last but not least, we have ensured that you all have the latest and most valuable information relating to COVID-19, how it impacts your businesses and client plans.

With that in mind, let's continue the trend of entertainment and education, with yet another Phia Group Newsletter! I truly hope you will enjoy the valuable information this edition has in store for you, and as always, thank you for being part of The Phia Family. Enjoy!

Enhancement of the Quarter: Subrogation Value Reports

To the Phia Group’s valued recovery clients: rejoice! We have supplemented our already-extensive reporting suite to provide you with a brand new report. The “Subrogation Value Report” is a new report that highlights recovery performance for a particular group, or across a TPA’s entire block of business – as well as compares those results to various benchmarks. The Subrogation Value Report provides the user with an easy-to-read summary of how much The Phia Group has recovered, on a quarterly or yearly basis (based on your preference), and it can also be run by The Phia Group’s Customer Success Team, on-demand.

This new report presents as a clean, clear PDF. Through the use of graphics and design, it provides an easy to digest yet comprehensive summary of the most valuable performance benchmarks, as well as compares those results to The Phia Group’s entire book of business, utilizing various useful metrics; an important retention and marketing tool for any user!

The Subrogation Value Report will be automatically provided on a regular basis, as well as being available to all clients upon request, so be sure to contact The Phia Group’s Customer Success Team as needed – and as with all our reports, they will be accurate as of the minute they were run.

New Service Offered by Phia: Patient Defender

The Phia Group is proud to introduce its “Patient Defender” program. For a PEPM fee, every plan participant has access to legal representation against collections lawsuits or crippling balances being sent to collections before legal action ensues. Best of all, Patient Defender can be coupled with any type of health benefit plan – from reference-based pricing plans to traditional network plans; if and when a patient is threatened by aggressive tactics, Patient Defender will be there.

To learn more about Patient Defender or any of The Phia Group’s services, please contact our Vice President of Sales and Marketing, Tim Callender, Esq., at 781-535-5631 or [email protected].

Service Focus of the Quarter: Plan Appointed Claim Evaluator® (PACE)

Years ago, in response to growing industry concern regarding fiduciary duties and appeals, The Phia Group created its Plan Appointed Claim Evaluator (PACE) service. PACE is a service whereby The Phia Group takes on fiduciary duty for, and protects clients against fiduciary liability arising from, final-level internal appeals. It is designed to help health plans ensure adverse benefit determinations are correct and defensible, thereby insulating the plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult determinations, and free itself from worry that an unintentional yet arbitrary mistake could result in excessive damages.

PACE includes:

• Plan Document and stop-loss policy “Gap Reviews” to ensure compliance, eliminate coverage gaps, and ensure PACE readiness

• Advanced-level webinars exclusively for PACE clients

• Assessment of eligible, final internal appeals resulting in a written directive

• Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (with The Phia Group covering all external review costs)

The PACE Certification Program is free of charge and will create immense value for your organization. By going through the Certification program, you, or a select person, or team, within your organization, can become PACE Certified. Once PACE Certified, the Program participant(s) will become highly educated PACE business owners and will serve to assist your organization in growing your PACE business, enhancing your PACE revenue, and assuring your appeals processes are the most compliant and best in the industry. Those who complete the Certification will also receive a PACE Certification Fact Sheet, providing an easy to understand summary of the content and best practices covered, which will allow you to maximize the lessons learned within your business.

The PACE Certification program will educate you using 3 distinct chapters of information:

Chapter One

Explore the ins and outs of self-funding while learning about its risks and rewards. This chapter will transform any individual into a self-funding pro.

Chapter Two

Take a deeper dive into the laws that apply to self-funded plans. We cover it all, from federal preemption to adverse benefit determinations and appeals.

Chapter Three

Explains what PACE is, what PACE does, and how it's obtained, implemented, and utilized.

Please see the PACE Certification flyer, as well as this video for more information.

Please contact Michael Vaz ([email protected]) for more information.

