The Book of Russo:

I love July! Here in New England the weather is perfect – not too hot, not too cold … just right. The same can be said for the services and advice that we at The Phia Group bring to the industry … just right. Speaking of what we bring to the industry, I am so proud of the amazing “Phia Forum” event we hosted last month in gorgeous Newport, Rhode Island for select clients and partners. We showcased both our talented staff and future endeavors. My hope going into the affair was that those in attendance would not only see that The Phia Group is comprised of hundreds of passionate individuals who have come together to deliver the best in cost containment and regulatory guidance for our clients, but also, that we are combining legal knowhow with a focus on future technologies to build some of the most impressive products and services. My lofty hopes were exceeded in every way.

As usual, everyone raved about the numerous subject matter experts who displayed their knowledge and experience while doing so with energy and gusto. Our guests also readily shared, however, that while they have always known that we are the preeminent experts when it comes to health care laws and regulations, they now see The Phia Group in another light – as an organization that is on the cutting edge when it comes to our software and technical prowess. We lead in process efficiency, price and quality transparency, compliance and regulatory demands, cost containment delivery, plan design and fiduciary prowess. I am so proud of what we have built here at The Phia Group and I am excited to see what the next few years will bring.

– Happy reading!

Service Focuses of the Quarter: Phia Unwrapped 

Ever feel like the tiny discounts and auditing restrictions of wrap, extender, and other leased networks aren't doing enough for you or your groups? Phia Unwrapped is the solution. We replace typical wrap network access and traditional non-network payment methods to secure the lowest possible payment, while still abiding by defensible fair market standards. 

With Phia Unwrapped, an EDI feed ensures that claims are automatically flagged, transferred, and repriced; fees are based on a percentage of your actual savings, so you'll get great savings without unexpected or undeserved costs. 

Claims processed through our Unwrapped program have averaged a 74% savings off billed charges. That's three times the average wrap discount. We don't set any minimum on claims for repricing or negotiation, and we strive to get providers to accept the plan's payment as full ― and if there are issues or balance-billing, our experienced Provider Relations team is prepared to handle it. 

For more information, please contact Garrick Hunt at [email protected]

Enhancement of the Quarter: Ignite Pricing Engine

Get ready for The Phia Group’s Ignite Repricing Engine, our supercharged cost-containment powerhouse, built specifically to supplement our Unwrapped, No Surprises Act Support, and Balance Bill Support services. 

We've designed Ignite to be a precise and efficient pricing model to help you better navigate the sea of healthcare claims confusion. Especially in light of the No Surprises Act and its various complex demands, taking into account everything from quality and cost to market effects on claims has never been more important. That's why the Ignite Repricing Engine doesn't just meet these challenges, but it runs circles around them, providing you with a smooth, reliable, and budget-friendly solution. 

Aside from the next-generation software we’ve designed, the magic of Ignite is the team that powers it. With a combination of certified clinical and medical coding professionals, legal eagles, process and reporting experts, and administrative staff (22 individuals in total!), our team has strong expertise in all parts of the process. Ignite stands out for its unparalleled defensibility, integration of quality metrics, and compatibility with future technology. 

Integration isn’t just a buzzword for the Ignite Repricing Engine. We’ve designed it to thrive on standard SFTP and 837 files – and even for our partners with platforms using more advanced tech, Ignite is versatile enough to be bound to any platform for pricing and support on claims and disputes through Phia’s Provider Relations Operating System (PROS) software. 

Using vast amounts of data, strategic benchmarking, reliable quality metrics, and artificial intelligence – and a crack team of humans as well – the Ignite Pricing Engine will soon be revolutionizing claims handling.

Phia Case Study:

A client of Phia’s Independent Consultation and Evaluation (ICE) service received stop-loss reimbursement denial in the amount of $140,000; the denial involved claims incurred by an employee who was out of work on a lengthy and unpaid, but approved, personal leave of absence. 

The employee handbook provided for one unpaid, personal leave of absence per year, but the employee had allegedly taken two, per the stop-loss carrier. There were no other explicit references made to other leaves of absence in the employee handbook. The Plan Document did not clearly reference leaves of absence under the continuation of coverage section. Phia’s legal team analyzed the applicable documents and found the best language in each to make the case that the carrier should reimburse the claims at issue. This is a stop-loss policy we had seen before, and we found terms in it that undercut the carrier’s argument, as well as language in the Plan Document that provided significant discretion to the employer. We also found additional details surrounding the actions taken by the Human Resources department that benefitted the employer’s position. 

