The Book of Russo:

I wish it would snow here in Boston; even a little dusting would be nice. While I am sure that my friends in the Midwest and Western New York may disagree (based on the feet of snow you have seen there), here all I see is dull pavement and sad looking grass. It would be nice to do some sledding with my kids, or enjoy an awesome snowball fight. This is not the January in Massachusetts that I remember, or to which I am accustomed! Indeed… We can get so used to something, like snowfall in Boston, that we take it for granted. We assume it will continue to happen the same way, year after year. Planning for change, therefore, isn’t something we often think about, until change slaps us in the face. When it comes to self-funding health plans, compliance and regulatory issues represent sudden and unexpected change.

Like New England snowfall in winter, you get comfortable assuming things will unfurl the same way, year after year. Then BOOM; the industry faces an unexpected blizzard of rulemaking, unlike anything seen in years. At The Phia Group, it almost seems like I am now your television meteorologist; monitoring a flurry of legislative and litigious changes, and telling the audience not to go outside! I’m here on the frontline, sitting on a sea-wall, about to get tossed into the water by gusty winds of transformation. Gosh. I guess things can change? Don’t get comfortable! In the world of insurance, there is always a “regulatory storm” out there… Sometimes it’s brewing in the atmosphere; sometimes it’s out to sea; and sometimes its bearing down on us! We can go months or even years, getting used to the peace and quiet (just like I have gotten used to annual picturesque winter snowscapes outside my home), only to suddenly have the status quo turn upside down. This is me, attempting to warn our listening audience of troubles ahead. That’s what our success at Phia has always been about – keeping you informed and knowing what we expect to happen before it does. Luckily for us, we are better at predicting what’s next, than the typical weather person.

– Happy reading!

Enhancement of the Quarter: Internal Handling of ICE Requests

As is common, The Phia Group’s intake processes have historically entailed email distribution groups. In other words, when an email is sent to a given email address, multiple people receive the email, and it is catalogued and handled accordingly by certain recipients. This is a sensible system, although perhaps not as efficient as it could be. 

However, there was an idea recently proposed by a Phia employee to help declutter our systems and promote efficiency! This potentially useful (and currently being deployed) strategy across other lines of business as well was developed by a member of the ICE intake team to streamline the receipt of requests, optimize our internal processes, and promote quicker response times to ICE clients’ consulting requests! 

The nature of ICE is such that we get numerous submissions on a daily basis and making our internal processes more efficient is just one way that Phia is constantly improving the level of service we are able to provide to our valued clients. Greater efficiency optimizes resource usage, which allows us to minimize turnaround times and keep our ICE fee low! For more information on The Phia Group’s ICE service, please contact [email protected].

Service Focuses of the Quarter: Independent Consultation and Evaluation (ICE) and No Surprises Act Support 

Independent Consultation and Evaluation

Here at The Phia Group, we’re not a TPA, but we sure do know ‘em. Like the back of our hand. That’s why we developed our Independent Consultation and Evaluation service, colloquially known as ICE.

We know how difficult processing claims can be, especially when those claims involve complex situations. Asking Plan Administrators for guidance to avoid TPA liability is always a good idea, but is sometimes not feasible due to time constraints or simply the fact that most plan administrators are not well-versed in the art and science of claims processing. Your clients are school districts, or textile manufacturers, or labor unions; what can they reasonably be expected to know about the law related to when an illegal acts exclusion can be applied, and when it can’t? 

Nothing, that’s what. Enter The Phia Group’s ICE service. We are experts in the law related to health benefit offerings, and we know plan documents like Tom Brady knows a football. ICE was created to ensure that health plans and the TPAs that work with them have a resource to tap when things get hairy – and since it’s billed at a flat monthly fee rather than on an hourly basis, there are no surprises. 

(And speaking of “no surprises”…) 

No Surprises Act Support 

Phia’s No Surprises Act (NSA) support services entail non-network claim pricing, “open negotiation” support, and Independent Dispute Resolution (IDR) defense. Although every TPA potentially has a different set of needs related to the No Surprises Act, Phia can be engaged to perform functions such as checking NSA-related communications to verify the NSA’s applicability and performing a deadline review to ensure that the NSA’s timeframes are being adhered to. 