Success Story of the Quarter: The Second-Level Appeal

A client of The Phia Group’s Plan Appointed Claim Evaluator (PACE) service recently received a large claim. The medical service from which the claim originated was performed in the emergency room of an out-of-network hospital, but the TPA’s initial medical review deemed it to be of a non-emergency nature; so the claim was processed the same as any normal non-network claim, rather than as a claim for emergency services. The provider was adamant that the services were emergency services, placed numerous calls to the TPA, and wrote an extremely long and detailed appeal.

On appeal, the TPA diligently had the claim reviewed by a qualified medical reviewer, with the same results, so the appeal was denied. The provider continued its tirade against the TPA’s customer service staff, and eventually submitted a second-level appeal, which the TPA referred to The Phia Group for review pursuant to the PACE service agreement.

The Phia Group obtained an independent medical review, which yielded the same results – that the claim was not emergent in nature. Phia rendered its determination, as a fiduciary, which the TPA relied upon in communicating the second-level appeal denial. As expected, the hospital renewed all its objections, but the administrative appeals were exhausted.

This situation is still ongoing. Since the second-level appeal response was issued, the hospital has made numerous threats to sue the Plan, the TPA, and Phia; luckily, the Plan and TPA can rest easy knowing that the second-level appeal determination was made by The Phia Group, rather than by the Plan or TPA, so in the event of a lawsuit, Phia is responsible for any fiduciary damages assessed should the court deem the denial to be inappropriate.

Regardless of the outcome, this is a perfect example of exactly how the PACE service works: the TPA and Plan can get back to their everyday business without worrying about liability from this and similar appeals.

Phia Case Study: The ASC OP

The beauty of this case study is in its simplicity.

A client of The Phia Group’s overpayment recovery service had issued an overpayment to an ASC to the tune of over $12,000 due to incorrect application of the plan’s Usual and Customary limitations. Specifically, the Plan allowed the claim at 140% of Medicare, but the TPA had incorrectly processed the claim at 80% of billed charges. The TPA had sent half a dozen letters to the ASC to no avail; ultimately the TPA referred the case to The Phia Group, to see if we could get any movement.

Upon receiving the file and discussing it with the TPA, we commenced recovery efforts, including sending an initial introductory and demand letter and following up with phone calls every few days. There was no response, so our legal team got involved; an attorney sent a very strongly-worded letter along with a vague warning that the Plan may be forced to take additional action if there was no response.

Within a week of sending that letter, we received a call from the ASC’s owner, apologizing for the delay and letting us know the overpayment request would be reviewed in the coming days. One week later, to the day, the owner called again to let us know that the check was in the mail.

The moral of this story? Sometimes all it takes is having that “Esq.,” on the end of a signature to make things happen – and sometimes having a reputation helps! In this case, The Phia Group’s legal team was able to recover $12,000 for the Plan.

Fiduciary Burden of the Quarter: SPD & PPO Contract Harmony

ERISA contains a broad framework of requirements regarding how health plans must notify claimants of a plan’s claim and appeal process and determinations. In the event of an Adverse Benefit Determination, a health plan must satisfy certain requirements. Three important requirements are (1) notifying the claimant of “[t]he specific reason or reasons for the adverse determination,” (2) including “[r]eference to the specific plan provisions on which the determination is based,” and also, (3) including “[a] description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary.” These are three requirements that are frequently overlooked.

The following example is simplified from the original issue, but it is still noteworthy: The Phia Group recently worked with a TPA who denied a claim on behalf of its client health plan because the provider erroneously submitted the claim directly to the TPA, rather than to the network. The TPA included verbiage on the EOB to the effect of – to paraphrase – “please submit this claim directly to the network for repricing.” There can scarcely be any doubt about what that means. Especially for a medical provider who is contracted with the network, and who understands how the network works.

Now, the interesting part of this anecdote is not really what happened, but instead the fact that even though the PPO contract specified that the claims should be submitted directly to the network – lending credence to the EOB’s remark code, the SPD itself did not contain that same requirement. Instead, the SPD specifically stated that claims must be submitted directly to the TPA. This creates a discrepancy between the PPO contract and the SPD in the most basic aspect of a claim: how to submit it! Recall that while benefit plans are contractually bound to abide by the terms of their network agreement, they – and beneficiaries of the Plan – are bound to obey the terms of the plan document. As a result, the EOB could arguably be deemed not to reflect the terms of the Plan, and the provider can thereby argue that the denial was not sufficient, (since the SPD technically does not support the denial, even though the provider is party to a network contract that says otherwise).

