The Book of Russo:

Happy New Year to everyone and I hope that your resolutions are still alive and in effect. My New Year’s resolution for 2025 was pretty simple. This year, I will enjoy every minute that I get to do this job… and what a year it will be. Indeed, this year we are celebrating The Phia Group’s 25th anniversary! I often reflect on how we got here, and to be honest, sometimes I have no idea. As I look back on a quarter century of hard work, innovation, passionate advocacy, and meaningful partnerships – this was never expected. Not in my wildest dreams did I imagine I’d be here 25 years later, still loving what I am doing, and loving the people with whom I’m doing it. All I know is that I approach each day with the same optimism and passion as I have for the last 25 years …

and I’m not going to change that any time soon. Being in an industry where there is so much innovation and new technologies is amazing. Attempting to balance legislative and regulatory requirements – amongst other obstacles, with new and existing processes presents a thrilling challenge. It’s exhausting yet exhilarating at the same time. Each day is different; there is no “Groundhog’s Day” experience in my role – always a new threat and opportunity on the horizon. Just as the challenges and ideas are always evolving, so too are the faces and personalities in our industry. I recall years ago how worried some of us were about how our industry’s leadership was aging, and how we needed an influx of new talent. Industry associations (as well as The Phia Group) invested heavily in future leader programs and young professional campaigns. Only a few years later, you only need to look at the conference attendees to appreciate that our industry is in good hands. I am so fortunate to meet and collaborate with you all; new friends and old. Regardless of whether you are an industry veteran, or new to the trade, we all need to tackle the same issues and leverage the same opportunities (albeit in different ways) – performing a balancing act between efficiencies and accuracy, services and savings. That is why – at The Phia Group – we offer the best in industry services to ensure the greatest outcomes, always balancing the sometimes-contradictory attributes and needs of our clients and their customers. In this market, no two clients are the same and that is reflected in the custom work that we do. Well, that’s enough from me. Let’s get to the good stuff! I hope your year is off to a great start and just remember that we are always here for you. - happy reading.

Service Focus of the Quarter: Phia Unwrapped (featuring Phia Ignite) 

Phia Unwrapped, featuring our groundbreaking Phia Ignite repricing engine, is revolutionizing the way self-funded plans approach cost-containment. This comprehensive solution empowers plans to take control of their healthcare spending by unwrapping the complex layers of medical billing and reimbursement. With Phia Ignite at its core, Phia Unwrapped offers a powerful combination of technology-driven analysis, expert negotiation, and strategic plan design to optimize healthcare costs without compromising provider access.

What sets Phia Unwrapped apart is its ability to seamlessly integrate with your existing plan structure while providing unparalleled flexibility and customization. Our team of industry experts works closely with you to tailor the solution to your specific needs, whether you're looking to implement reference-based pricing, narrow your network, or explore hybrid models. 

By leveraging advanced data analytics and our extensive industry knowledge, Phia Unwrapped not only helps you achieve immediate savings but also provides long-term strategies for sustainable healthcare management. Experience the transformative power of Phia Unwrapped, and let Phia Ignite ignite your potential for success in today's challenging healthcare landscape. If you haven’t used, seen a demo of, or heard great things about Phia Ignite we urge you to email [email protected] today.  

Enhancement of the Quarter: Care Empowered Pricing  

This quarter, we are excited to highlight Care Empowered Pricing. This innovative addition to The Phia Group's suite of services represents a significant advancement in our cost containment offerings, creating a new breed of reference-based pricing. 

One of the key features of Care Empowered Pricing is its technology-enabled provider selection and access support, which ensures that clients can provide access to optimal high-quality care at the lowest possible price point. Additionally, this enhancement includes balance bill resolution services supported by our legal team at no extra cost, further protecting you, your clients, and their employees from unexpected expenses associated with healthcare services. 

By integrating Care Empowered Pricing into our existing services, we empower stakeholders to make informed decisions that improve outcomes for both plans and individuals seeking healthcare. This enhancement not only strengthens our commitment to delivering high-quality care but also reinforces our mission to provide effective cost-containment solutions in an ever-evolving healthcare landscape.

Phia Case Study: Hidden Parity Issues  

Our consulting team recently uncovered a subtle but significant mental health parity violation in a large health plan's provider credentialing process. While the plan claimed to apply the same standards to both medical/surgical and mental health providers, we noticed a crucial discrepancy. Medical/surgical specialists were allowed a 60-day grace period to complete certain credentialing requirements after being provisionally approved to see patients, while mental health providers were only allowed a 30-day grace period. 

This seemingly minor difference had a substantial impact on network adequacy and patient access to mental health services. The stricter credentialing timeline for mental health providers led to longer wait times for patients seeking mental health care, a smaller network of available mental health providers, and an increased likelihood of out-of-network care for mental health services. We recognized that this disparity in credentialing processes violated the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires that non-quantitative treatment limitations (NQTLs) for mental health services be no more restrictive than those for medical/surgical benefits. 