Ultimately, after formulating the best positions for the Plan to take, Phia drafted content for a letter that the TPA sent to the stop-loss carrier, which ultimately led to the carrier reversing its denial, and reimbursing the Plan $140,000. 

Fiduciary Burden of the Quarter: Doing What The SPD Says!

We still find ourselves revisiting this important fiduciary duty every so often, since it is perpetually relevant and it never stops being problematic for many – especially in light of drastic industry changes. As one example, many SPDs have not been updated to account for the many requirements of the No Surprises Act! 

Here are some general suggestions about SPD language in light of the NSA, and how to best ensure compliance with this important fiduciary duty of complying with the SPD: 

• Try to update SPDs as soon as possible when new laws become applicable 

• Avoid “lesser of” payment language since network contracts, an Independent Dispute Resolution decision, or a court might contradict it 

• Make sure the plan has authority to pay a negotiated rate or IDR directive if there is one 

• Clearly explain the plan’s patient responsibility calculations with an eye on compliance 

• Allow payments based on IDR or court decisions when appropriate 

• Ensure that there is a clear distinction between a denial eligible for a normal plan appeal (such as under ERISA) and a denial eligible for open negotiations and potentially IDR

Webinars:

• On May 18, 2023, The Phia Group presented “The Business of Benefits,” in which we discussed current issues and case studies that impact the success of organizations in the health benefit plan industry. 

• On April 20, 2023, The Phia Group presented “Before and After – Examples of Mistakes that Were Addressed and How to Avoid Them,” in which we discussed case studies and examples where The Phia Group was called upon to address some avoidable losses, as well as compare them to scenarios where the proper preemptive steps were taken. 

Be sure to check out all of our past webinars!

Podcasts:

• On June 26, 2023, The Phia Group presented “Artificial Intelligence Meets Subrogation,” in which our hosts, Jon Jablon and Cindy Merrell, discussed how AI could have a monumental impact on the field of subrogation within the larger context of healthcare law. 

• On June 9, 2023, The Phia Group presented “The Key to a Successful Self-Funding Experience: Knowledge!” in which our hosts, Andrew Silverio and Christopher Aguiar, discussed the challenges that arise when self-funded plans aren’t educated about their benefit offerings, risk mitigation mechanisms, and cost containment tools ensuring the plan’s viability. 

• On May 19, 2023, The Phia Group presented “ChatGPT: Disrupting the Healthcare Industry,” in which our hosts, Brady Bizarro and Brian O’Hara, discussed ChatGPT and how it affects the healthcare industry, and in particular, the advantages and potential disadvantages of using AI to act as a virtual assistant for patient care. 

• On May 12, 2023, The Phia Group presented “Mind the Gap 2.0: Don’t be Afraid to Ask for a Handbook,” in which our hosts, Kelly Dempsey and Kevin Brady, described our Handbook Gap Free Reviews service and discussed the case studies which gave rise to this service. 

• On April 28, 2023, The Phia Group presented “New Challenges to Old Favorites – NSA, ACA, and more (Acronyms)!” in which our hosts, Nick Bonds and Corey Crigger, discussed the No Surprises Act (NSA) and the Affordable Care Act (ACA), as well as the recent legal challenges out of Nick’s home state of Texas. 

• On April 18, 2023, The Phia Group presented “How the Ending of COVID-era National Emergency Impacts Your Health Plan,” in which our hosts, Jen McCormick and Joanie Verinder, discussed the sudden end to the National Emergency, the ways in which health benefit plans are affected, and the information their respective participants need to be aware of.

Be sure to check out all of our latest podcasts!

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Phia Fit to Print:

• BenefitsPro – Factors for compliance: CAA gag clause attestations – June, 2023 

• Self-Insurers’ Publishing Corp. – Gene and Cell Therapy: Where Compassion and Cost Collide – May, 2023 

• America’s Benefit Specialist – Price transparency Issues – April, 2023 

• Self-Insurers’ Publishing Corp. – Eli Lilly Caps Insulin Cost – April, 2023 

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From the Blogoshpere:

• Merck vs. Biden. A first attempt by a drugmaker to challenge the Medicare drug price negotiation program contained in the Inflation Reduction Act. 

• What Happens When Auto and Health Insurance Collide? An overview of the intersection of auto insurance and health benefits in the event of an auto collision. 

• A Weight Off My Chest. A discussion of health plans and how they are affected by the increasing number of prescriptions of drugs with weight loss properties. 

• Autism Benefits: DOL Enforcement for Sufficient Coverage. The Department of Labor (DOL) strongly advocates for more comprehensive autism coverage under group health plans. 