So, while this EOB remark code does seem to have contained “[a] description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary,” it arguably cannot meet the other two requirements since, literally speaking, language in the SPD does not exist to that effect.

This is an example of the common situation where two agreements conflict with one another, and the Plan Administrator has to make a choice of which one to follow. Making that choice is never ideal, so our advice is to say what you mean and mean what you say, in every agreement you have signed. Do not leave anything to chance or to anyone’s imagination!
 

Phia Fit to Print:

• Self-Insurers Publishing Corp. – Be Ready For The Drug Pricing Debate To Return With A Bang – June 3, 2020

• BenefitsPro – Voluntary travel, COVID-19 and hazardous activity exclusions – June 03, 2020

• Self-Insurers Publishing Corp. – Continuing Coverage During COVID-19 – May 6, 2020

• BenefitsPro – Employer compliance beyond CARES and FFRCA: Don't forget the basics – April 22, 2020

• Self-Insurers Publishing Corp. – Are Your ICS Really EES? A Look Who's Who on an Employee Benefit Plan – April 7, 2020

• BenefitsPro – The black box: A cautionary anecdote – April 3, 2020


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From the Blogosphere:

• No Contract? No Problem! Without a signed service agreement, some things can be left up in the air.

• Privacy Pitfalls – Considerations for Reopening the Office. Planning on reopening your office? Here’s what you need to know.

• DPC During a Crisis. The many benefits of Direct Primary Care.

• Did HHS Just Ban All Surprise Billing During The COVID-19 Pandemic? Apologies for the attention-grabbing headline, but no, as good as that would be for payers, it didn’t.

• COVID-19: Social Distancing and Paid Sick Leave. The national shift to social distancing has effectively changed the way almost all of us go to work.

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

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Webinars

• On June 16, 2020, The Phia Group presented, “Old Issues, New Environment – Not The Same Old Song,” where we discussed familiar issues such as balance billing, surprise billing, mental health parity, telemedicine, COB, and others, while framed in the context of these unique times.

• On May 19, 2020, The Phia Group presented, “A Pandemic Economy – Industry Risks and Opportunities,” where we took a deeper dive on ways administrators are extending benefits and taking care of those in need.

• On April 23, 2020, The Phia Group presented, “Reasons for Optimism,” where we discussed the many GOOD and POSITIVE things that have both improved our industry since the end of 2019, and that are on the way.

Be sure to check out all of our past webinars!

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Podcasts:

Empowering Plans
 

• On June 1, 2020, The Phia Group presented, “Workers' Comp. & COVID-19 - Preparing for an Influx,” where our hosts, Jennifer McCormick and Brady Bizarro discuss the impact of COVID-19 on workers' compensation claims.

• On May 6, 2020, The Phia Group presented, “A Million Dollar Start,” where our hosts, Ron and Brady, interview, Attorney Robert Martinez, and explore a case in which he secured a massive balance bill write-off from a hospital using some creative tactics.

• On April 27, 2020, The Phia Group presented, “Video Conferencing & the Risk to PHI,” where our hosts, Ron Peck and Brady Bizarro are joined by consulting attorney Nicholas Bonds to discuss the unique concerns facing covered entities and their business associates as more of us utilize video conferencing platforms while under quarantine.

• On April 13, 2020, The Phia Group presented, “COVID-19: Studies on Treatment Costs & Industry Impact,” where our hosts, Jennifer McCormick and Brady Bizarro, discussed some of the latest studies on the potential cost of COVID-19 treatment for self-funded plans, the projected impact on employer-sponsored insurance, and how they think this pandemic could change the industry.

Be sure to check out all of our latest podcasts!

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The Phia Group’s 2020 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 2020 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 8-18, signed up as club members. In the 25 years since, 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 Brockton 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 programming.