We are also well-equipped with the necessary benchmarking data, domain knowledge, and experience to negotiate claims with medical providers. In addition, if a claim becomes subject to Independent Dispute Resolution, our support services are available to vet and challenge an IDR entity if necessary, as well as review or draft the plan’s offer of payment. 

Our NSA support services provide the backbone of post-payment NSA compliance, with a particular focus on cost-containment. 

Please contact [email protected] for more information on Independent Consultation and Evaluation (ICE) or No Surprises Act support!

Success Story of the Quarter: The NQTL Audit

The Phia Group was approached by a health plan currently undergoing an audit of its treatment of mental health and substance abuse disorder benefits. Rather than engaging Phia to perform an NQTL analysis, the plan asked us instead to help interpret certain criticisms of the plan’s treatment of mental health and substance abuse disorder claims, and help the plan become more compliant. 

What we discovered is that the criticisms of the plan were largely focused on medical necessity criteria relating to mental health and substance abuse disorder claims compared to medical necessity criteria applied to medical and surgical claims. This particular plan had engaged a vendor specifically to review medical necessity and perform other UM functions for its mental health claims, while the plan engaged its TPA to handle medical and surgical claims, considering the latter to be more “run-of-the-mill”. 

As can be expected, the UM vendor in charge of making determinations regarding mental health and substance abuse disorder claims applied a totally different set of criteria from what was listed in the plan document! Although the TPA followed the plan document to the letter (and in fact the relevant plan language was drafted specifically with this TPA’s UM processes in mind), the UM vendor disregarded plan language and applied its own chosen criteria, which were both more stringent and relied on different professional sources, notably including the UM vendor’s own internal set of medical policies. The discrepancy was identified, and Phia’s attorneys worked with the plan to coordinate with the UM vendor to make sure the vendor didn’t ignore the terms of the plan document. 

Unfortunately, it became clear that the UM vendor refused to deviate from its current processes; in order to be compliant, the plan was faced with the choice of either engaging the UM vendor for all claims – both mental health/substance abuse disorder and medical/surgical – or abandoning the vendor altogether and instead having the TPA perform UM functions for both medical/surgical and mental health/substance abuse disorder claims. The group ultimately erred on the side of its TPA, and although it required a major change in processes, the TPA has been working diligently to minimize the disruption.

Phia Case Study: TPAs Making Coverage Decisions

A question our consulting team is commonly asked is regarding to what extent a TPA should make claims determinations. As a TPA, of course, your groups rely on you to carry out everyday administrative functions; although making claims determinations may seem like just another one of those, in practice it can be far more complex. 

At its core, a benefit determination is a fiduciary action. That is, anyone who makes a benefit determination becomes a fiduciary to the extent discretion was exercised. Take the examples of two claims – one that requires only a certification of medical necessity to cover, and one that requires interpretation of a plan’s “illegal acts” exclusion. While the former is as simple as “If X, then Y”, the latter requires whoever is making the decision to exercise discretion to interpret the illegal acts exclusion. 

Rather than providing a very specific fact pattern to apply this principle to, this case study focuses more on the very common question from TPAs regarding how they should treat this claim’s determination burden. On one hand, groups are often loathe to make decisions like this on their own (either lacking the know-how, simply not feeling comfortable, or believing that the group’s TPA was contracted to make this decision for them [the “isn’t this what we pay you for?” approach]). On the other hand, though, many TPAs have the resources – and the vendor partners – to make these types of determinations with a degree of certainty. 

When making business decisions, we urge you all to remember that The Phia Group is here to help wherever you need us. Want to make claim determinations? Run a complex claim through ICE! Want to lower claims expenses and reliably limit balance-billing? Check out Phia Unwrapped! Want to take on appeals? PACE is here! Want to nail the No Surprises Act? We’ve got you covered there, too. Just let us know what you need, and we’ll find a way to make it happen.

