Phone: 781-535-5600 | www.phiagroup.com
The Book of Russo: From the Desk of the CEO
The fall season is here and that means cooler weather, shorter days, changing leaves… and lots of travel for those of us in the self funding space. The airport terminal is starting to get to me, but as we all know, once October ends, we have a few months at home before the spring events. But that doesn't mean that it's not busy; in fact, with the amount of new business that so many of you are bringing to the table, it's busier than ever here at The Phia Group. We are talking about new plan documents to write, new stop loss policies to assess, more data to scrub for recovery opportunities, and more claims to review. But all of this growth comes with potential land mines. We cannot take our eyes off the ball and must continue to innovate while being cautious of not overstepping. There are so many ways we can empower our plans but we need to ensure that we do it right.
Service Focus of the Quarter: The Phia Group Flagship Template New Services and Offerings Phia Group Case Study Phia Fit to Print From the Blogosphere Webinars Podcasts The Phia Group’s 2017 Charity The Stacks Phia’s Speaking Events Employee of the Quarter Phia News
Service Focus of the Quarter: The Phia Group Flagship Template
Our plan document can now be yours in a fraction of the time. Taking the guesswork out of best practices and utilizing optimal provisions, The Phia Group Flagship Template offers an unrivaled plan document, with time and cost effectiveness in mind. Let us make your life easier and your plan document drafting experience more accurate. With minimal time or monetary investment, you can now take advantage of the industry's most thorough yet efficient plan document production tool. Despite having 75% fewer questions than any other customizable plan document template, The Phia Group Flagship Template is both compliant with federal law, as well as innovative in its use of cost-containment tools and participant incentivizing provisions. It should therefore come as no surprise that following in-depth review and assessment, The Phia Group Flagship Template is supported by many leading stop loss carriers. Contact Garrick Hunt at [email protected] or 781-535-5644 to learn more about how The Phia Flagship Template can help you.
New Services and Offerings:
New Phia Tableau Reporting Portal Tool now available:
At The Phia Group, we value transparency and customer satisfaction above all else. In recognition of those priorities, we routinely improve our client facing reports and reporting capabilities. To that end, we are proud to announce that we will be further expanding our reporting service features. Through the use of Tableau (Tableau Home Page), reports will now offer a new level of customization, enabling you and The Phia Group to collaborate like never before. These features are not only available to our Subrogation and Third Party Claim Recovery clients, but also customers utilizing any of our Provider Relations services (such as Phia Unwrapped, Balance Bill Support, and Claim Negotiation and Signoff). For more information regarding the new Phia Tableau Reporting Tool and pricing, please contact Garrick Hunt at [email protected] or call him at (781) 535-5644
Cutting back on Questionnaires:
It is The Phia Group’s mission to reduce the cost of healthcare through the use of innovative legal techniques and the most sophisticated technology. In keeping with this goal The Phia Group is always taking steps to improve all of our services, including our earliest: subrogation. Recent upgrades to The Phia System™ and advancements in our investigational techniques have led to faster identification of third party liability claims and quicker engagement by The Phia Group’s team, without relying upon or otherwise communicating with the plan participants. These new resources allow us to identify opportunities more often and more effectively, while at the same time reducing the volume of accident questionnaires we send to plan participants. While accident questionnaires are still a useful tool when investigating and collecting accident details – they are no longer the only tool. As such, we are pleased to now provide all of our subrogation clients with the ability to increase, decrease, or cease the use of plan participant accident questionnaires. Clients can also opt to utilize their own letters, or have the employer communicate directly with plan participants. The Phia Group is committed to ensuring you and your clients are provided with nothing but the highest quality service, best-in-class performance, and a member first approach. That is why we are continuously improving our services to provide the best performance (and most options) possible. To discuss these new customization capabilities, or our other services, please contact Garrick Hunt at [email protected] or call (781) 535-5644.
Phia Group Case Study:
The Phia Group was presented with a case where a self-funded health plan paid a claim based on a network rate; the billed charges were $211,500, and the network rate was 51% of billed charges – netting payment of $107,865. When submitted to stop-loss the group’s carrier denied a portion of the claim paid, citing the stop-loss policy exclusion of all amounts in excess of Usual and Customary amounts, as determined by the carrier. The kicker: that was all the stop-loss policy’s exclusion said - Usual and Customary was not defined anywhere within the policy. The carrier was of the opinion that 150% of the Medicare rate was Usual and Customary, and upon that basis allowed only $22,000 – denying reimbursement of nearly $87,000 that the Plan paid pursuant to its PPO contract. The group attempted to appeal the denial, but the carrier stood firm; the group was all but ready to give up the fight, when the group changed brokers and the new broker’s first order of business was to consult The Phia Group. The Phia Group got in touch with the stop-loss carrier on the group’s behalf and attempted to explain the group’s position. The existence of the PPO contract and required payment amount combined with the carrier’s lack of explicit, supporting policy language in the stop-loss policy (along with other arguments – legal and common sense) formed the basis of our position. After many rounds of discussions, the carrier agreed to reimburse the entire claim paid except for $2,073 in “ineligible” charges. The plan’s liability for the denied stop-loss claim was $87,000, and The Phia Group’s intervention helped save $85,000.