Youth of the Year: Abiana Cruz

Each year, the Boys & Girls Clubs of Metro South holds a competition to award the most prestigious honor that a teenager can receive as a member of their local Boys & Girls Club. The Youth of the Year award is the Boys & Girls Club signature effort to foster a new generation of leaders, fully prepared to live and lead in a diverse, global and integrated world economy.

One lucky teen has officially been awarded a $5,000 scholarship and a new laptop, courtesy of The Phia Group. The Boys and Girls Clubs of Metro South has announced, Abiana Cruz, as the Boys & Girls Clubs of Metro South’s 2020 Youth of the Year.

Cruz is a junior at Taunton High School and has been a member of the Taunton Clubhouse for 10 years. In addition to her many contributions to the Taunton Clubhouse as a member, Cruz works at the Club after school as an arts specialist, sharing her passion and creativity with younger Club members, and at Camp Riverside in the summer months as a camp counselor.

Grab-and-Go Dinner Program

The Boys & Girls Club has been hit hard and the Phia family is here to help! The Boys & Girls Club is averaging 100 meals served per night with 85% of those meals being served in Brockton. They are also providing boxes with fresh produce and non-perishable food (pasta, canned goods, etc.) to an average of 25 Brockton families per week on Friday afternoons.

Since the pandemic started in March, The Boys & Girls Club has been suffering financially. In total, the loss of programming revenue, public support, and special events fundraising between March 15th and June 30th is estimated at nearly $1M, or roughly 25% of their FY20 operating budget of $3,890,498.

That figure continues to climb each time Clubhouse re-openings are further delayed. The Phia family came together and donated a total of $3,500.00 while our employees were working from home. We encouraged employees to utilize Venmo to make their donations, and they happily did so. We are so proud of the Phia family and happy to have the ability to assist families in need.

If you would like to make a donation, please visit their website today and help a family in need. Here is their donation link: for the Boys & Girls Club

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The Stacks

Be Ready For The Drug Pricing Debate To Return With A Bang

By: Nicolas Bonds, Esq. – June 2020 - Self-Insurers Publishing Corp.

As 2020 dawned, one of the fiercest debates around containing healthcare costs pivoted on addressing the runaway prices of prescription drugs. In May of 2018, the Trump administration first floated their “blueprint” to lower drug prices, but hit a number of walls, legal and political.

Meanwhile, Congress labored on a number of pieces of legislation to curtail drug prices, with House Democrats’ approach culminating in the Elijah Cummings Lower Drug Costs Now Act. Named for the late Baltimore Democrat who pressed the Trump administration to do more to rein in drug costs, the bill was designed to empower the federal government to negotiate Medicare drug prices directly. The bill would have also placed a cap on the out-of-pocket prescription drug costs paid by those covered by Medicare Part D, while expanding dental, vision, and hearing coverage for Medicare recipients.

Click here to read the rest of this article

Continuing Coverage During COVID-19

By: Andrew Silverio, Esq. – May 2020 – Self-Insurers Publishing Corp.

For the last month or so, like just about every industry, self-funded plan sponsors and those serving them have been frantically grappling with how to quickly and thoroughly address issues they’ve never had to encounter before. Entire segments of our economy have shut down essentially overnight, travel has screeched to a halt, and employers are dealing with questions of a type and scope they’ve never seen. Against this backdrop, individuals’ healthcare needs have never been more vital, while for many employers the path to ensuring they can continue to be covered has never been more wrought with pitfalls.

Click here to read the rest of this article
 

A Look Who's Who on an Employee Benefit Plan

By: Kelly Dempsey, Esq. – April 2020 – Self-Insurers Publishing Corp.

The glory of self-funding is the flexibility an employer has to create a benefit plan that truly suits the individual employer. Employers with ERISA-governed self-funded plans have the opportunity to craft benefits and exclusions that align with the needs of their employee population, while implementing various cost containment solutions to assist the employer in offering a robust benefit plan, and, perhaps even more importantly, controlling the costs for the employees and the employer. But where does that flexibility stop?