Fiduciary Burden of the Quarter: The “Kitchen Sink” Approach to Adverse Benefit Determinations

A recent case out of the 9th Circuit Court of Appeals has brought up an issue that Phia’s attorneys and consultants have discussed with numerous clients through the years. The issue is whether or not to include all possible denial rationales in any given denial letter. 

Many TPAs and plans choose the most compelling and seemingly defensible denial reason and hang their respective hats on that, but Phia has always recommended that an Adverse Benefit Determination should identify any and all possible denial reasons that are supported by the SPD. The reasons for that are twofold: one is to be better able to defend itself in the event a claimant is able to successfully refute the denial reason used; the other is that we have not been confident that a court’s review would permit the plan to introduce new denial justifications not previously provided. This case underscores that second reason. 

In Collier v. Lincoln Life Assurance Co. of Bos., the court held that when a denial is litigated, the health plan may not introduce new arguments (i.e., new reasons) that were not previously brought up in the plan’s previous denials. According to the court, since ERISA’s claims procedure regulations provide that a denial letter must contain the specific reasons for the denial, “a plan administrator undermines ERISA and its implementing regulations when it presents a new rationale…that was not presented to the claimant as a specific reason for denying benefits during the administrative process.” Basically, judicial review of a denied appeal is not designed to erase what was already done and let the plan re-justify its denial; instead, it is designed to verify whether the Plan’s previous denial is supported by the facts and law underlying the claim. Another way to think about it is that if a patient sues the plan over a claim, it’s not really about the claim itself, but about the plan’s denial of the claim. 

As a general rule, if a health plan includes multiple provisions upon which a denial should be based, use them all! Don’t assume that the one chosen will necessarily hold up.

Webinars:

• On December 13, 2022, The Phia Group presented “A Flip of the Calendar: Looking Ahead to Healthcare in 2023,” in which the team discussed increasing healthcare costs, the No Surprises Act, and more. 

• On November 15, 2022, The Phia Group presented “Down the Stretch: Wrapping up a Historical 2022,” in which the team discussed what they felt were the 10 most impactful healthcare developments of 2022. 

• On October 20, 2022, The Phia Group presented “The Witching Hour for Healthcare Plans,” in which we discussed regulatory changes impacting the healthcare industry (i.e., mental health parity, discretionary authority) and developments concerning plan drafting language.

Be sure to check out all of our past webinars!

Podcasts:

• On December 20, 2022, The Phia Group presented “The Who, What, and When of Offsetting Benefits,” in which our hosts, Chris Aguiar and Cindy Merrell, discussed offsetting benefits and when a Plan may consider it. 

• On December 8, 2022, The Phia Group presented “Manufacturer Assistance Programs,” in which our hosts, Brady Bizarro and Andrew Silverio, discussed manufacturer/copay assistance programs and some of the different approaches being utilized to manage specialty drug spending. 

• On November 17, 2022, The Phia Group presented “Another Ping-Ponging of IC/EE Rules?,” in which our hosts, Kelly Dempsey and Kevin Brady, discussed the ever-changing world of employee classification rules. 

• On November 3, 2022, The Phia Group presented “The Ever Changing Times of Healthcare,” in which our hosts, Corey Crigger and Nick Bonds, discussed some of the more interesting developments they’ve seen in 2022. 

• On October 27, 2022, The Phia Group presented “Transparency & More: Burning CAA/NSA FAQs,” in which our hosts, Jen McCormick and Jon Jablon, discussed some of the most common questions that The Phia Group’s consulting team has been asked to field over and over again. 

• On October 14, 2022, The Phia Group presented “A Possible Threat to a Plan’s Discretionary Authority,” in which our hosts, Ron E. Peck and Kaitlyn MacLeod, discussed a new bill that has been announced that would ban all references to a plan administrator’s discretionary authority, as well as remove all deference courts give to their claims determinations. Book of Russo 

• On October 21, 2022, The Phia Group presented “Book of Russo: Chapter 5,” in which our host, Adam Russo, and guest host, Mike Ferguson, discussed SIIA’s 2022 National Conference, the history of SIIA, and what to expect from SIIA in years to come.