• Digitizing Subrogation. Read about The Phia Group’s own digitization of The Phia System and Case Management System. 

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

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The Stacks:

Gene and Cell Therapy: Where Compassion and Cost Collide

By: Jen McCormick, Esq. – June 2023 – Self-Insurers Publishing Corp. 

As advancements in how individuals consume healthcare have drastically and rapidly improved (i.e., the prevalence of virtual patient care, online pharmacies where treatments can be received and delivered to the home, etc.) face-to-face communication between providers and patients has often been supplanted by virtual interactions that expedite processes. The result is faster and easier access to healthcare.

Click here to read the rest of this article

Eli Lilly Caps Insulin Cost

By: David Ostrowsky – April 2023 – Self-Insurers Publishing Corp. 

On March 1, Eli Lilly, a pharmaceutical company with vast global reach, announced that it was indeed capping the out-of-pocket cost of its insulin at $35 a month—in addition to slashing the price of its two highest-selling insulin products, Humalog and Humulin, by 70%—and thus falling in line with a provision in the recently passed Inflation Reduction Act, which ensured that seniors enrolled in Medicare pay no more than $35 per month for insulin. Eli Lilly’s announcement made for above the fold news because now some individuals with private insurance—and not just Medicare recipients—would reap the considerable benefits of a $35 cap. For those without insurance, they too can pay just $35 per month by downloading Eli Lilly’s Insulin Value Program savings card. 

Click here to read the rest of this article.  

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 Boys & Girls Clubs’ mission is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.

The Boys & Girls Clubs of Metro South (BGCMS) was founded in 1990 to create a positive place for Brockton, Massachusetts, youths. It immediately met a need in the community: in the first year alone, 500 youngsters, ages 8-18, became members. In the 30-plus years since then, BGCMS has expanded its scope exponentially by offering a unique mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities.

Since BGCMS’ founding, over 20,000 youths have been welcomed. Currently, they serve over 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs.

Boys & Girls Club of Metro South 2023 Bids for Kids Gala Auction

The Phia Group was the Cocktail Reception Sponsor at the Boys & Girls Club of Metro South 2023 Bids for Kids Gala Auction on April 14, 2023, at Gillette Stadium. Thanks to the bids, donations, and dedication from the Boys & Girls Club’s partners, including Phia and special surprise guest New England Patriots quarterback Mac Jones, this event raised half a million dollars towards youth development programming!

Boys & Girls Club Youth of the Year Scholarship

Each year, the Boys & Girls Club 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’s signature effort to foster a new generation of leaders, fully prepared to live and lead in a diverse and integrated world economy. The Phia Group is a proud sponsor of the local competition and awards the winner with a $5,000 scholarship and a laptop. 

On March 27, 2023, we hosted the competition for this scholarship in our Canton office. There were four candidates, and the winner, 2023 Youth of the Year, is Sarah Chavez, pictured below with Phia’s Co-Founder and CEO, Adam!

The 2022 Youth of the Year, Kiley Georges, and the President/CEO of The Boys & Girls Club of Metro South, Derek Heim, both spoke at our conference in Newport on Monday, June 12.

The Phia Group Great Futures Scholarship

The Great Futures Scholarship was established in 2018 by Adam V. Russo, Esq., Co-Founder and CEO, of The Phia Group. Once a Boys & Girls Club kid himself, Adam has set his mind and heart on supporting the ambitions of our club kids and their amazing potential. Adam has first-hand experience understanding the struggles and challenges of overcoming obstacles, facing adverse circumstances, and the determination necessary for self-perseverance. The Great Futures Scholarship recognizes one graduating senior annually for their commitment to education and dedication to a better future. With Adam’s vision, our club annually awards a $10,000 scholarship to assist one student in their pursuit of their educational dreams as they develop a strong work ethic and self-appreciation. 

The 2023 Youth of the Year, Sarah Chavez, also won the 2023 Phia Group Great Futures Scholarship… bringing her total to $15,000 from The Phia Group!

The Leukemia and Lymphoma Society

The Phia Group’s Louisville-based employees, Rebekah McGuire-Dye, Cindy Merrell, and Corey Crigger, and their wonderful relatives, represented our company with style at The Leukemia and Lymphoma Society (LLS)’s Student Visionaries of the Year Grand Finale Celebration, held at the Kentucky Derby Museum. The Phia Group is heavily invested in LLS and proudly supported the noble organization by participating in the “Big Climb” event and fundraiser (May 13 at 1 Beacon St., Boston). Please see the following link to learn more about how LLS performs lifesaving blood cancer research for patients worldwide.