By identifying this hidden parity violation, we helped the plan (through its network) align its credentialing processes across all provider types, improve patient access to in-network mental health services, and avoid potential regulatory penalties and litigation risks. This case demonstrates the importance of thorough, nuanced analysis in uncovering less obvious parity violations, ultimately leading to better mental health coverage and improved patient care. 

Fiduciary Burden of the Quarter: ASA Termination Penalties

As a TPA, it's crucial to understand the implications of federal regulations on your contracts with ERISA plans. One particular regulation (found at 29 CFR § 2550.408b-2[c]) stipulates that a contract isn't considered “reasonable” if it doesn't allow the plan to terminate without penalty on reasonably short notice. While you can include provisions for recouping actual losses upon early termination, substantial penalties that effectively lock plans into long-term arrangements (or even the lack of ability to terminate without cause) are prohibited. 

This requirement impacts your contract structures and fee models significantly. You'll need to carefully balance your business interests with regulatory compliance. Consider transparent fee structures that clearly demonstrate the ongoing value of your services, rather than relying on long-term commitments or hefty early termination fees. After all, if challenged by a plan, federal law places the burden on the TPA to justify any early termination costs as actual losses rather than penalties. 

While you may not always be considered a fiduciary under ERISA, your actions and contract terms can sometimes lead to functional fiduciary status. In such cases, imposing substantial early termination penalties could be seen as a breach of fiduciary duty. Even as a non-fiduciary, including such penalties could invite legal challenges or regulatory scrutiny. Focus on creating flexible, value-driven relationships with your clients that comply with ERISA's protective intent while still safeguarding your business interests.

Webinars:

• On November 19, 2024, The Phia Group presented “A New Year, a New Administration, but the Same Old Problem?,” in which we broke down how election results would impact the industry and looked ahead to what compliance changes are afoot. 

• On October 17, 2024, The Phia Group presented “Industry Crossroads – How the 2024 Election Impacts You & Major Implications For Our Industry,” in which we discussed how the results of the historic election would have a major impact on healthcare and health benefit plans alike.

Be sure to check out all of our past webinars!

Podcasts:

• On December 19, 2024, The Phia Group presented “Denied Claims Beyond the Headlines,” in which our hosts, Corey Crigger and Cindy Merrell, discussed the murder of UnitedHealthcare’s CEO, which fueled public outcry over denied claims. 

• On December 5, 2024, The Phia Group presented “Non-Preferred Carrier Fees: Incentives or Control?,” in which our hosts, Jon Jablon and Brady Bizarro, dove into the details of a recent lawsuit involving BCBS of Michigan. 

• On November 5, 2024, The Phia Group presented “Lessons From a Florida IDR Case,” in which our hosts, Ron Peck and Nick Bonds, discussed a recent Florida case addressing judicial review of IDR determinations and highlighted some of the key insights and takeaways for any entity subject to the No Surprises Act. 

• On October 24, 2024, The Phia Group presented “Nightmares on Self-Funded Street,” in which our hosts, Corey Crigger and Kendall Jackson, delved into ways to protect your plan from the scary cost of gene therapies. 

• On October 15, 2024, The Phia Group presented “Gender-Affirming Care, Is it Covered?,” in which our hosts, Jon Jablon and Cindy Merrell, discussed the changing landscape of several state and federal laws that affect coverage of gender-affirming care.

Be sure to check out all of our latest podcasts!

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Phia Fit to Print:

• BenefitsPro – Trump's health appointments spark controversy and change – December 2024 

• The Self-Insurer – Navigating The New Frontier In Reference-Based Pricing: NSA Impacts, Data Overload, and The AI Revolution – December 2024 

• BenefitsPro – The end of the year is near: Health plan preparation for 2025 – October 2024 

• The Self-Insurer – Summer Olympics Showcased Advances In Mental Health Services Lessons For Self-Insured Health Plan Sponsors – October 2024

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From the Blogoshpere:
 

• Anthem Blue Cross Blue Shield’s Major Reversal. On November 1, Elevance Health issued a news release detailing its proposed billing guideline changes for Connecticut, New York, and Missouri. 

• New Requirements Under the Mental Health Parity and Addiction Equity Act (“MHPAEA”). The deadline to comply with several of the new final rules regarding the Mental Health Parity and Addiction Equity Act (“MHPAEA”) is quickly approaching. 

• Navigating Balance Billing and Post-Payment Disputes: Solutions for TPAs and Self-Funded Employers. Preventing and addressing balance billing and post-payment disputes is essential for the success of any RBP program. 

• The Future of Birth Control in America. 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. 

• Cobenfy: A Potential Game-Changer for Schizophrenia Patients – But at What Price? Will drug prices be coming down in the near future?

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

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The Phia Group's 2025 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 2025 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 Delivery!