Click here to read the rest of this article

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

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Get to Know Our Employee of the Quarter: Regina Cattel

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 expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.

The Phia Explore team will only allow an Explore member to receive this award in the most exemplary of situations; and it is without question that we had one of those types of situations this quarter. As the pandemic advanced, and forced Phia to send most of us home to weather the storm, this employee made herself available to perform any and all duties necessary to maintain Phia’s essential operations that went above and beyond her day to day job duties. Whether it was taking on responsibilities such as managing and sorting the mail, scanning, assisting facilities with the office move, working late handling COVID task force preparations, while still managing to be available 24/7 for employee questions and concerns…you name it – this person has truly done it all. She has made The Phia Group a truly exceptional place to work, and strives to make us even better!

Explore has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Regina Cattel, your Q2 Employee of the Quarter!

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

Job Opportunities:

• Case Investigator

• Health Plan Documentation Specialist/Plan Drafter

• Claim and Case Support Analyst

• Sr. Software Engineer

• Health Benefit Plan Administration Attorney/Consulting Attorney

See the latest job opportunities, here: Our Careers Page

Promotions

• Alyssa Pisco has been promoted from Case Investigator to Claim Recovery Specialist III

New Hires

• Nicole Capazzoli was hired as a Sr. Claim Recovery Specialist

• Krishna Pathuri was hired as a Director, Business Analysis

• Morganne Wagner was hired as a Project Manager

• Irene Yalch was hired as an Office Administrator

• Michael Young was hired as a Legal Intern

• Michael Hutshell was hired as a Sr. Claim Recovery Specialist

• Tara Otoka was hired as a Plan Drafter

• Susan Bivens was hired as a Data Architect

• Cindy Merrell was hired as a Subrogation Attorney

• Katelyn Jalkka was hired as an Accounting Intern

• Caelin McDonald was hired as a Sales Coordinator

• Pruett Cunningham was hired as an Executive Assistant

Phia News

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.

Welcome to Phia’s New Home!

The Phia Group has officially moved! We are proud to announce that after 20 years in business, we have officially moved into an office that we have worked extremely hard for. Our growing staff needed more room and we wanted to make sure they felt right at home when they came to work. Check out our new office!

Welcome to Phia’s New Home in Louisville, KY!

The Phia Group has officially outgrown its Kentucky office after less than one year of opening, and will in Septemeber be moving to a bigger, better location. Since operations began in Kentucky, we have hired over 20 individuals from the Louisville area. We are amazed by the rapid growth of The Phia Group’s sister office and can’t wait to add more Louisville locals to the Phia family!

Customer Success Team

The Phia Group is proud to announce the restructuring of it’s Customer Success Team. As many of you may know from experiences within your own organizations, every sector is experiencing a fundamental shift in customer expectations. It no longer is enough to just be the industry leader in results, one must be the industry leader in customer relations as well. Our Customer Success Team (“CST”) is lead by Rebekah McGuire-Dye. Mrs. McGuire-Dye has over 25 years of experience working in cost containment. Her experience lends her to be an exceptional advocate for The Phia Group’s clients. Mrs. McGuire-Dye will lead her team in providing not just reactive responses to our clients, but in a pro-active approach to ensure every client of The Phia Group is maximizing the value of our many services while always looking for new and innovative products to help our clients grow and lead in their respective areas.

Here are a few items with which the CST can assist you with:

• Identify concerns regarding any and all Phia Group services or results, confirm the absence of an issue or resolve the matter, and ensure customer satisfaction with the explanation or revision;

• Identify any delays or roadblocks to remove them and ensure optimal performance;

• Deliver all reports and resolve any issues associated with them;

• Fully analyze, utilize, and interpret Value Reports and other reporting tools to identify both issues and opportunities;

• Respond to routine file specific client questions (e.g., status on file #12345); and,

• Provide subject matter expert (“SME”) assistance as needed.

Although our CST team continues to grow, it is already one of the best staffed and most professional departments at The Phia Group. We encourage all clients to reach out directly if they have any questions at [email protected].

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