the 2024 election it seems as if healthcare is an afterthought.
Recognizing that abortion, LGBTQIA+, and gun violence all relate to healthcare, and are certainly top issues during this presidential race, please note that when I suggest that “healthcare” isn’t the most pressing topic (compared to past elections), I am referring to general healthcare costs.
It would seem, based on the aforementioned KFF poll, that I am not far off. That poll revealed that for American voters, only 5% consider “healthcare costs” to be their top issue. When asked to specifically rank healthcare issues by importance to them, 21% to 24% of Democrats and Republicans (respectively) indicated that the cost of healthcare is the most pressing healthcare issue, followed by prescription drug costs (which 9% to 12% of respondents – Republicans and Democrats respectively – felt was the most urgent healthcare topic).
Herein lies my concern. According to the same poll, four in ten voters stated that the economy and inflation is the most important issue. Yet, if healthcare costs are allowed to increase without checks and balances, it will impact individual and societal spending – thereby affecting the economy like nothing else. Indeed, according to the Centers for Medicare and Medicaid Services (CMS), 17.3% of our nation’s spending is attributable to healthcare costs[2]. As a basis for comparison, various sources indicate that our national spending on the military ranges between 3.4% and 3.5%.
This reveals the first misunderstanding on the part of the American voter. Specifically, that if you care about the economy, you must care about the cost of healthcare. As for the second misunderstanding on the part of the American voter, that would be understanding the difference between healthcare costs and premiums.
For many years, I have spoken at length about how people (and especially politicians) will refer to the “cost of healthcare” when in fact they are talking about premiums. Time and time again, a politician will claim to have “lowered the cost of healthcare” when they, in truth, only capped what an insurance carrier can charge in the way of premium. The actual price being charged by the provider of healthcare services (i.e., the doctor or hospital) hasn’t been addressed or reduced. The insurance carrier is merely being forced to pay a greater share of that cost without offsetting that cost onto their insureds in the form of higher premiums. This would seem to be a win for the premium-paying-populace – until they see an increase in co-pays, co-insurance, and deductibles – coupled with reduced benefits and coverage. As my grandmother used to say, “Nothing is free. The money needs to come from somewhere!”
I have often assumed that the politicians mentioned above honestly don’t understand the difference between the cost of healthcare and the cost of health insurance. The KFF poll, however, has me wondering whether I may have been mistaken. In that poll, the same people who advised that – of healthcare topics “health costs” is far and away the most pressing issue (over 20%) – a mere 6% felt that “premium costs” are the most important healthcare topic. So – if 20% or more of my constituents want to hear that I am doing something about the cost of healthcare, but only 6% care to hear about my efforts to reduce health insurance premiums . . . and all I’ve done is reduce health insurance premiums . . . do I tell the truth and appease the 6%? Or do I equate health insurance premiums with the “cost of healthcare,” communicate that my reduction of health insurance premiums is actually a reduction of healthcare costs, and satisfy the 20%? The latter is the obvious, if disingenuous, answer.
The fact of the matter is that unless the actual cost of healthcare (that being the cost incurred by providers when they provide care, and the cost payers – both insurance and patients – pay when they receive care) is reduced, we will all pay that cost one way or another. When I see, for instance, Vice President Harris’ campaign website celebrate a $35 “cap” on insulin prices, I am left wondering how many people realize that this doesn’t mean the insulin manufacturer is accepting a grand total of $35 for the insulin. Rather, patients’ out of pocket responsibility may in some instances be capped, and/or Medicare may be able to pay less, but the drug manufacturer is still going to be paid as much – or more – than they were receiving prior to the implementation of such a cap; even if it means charging commercial payers more to make up the difference. Commercial payers from whom many Americans receive their insurance (even those who were convinced to move to the ACA and State exchanges), and who – therefore – will pay the cost.
For those voters who say that the economy is the biggest issue, healthcare costs is a lesser issue, and premium costs are a smaller issue still . . . I wonder what they would say if I told them that these and so many other issues are actually different sides of the same coin?
The cost of healthcare may not be America’s hot topic anymore . . . but it likely should be.
[1] https://www.kff.org/womens-health-policy/poll-finding/kff-health-tracking-poll-september-2024-harris-v-trump-on-key-health-care-issues/
[2] https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/