Be sure to check out all of our latest podcasts!

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Phia Fit to Print:

• BenefitsPro – The debate behind “quiet quitting”: The younger generation’s approach – December 15, 2022 

• Self-Insurers’ Publishing Corp. – A Historic Opioid Settlement Could Present Opportunities For Insurers To Seek Reimbursement – December 2, 2022 

• Self-Insurers’ Publishing Corp. – In Subrogation: Superior Contract Language Matters – October 7, 2022

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From the Blogoshpere:
 

• Being “in the business” of Adderall: How the shortage is affecting millions of Americans. Across the country, Americans with attention-deficit hyperactivity disorder (ADHD) are struggling to find good alternatives to Adderall. 

• Healthcare Subrogation and Reimbursement and Why it Matters. There is distinction between subrogation and reimbursement. 

• NSA’s Model Notice: Doing Your Own Thing. The NSA imposes some major requirements on health plans. 

• RxDC Reports Are Almost Due – Make Sure You Are on Track for Compliance. How much do you know about the Prescription Drug and Health Care Spending reporting (RxDC) requirements? 

• Mental Health Matters Act: Why the MHPAEA Needs Reinforcement. An update on the Mental Health Parity and Addiction Equity Act.

To stay up to date on other industry news, please visit our blog.

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The Stacks:

A Historic Opioid Settlement Could Present Opportunities For Insurers To Seek Reimbursement

By: Brady Bizarro, Esq. – December 2022 – Self-Insurers Publishing Corp. 

On November 1, 2022, major media outlets reported that the nation’s three largest retail pharmacies – CVS, Walgreens, and Walmart – had agreed in principle to pay $13.8 billion in damages in a settlement to resolve thousands of claims related to the opioid epidemic. Due to the uniquely insidious nature of opioid addiction and the truly devastating scale of the crisis, hundreds of thousands of Americans have lost their lives, families have been shattered, and governments and health insurers alike have spent tens of billions of dollars on rehabilitation and increased claim costs. If this settlement proceeds, as appears very likely as of this writing, insurers, including self-funded plan sponsors, could have new opportunities to recover funds on behalf of their plan participants.  

Read the rest of this article
 

In Subrogation: Superior Contract Language Matters

By: Scott Byerley, Esq. – October 2022 – Self-Insurers Publishing Corp. 

The United States Congress enacted the Employee Retirement Income Security Act ("ERISA") in 1974 to protect employees and place requirements on pension and health care plans. The legislation arose from the discourse and fallout that occurred after Studebaker-Packard (Studebaker), an automobile manufacturer that was very poorly fiscally managed, closed its plant in South Bend, Indiana, effectively eliminating employee pensions for thousands of employees. The problem wasn’t a new one or limited to Studebaker’s closure, which came about in 1963, but rather a systemic one: the lack of corporate accountability in financial reporting and management of pension and health care plans posed significant risks, prompting Congress to protect employees nationwide.  

Read the rest of this article

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The Phia Group's 2023 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 2023 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. 

Thanksgiving Dinner Delivery

The Phia Family was out and about the week of Thanksgiving, handing out 25 Thanksgiving dinners to the families of The Boys and Girls Club of Metro South! Additionally, our Phia Family in Idaho and Louisville were 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!

Salvation Army Angel Tree

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 150 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 150 children. We hope these children enjoy their new toys as much as they enjoyed spending time with Santa!

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Get to Know Our Employee of the Year: Kelsey Dillon

To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. 

The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Kelsey Dillon as The Phia Group’s 2022 Employee of the Year! 

Here is what Kelsey’s Supervisor had to say about Kelsey: “Kelsey joined The Phia Group in December 2017. In her 5-year tenure with The Phia Group, she quickly became a top producer for the Claim & Case Support department & in 2021 was promoted to co-Team Lead. 

In early 2022, Kelsey took on an additional challenge – participating in the Lean Six Sigma Certification Program. This is a huge accomplishment for her to have successfully completed. 

Heading into 2023, she will be taking this skillset into a new role within the company, to support both incoming & existing clients in the Recovery Department. We are very excited to see what is in store for Kelsey & look forward to her continued success at The Phia Group.”