Fiduciary Burden of the Quarter:
Traditionally, we have discussed fiduciary burdens in terms of companies that perform “plan” functions– such as repricing claims or administering appeals – but this quarter has seen certain instances in which those that perform “settlor” functions (most prominently a broker placing stop-loss or network coverage) have encountered some fiduciary issues. For example: a recent dispute between a plan, its broker, a network administrator, and stop-loss carrier in which the broker apparently placed inadequate or insufficient stop-loss coverage to support a network’s standard policies. The issue is that the network contract required payment of claims that the carrier did not cover; caught in the cross-fire is the broker, who placed this business, and who allegedly should have been aware of the potential discrepancy. The allegation? That the broker simply provided bad guidance regarding the choice of which network/carrier combination the plan should use. It is a very easy mistake to make and one that can potentially be made by anyone placing business. Our advice to brokers, TPAs, and other advisors, is to make sure you are as diligent as possible when making decisions for, or even making suggestions to, your clients. Self-funded plan sponsors and plan administrators rely heavily on their advisors; when they are given questionable advice, the backlash can be huge – and it can be unexpected. Our popular services: plan document review, stop loss policy review, and Gap-Free Analysis (which compares the stop-loss policy to a plan document, network contract, or other materials), can help identify issues and potential “gaps” in coverage before they happen. This can mean the difference between spending $120,000 on a new Maserati, and spending $120,000 to indemnify your client from an unexpected stop-loss denial.
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Phia Fit to Print:
• Money Inc. – “Affordable” Health Insurance Is Not “Affordable” Health Care – May 11, 2017
• Boston Voyager – Meet Ron E. Peck of The Phia Group in Braintree – August 7, 2017
• Money Inc. – All Against One and One Not for All: A Case Against a Single Payer System – August 21, 2017
• Bloomberg – Employers Taking Action to Control Health-Care Costs – September 5, 2017
• California Broker Magazine – Even as “Repeal and Replace” Falters Self-funding Remains Strong – September 7, 2017
• Self-Insurers Publishing Corp. – State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know – August 4, 2017
• Self-Insurers Publishing Corp. – Taking Health Care International - The Growing Trends of Importing Care and Exporting Patients – July 3, 2017
From the Blogosphere:
• Stop Loss and My Infinite Sadness. You get what you pay for.
• Uncertainty Prevails in the Health Care Debate. The dog days of summer have come and gone.
• Reverse Medical Tourism. US patients are seeking services abroad to obtain services and care at more affordable rates.
• Spinning the Web of the Plan Document. No, this isn’t about spiders.
To stay up to date on other industry news, please visit our blog.
Webinars
Best Practices for Today's Plan Documents
On October 17, 2017, The Phia Group will present “Best Practices for Today's Plan Documents,” where our legal team will discuss best and worst plan document practices, provide some creative ideas for plan formation, and suggest some concepts to help perfect plan document drafting.
Click HERE to Register!
On September 21, 2017, The Phia Group presented “It’s Time To Renew – Revisiting Stop Loss Trends,” where we discussed understanding procedures preemptively, reviewing a plan document side-by-side with the stop loss policy, and agreeing upon language interpretations.
On August 22, 2017, The Phia Group presented “A True Impact on the Bottom Line – Identifying Current Issues, Implementing Solutions & Seeing Results,” where we discussed the biggest issues impacting the health benefits industry today.
On July 13, 2017, The Phia Group presented “Consulting Headlines – The Hottest Topics in Benefit Plan Administration,” where our legal team discussed how laws are changing, regulations are shifting, and benefit plans are scrambling to keep up.
Podcasts:
On September 11, 2017, The Phia Group presented “Cutting Out Conflict,” where our legal team explained what plan administrators can do to cut out conflict and tie up loose ends before they suffer a costly loss.
On August 21, 2017, The Phia Group presented “In Reference to reference Based Pricing,” where Adam Russo and Ron Peck picked apart the method for containing costs, identified the pros and cons of an “RBP” plan, and discussed options to customize such a program.
On August 11, 2017, The Phia Group presented “Stopping the Bleeding,” where The Phia Group’s CEO, Adam Russo and Attorney Brady Bizarro interviewed Garrick Hunt, Phia’s Sales Executive.