The tradition continues! Right before Thanksgiving, The Phia Group once again had a large contingent of volunteers helping to hand out Thanksgiving meals at the Boys & Girls Clubs of Metro South. Over twenty-five families received dinner and dessert! We hope everyone had a great Thanksgiving!

Phia's Angel Tree

Our Angel Tree was on display in our Canton office! We are thrilled to share that this marks our 10th consecutive year participating in the Salvation Army Angel Tree program. We had 150 tags on our tree this year, which means that we got to bring joy to 150 children this holiday season. Discover more about this heartwarming initiative that brings us so much joy in the link below: Angel Tree's Site.

Senior Care Package Corner

Through the Angel Tree Program, The Phia Group spreads holiday cheer to dozens of seniors in the Greater Boston area, many of whom do not have families who are local. Thanks to the generosity and dedication of our employees, a Senior Care Package Corner was set up for the collection of basic necessities such as hats and gloves as well as some tasty treats. The Phia Group continues to look forward to making a difference in our local community in the upcoming year.

Santa’s Special Delivery

On the evenings of December 17th and 18th, The Phia Group – with CEO Adam Russo serving as Santa, accompanied by a dozen elves – delivered gifts to 150 kids at the Brockton & Taunton Clubhouses of the Boys & Girls Clubs of Metro South. We hope they enjoyed all of the gifts they received!

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Phia News: 

Stein Holding Contest

Oktoberfest wouldn’t be complete without a good old-fashioned Stein holding contest! This year we had fifteen participants willing to put their strength to the test. As always, there could only be one winner, which was David Ostrowsky! Congratulations, David, and we look forward to another great Oktoberfest next year!

Halloween at Phia

In late October, many of our employees brought in their children for the annual Halloween extravaganza at our Canton headquarters, as well as at our Louisville office. Everyone – kids and adults alike – had a blast trick-or-treating around the office and then enjoying a delicious pizza party afterwards! On behalf of everyone here at The Phia Group, we would like to thank all those who made that day so special for the Phia Phamily kids!

Best Costume

As is tradition, Phia held its annual Halloween costume contest. The Phia staff did not disappoint! And the winner was clear. Congratulations to the HR Team, who dressed up as the Wizard of Oz cast! Check out their amazing costumes below.

Candy Corn Contest

As is tradition, Phia held its annual candy corn contest. The Phia Family made some great guesses, but there was one person who came particularly close to guessing the exact number. Congratulations to Matt Painten on guessing 897 pieces of candy corn. This was a good guess, as we had 998 pieces of candy corn in the jar!

Get to Know Our Employee of the Year: Harman Singh

To be designated as 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 Harman Singh as The Phia Group’s 2024 Employee of the Year!

Congratulations, Harman, and thank you for your ongoing and future contributions.

Get to Know Our Employee of the Quarter: Rand Lennox

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 Rand Lennox to be recognized as The Phia Group’s Employee of the Quarter for Q4 of 2024.

Congratulations, Rand, and thank you for your ongoing and future contributions.

Phia Attending the SIIA National Conference

Several of Phia’s industry experts will attend SIIA’s 2025 National Conference in Phoenix, Arizona, from October 12th – 14th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: https://www.siia.org/i4a/calendar/?pageid=7767&showTitle=1

Job Opportunities:

• Accounting Administrator I 

• Healthcare Consulting Attorney 

• Health Plan Documentation Specialist 

• Senior Claim Recovery Specialist 

• Health Claim Investigation Specialist

See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers

Promotions

• Vanessa Leurini has been promoted from Case Investigator to Claims Recovery Specialist III. 

• Ethan Forrest has been promoted from Sr. Claims Recovery Specialist to Team Lead, Recovery. 

• Kendall Felici has been promoted from Project Coordinator I to Project Coordinator II. 

• Tara Otoka has been promoted from Health Benefit Plan Consultant to Quality Assurance Specialist. 

• Michelle Moyal has been promoted from Health Benefit Plan Consultant to Quality Assurance Specialist.

New Hires

• Tracey Tostanoski was hired as a Claim Recovery Specialist 

• Mutyam Bejjanki was hired as a BI Assistant 

• Christine McFadyen was hired as an Accounting Assistant 

• Liam Tangney was hired as an Accounting Intern 

• Emillya Vieira was hired as a Case Investigator 

• Amy Holladay was hired as a Sr. Claim Recovery Specialist 

• Allie Hanserd was hired as a Subrogation Attorney 

• Gina Vaught was hired as a Claim Specialist 

• Jesse Wilkins was hired as a Case Investigator 

• Iliet Alvarez was hired as a Claim Recovery Specialist 

• Taisha Brooks was hired as a Customer Service Rep 

• Erica Risch was hired as a Customer Service Rep 

• Kristina Bernal was hired as a Customer Service Rep 

• Averee Leonard was hired as a Case Investigator 

• Nathan Cook was hired as a Sr. Systems Administrator

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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