Congratulations Kelsey, and thank you for your many current and future contributions.

Get to Know Our Employee of the Quarter: Jeff Hanna

To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. 

The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Jeff Hanna as The Phia Group’s 2022 Q4 Employee of the Quarter! 

Here is what one person had to say about Jeff: “Even though Jeff is a member of the Accounting team, he has become an integral part of the Provider Relations team. For years now Provider Relations has depended on Jeff's excellent work product, his turnaround time, and attention to detail. We depend on Jeff greatly to complete the accounting end of our work and it is often a very heavy workload and all with the specter of timeliness and deadlines hanging over him, creating even further urgency and stress to the work. The work that Jeff receives from Provider Relations is already heavy enough, and done under such time constraints, that it would qualify as "above and beyond" and he has worked in this manner for years with little or no recognition. Thank you for everything you do, Jeff!” 

Congratulations Jeff, and thank you for your many current and future contributions.

Phia News:

Job Opportunities:

• EDI Data Engineer 

• PGC Attorney 

• Case Investigator 

• Senior Accountant 

• Accounting Assistant

See the latest job opportunities, here: Careers Page

• Sandra Croteau has been promoted from Senior Manager of Client Success Team to Director of Client Success Team 

• Tara Otoka has been promoted from Health Benefit Plan Consultant I to Health Benefit Plan Consultant II 

• Brittney Willoughby has been promoted from Team Lead, Recovery Services to Manager, Recovery Services 

• Jacky Davis has been promoted from Health Benefit Plan Consultant I to Health Benefit Plan Consultant II 

• Bryan Dunton has been promoted from Health Benefit Plan Consultant I to Health Benefit Plan Consulting Attorney 

• Emily Rodriguez has been promoted from Project Coordinator I to Project Coordinator II 

• Adam Doherty has been promoted from Project Coordinator I to Project Coordinator II

New Hires

• Michelle Haga was hired as a PACE Appeal Specialist 

• LaTrisha Keierleber was hired as a PACE Appeal Specialist 

• Kelvin Chun was hired as a Sr. FP&A Analyst 

• David Palmer was hired as a Claim Recovery Specialist 

• Kaycee O'Toole was hired as a Case Investigator 

• Michael Laino was hired as a Clinical Coding Analyst 

• Even Forrest was hired as a Case Investigator 

• Patrick Murphy was hired as a Case Investigator 

• Tanya Mendlowitz was hired as a Customer Service Representative 

• Shannon Mortimer was hired as a Claim and Case Support Analyst 

• Sabrina Dunn was hired as a Customer Service Representative 

• Gerry Dieudone was hired as a Provider Relations Coordinator 

• William Parlee was hired as a Case Investigator 

• Ray Joseph was hired as a Claim and Case Support Analyst 

• Julia Harvey was hired as a Customer Service Representative 

• Dylan Cleaves was hired as an Accounting Intern

Halloween at Phia Phia

The Phia Family celebrated Halloween in style as dozens of costumed employees and their families enjoyed trick-or-treating and a haunted house in the office. We are beyond thankful for everyone who helped make this an amazing and successful day! 

Ugly Sweater Day

As is tradition, The Phia family had employees dress up in their ugliest sweaters the week before Christmas, and we had a great turnout this year! With all of the great sweaters, we had to get a group photo, and, as you can see, there were many people who wanted to show off their ugly sweaters, as well as some adorable holiday outfits! Thanks to everyone who participated! 

Pumpkin Carving at Phia

As is tradition, The Phia family had employees carve pumpkins right before Halloween, and we had a great turnout this year! There was a large number of pumpkin carvers, and the pumpkins all turned out beautiful. Thanks to everyone who participated!
 

Phia BBQ and Ice Cream Truck

During what turned out to be a brilliant early autumn day, Phia employees enjoyed a delicious barbeque. Not only was there a wide assortment of both traditional and vegan meats to go along with savory side dishes, but an ice cream truck rolled by to cap off the event. We hope you enjoyed the delicious food and sweets!

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.

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