On August 7, 2017, The Phia Group presented “Repeal & Replace Fails: What’s Next,” where The Phia Group's CEO, Adam Russo, Sr. VP, Ron Peck, and Attorney Brady Bizarro discussed the dramatic events on Capitol Hill and the shocking failure of Senate Republicans to repeal and replace Obamacare.
On July 17, 2017, The Phia Group presented “Your Friendly Neighborhood Provider,” where Ron Peck, Jon Jablon and Andrew Silverio shared stories and examples of providers working with payers to preserve the private employer based group health plan industry.
On July 10, 2017, The Phia Group presented “The Cost of Care,” where The Phia Group's CEO, Adam Russo and Sr. VP, Ron Peck, interviewed Attorney Jon Jablon - Director of Provider Relations
Be sure to check out all of our latest podcasts!
The Phia Group’s 2017 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 2017 charity is the Boys & Girls Club of Brockton.
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 Brockton (BGCB) 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 youth have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.
On Friday, August 24th, employees of The Phia Group participated in the annual volunteer day at The Boys & Girls club of Brockton. Employees of The Phia Group hosted a number of activities that all of the children truly enjoyed. This year, The Phia Group collected and donated $4,500 to help keep this program running and enjoyable for years to come!
The Phia Group invites its staff to donate various items for the benefit of The Boys and Girls Club of Brockton. For more information or to get involved, visit www.bgcbrockton.org.
The Stacks
Aid-in-dying Laws and the Implications for Self-Funded Plans
By: Maribel E. McLaughlin, Esq. – September 2017 - Self-Insurers Publishing Corp.
Two years ago, a woman close to my mother was diagnosed with an aggressive form of brain cancer. Along with her two daughters, she went through the various treatment options presented to her and determined that she was going to try all of them. She wanted to put her best foot forward for her daughters and her granddaughter, and she found the strength to fight the cancer with every cell in her body.
Click here to read the rest of this article
State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know
By: Brady Bizarro, Esq. – August 2017 - Self-Insurers Publishing Corp.
According to one prominent health law attorney, “Although in its text ‘hospital’ appears only once and ‘physician’ not all, ERISA may be the most important law [prior to the Affordable Care Act] affecting health care in the United States.” William Sage, “Health Law 2000”: The Legal System and the Changing Health Care Market, 15(3) Health Aff. 9 (Aug. 1996). Understanding the intricacies of the Employee Retirement Income Security Act of 1973 (“ERISA”) and its preemption clause can be a challenge for even the most assiduous attorney. The statute supersedes any and all state laws insofar as they “relate to” any employee benefit plan. It also contains a “savings clause” which preserves the state’s traditional role of regulating insurance. That clause is then qualified by the “deemer clause,” which acts as a kind of escape hatch through the savings clause. For employers, that escape hatch is key because it allows them to avoid state insurance regulations by self-funding their health plans rather than by purchasing health insurance. Increasingly, however, states are testing the limits of preemption by passing leave laws which mandate that employers continue health insurance coverage for eligible employees out on leave.
Click here to read the rest of this article.
Taking Health Care International – The Growing Trends of Importing Care and Exporting Patients
By: Andrew Silverio, Esq. – July 2017 – Self-Insurers Publishing Corp.
Esteemed physicist Richard Feynman is remembered by many for the phrase “If you think you understand quantum mechanics, you don’t understand quantum mechanics.” This sentiment rings true for the continually evolving landscape of our healthcare system as well, and the problems facing all of us, particularly as insurers, employers, and patients. For those of us within the healthcare or health risk industries, the more we learn about the problems we face and what is causing them, the more we realize just how complex the landscape is and what an impossible task it would be for any single solution to reel in the cost of care.
To stay up to date on other industry news, please visit our blog. Back to top ^
Phia’s Q4 Speaking Events:
Phia’s Speaking Engagements:
• 7/12/17 – Montana Captive Conference – Whitefish, MT “High Performing Self-Insured Health Plans – The Key to Successful Stop-loss Captive Programs”
• 8/9/17 – NAHU Region 1 Meeting – Stamford, CT “The Best gets Better: Getting the Most out of Your Self-Funded Plans”
• 9/19/17 – Custom Design Benefits – Cincinnati, OH “The Top 10 Innovations in Self-Funding”
• 9/27/17 – TABA’s 2017 Fall Conference and Membership Meeting - The Woodlands, TX “Gap Traps: Avoiding Variances between the Employee Handbook and the Plan Document”
• 10/3/17 – NHAHU – Bedford, NH “Top 10 Do’s & Don’ts of Self-Funding”
• 10/4/17 – Hewitt Coleman Broker Meeting – Greenville, SC “The Future of Self-Funding & Reference Based Pricing”
• 10/16/17 – Captivated Health Membership Meeting – Woburn, MA “Empower & Engage Through Your Handbook”
Ron Peck’s 2017 Speaking Engagements:
• 9/19/17 – CIC-DC 2017 Annual Conference – Washington, D.C. “Cost Containment Strategies”
Tim Callender’s 2017 Speaking Engagements: • 7/17/17 – Health Care Administrator’s Association TPA Summit – St. Louis, MO “Conference Emcee”
• 8/17/17 – FMMA 2017 Annual Conference – Oklahoma City, OK “Critical Strategies in Self-Funding to Promote the Free Market”
• 9/21/17 – Metro Detroit Association of Health Underwriters, Annual Conference – Troy, MI “The Real Causes of High Healthcare Costs & True Cost-Containment Strategies to Combat Cost.”