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Phia News: Phia Made the Top Workplace USA 2023 List

This award celebrates nationally recognized companies that make the world a better place to work together by prioritizing a people-centered culture and giving employees a voice. The Top Workplaces USA award is based entirely on feedback from an employee engagement survey completed by the employees of participating workplaces.

May is Mental Health Awareness Month

In May, Phia held different activities each week such as Meditation Mondays, encouraging employees to take a break from their busy days for a brief guided meditation to help reduce negative emotions and build concentration. Employees were able to follow along anywhere — at their desks, outside, or at home! Phia also held Wellness Wednesdays to provide employees with a fun and stress-free activity during/after lunch, including Chit Chat & Color, Paint & Plant, and Food Truck & Trivia. Our remote employees in Idaho got together for a nature walk, and our employees in Louisville painted birdhouses together.

May Mixer

On May 25, 2023, Phia employees gathered at Trillium Brewery for our May Mixer! There was no better way to usher in the Memorial Day weekend than getting together for craft beers and homemade pizzas in postcard weather.

Trivia Champions

A small group of Phians went out for some 2000-2010 Pop Culture Trivia and won 1st Place! Congratulations to everyone who was able to attend!

Leader Appreciation Event

Phia held this event for Team Leads & above in honor of all their hard work! There were handwritten, personalized notes from Adam and gift cards for everyone. Everyone who attended was also entered into a raffle to win amazing prizes, such as Ed Sheeran concert tickets, Red Sox tickets in the first row behind home plate, Red Sox tickets in the grandstand behind home plate with field access, batting practice, and a tour before the game, tickets to TreeTop Adventures, and a brewery gift certificate.

Wednesday Lunches: Food Trucks & BBQs

Each Wednesday, Phia caters lunch for everybody, giving employees the opportunity to chat and eat together!

1st Ping Pong Tournament

Phia held its first-ever ping pong tournament, and the winner was Boris Senic! The top two players were he and his brother, Igor.

Cleveland Opening Day

On April 6, 2023, Phia held a bbq to celebrate Cleveland Opening Day, as well as Adam’s birthday!

Get to Know Our Employee of the Quarter: Brittney Willoughby

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 has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Brittney Willoughby as The Phia Group’s 2023 Q2 Employee of the Quarter!

 Here is one person’s comments about Brittney: “Brittney not only goes above and beyond daily to ensure the success of her team, she also takes care of business in the Louisville office that is not in her job description, such as ensuring that all desks are set up with proper IT equipment and that the equipment is up and running in time for new hires to start work. This takes extra hours away from her team but she does whatever is asked with zero complaint.”

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

Phia Attending the SIIA National Conference

Several of Phia’s industry experts will attend SIIA’s National Conference in Phoenix, Arizona, from October 8th – 10th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: SIIA 2023 Index
 

Job Opportunities:

• Claims Negotiator 

• Customer Care Representative 

• Claim and Case Support Analyst 

• Project Manager (PMO) 

• Project Coordinator (PGC)

See the latest job opportunities, here: Our Careers Page

New Hires

• Bridget Binda was hired as Case Investigator. 

• Brittany Farr was hired as Sr. Customer Care Auditor and Trainer. 

• Vrushali Nar was hired as Instructional Designer. 

• Susan Bodner was hired as Claim Recovery Specialist – WC. 

• Jack Lauro was hired as Canton High Extern. 

• Andrew Sheehan was hired as Customer Service Rep. 

• James Ruel was hired as EDI Data Engineer. 

• Sabina Gill was hired as Customer Service Rep. 

• Kaya Dua was hired as DSG Intern. 

• Gabby Peck was hired as Data Quality Analyst. 

• Allison Jo was hired as Marketing Intern. 

• Robert Lewis was hired as Director, Data Services. 

• Emily Kewer was hired as Lead Case Investigator. 

• Max Tremblay was hired as Claim and Case Support Analyst. 

• Jessie Boyle was hired as Content Specialist Intern. 

• Jamie Izlar was hired as Sr. Subrogation Attorney. 

• Owen Langan was hired as Claim and Case Support Analyst.

• Tracey Wilson was hired as Sr. Claim Recovery Specialist.

• Kiron Allen was hired as Customer Service Rep. 

• Laura Good was hired as HR Generalist.

Phia Attending the SIIA National Conference

Several of Phia’s industry experts will attend SIIA’s National Conference in Phoenix, Arizona, from October 8th – 10th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: SIIA Index Page. 

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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