• 10/10/17 – SIIA, National Educational Conference & Expo – Phoenix, AZ “Through the Looking Glass – a Non-Vendor Take on Reference Based Pricing”
Brady Bizarro's 2017 Speaking Engagements: • 7/18/17 – HCAA TPA Summit 2017 – St. Louis, MO “Ethics” • 8/9/17 – TPAC 2017 Conference – Philadelphia, PA “Most Common Mistakes Employers Make in Their Plan Documents.” • 9/26/17 – TABA’s 2017 Fall Conference and Membership Meeting - The Woodlands, TX “Gap Traps: Avoiding Variances between the Employee Handbook and the Plan Document”
Get to Know Our Employee of the Quarter: Kerri Sherman
Congratulations to Kerri Sherman, The Phia Group’s Q3 2017 Employee of the Quarter!
“Kerri consistently goes above and beyond to help all of us when help is needed. Kerri is always around to provide assistance and help out wherever she can! Whether it be training, or making sure we have all the tools we need to complete our work. She has been in the training room at times working with new people, but always keeps us informed of where she will be and what she is doing, so if any issues arise, we know how to proceed. We think she is a fantastic multi-tasker and is always supportive. She always provides quick feedback if something requires immediate attention and always provides detailed explanations of everything that needs to be done in order to solve the issue. We have appreciated all the hard work she has done to help me keep my case load at bay especially while we were preparing to go on vacation. We think she has been phenomenal and we are happy to have her on our team. She is reasonable and fair, while maintaining professionalism.”
Congratulations Kerri and thank you for your many current and future contributions. Back to top ^
Phia News
Catherine Dowie’s Latest Win
We would like to congratulate Catherine Dowie on her latest win! Phia’s own Catherine Dowie won a $25,000 prize in the Philip Shawe Scholarship Competition, tying for second place in a pool of 240 applicants who submitted briefs to the crowd sourcing contest. We are proud to have you on our team. Get all of the details in recent article published by Suffolk University Law School.
• Customer Service Representative
• Claims Specialist
• Medical Bill Negotiator
• Health Benefit Plan Consultant I
• Health Benefit Plan Administration – Attorney II
• Product Development Manager
See the latest job opportunities, here: Our Careers Page
Babies
• Jamie Johnson gave birth to Miles and Kaia on 7/10/2017
Promotions
• Ulyana Bevilacqua was promoted from Consultant to Supervisor, PGC • Elizabeth Pels was promoted from Legal Assistant to Claim Recovery Specialist • Joseph Bacon was promoted from Legal Assistant to Claim Recovery Specialist • Vourneen O’Donovan was promoted from Legal Assistant to Claim Recovery Specialist • Cheyenne Fonseca was promoted from Legal Assistant to Claim Recovery Specialist
New Hires
• Joseph Bacon was hired as a Legal Assistant • Naveen Omkar was hired as an IT Technologist • Trevor Schramn was hired as a Sales and Accounts Coordinator • Jeff Booth was hired as a Training and Development Manager • Jen Montalto was hired as a Case Investigator/Stop Loss • Mike Mears was hired as a Claim Analyst • Gordon Glenn was hired as an IT Technologist • Olesya Avramenko was hired as a Consultant I • Michelle Rowland was hired as a Consultant I • Alexandra Simboski was hired as a Consultant I • Patrick Ouellette was hired as a Juris Doctor • Andrew Fine was hired as an Intake Specialist • Erin Hussey was hired as an Attorney I • Catina Griffiths was hired as a Case Investigator • Samad Khan was hired as a Contract Administrator • Zackery McLaren was hired as a Case Investigator • Kaley Dennison was hired as a Case Investigator • Ekta Gupta was hired as an ETL Specialist • Kathy baker was hired as a Claim Recovery Specialist IV-WC • Annie Heskin was hired as a Talent Acquisition Specialist
Fun at Phia:
Solar Eclipse of 2017
Rock Star Recognition: The Phia Group was recently awarded the “Rock Stars of Health GOLD Award” during The Rock Stars of Health Summit held in Missoula, Montana on September 29, 2017. Back to top ^