Service Focus of the Quarter: Plan Appointed Claim Evaluator® and PACE Certification

Plan Appointed Claim Evaluator®, or “PACE”

Some years ago, in response to growing industry concerns over the difficulty of exercising fiduciary duties with respect to internal appeals, The Phia Group created its Plan Appointed Claim Evaluator® (PACE) service. PACE is a fiduciary transfer service for applicable final-level internal appeals. It is designed solely to help the health plan ensure that it has made correct determinations, thereby insulating the health plan from liability and allowing the Plan Administrator to focus on its core business rather than difficult fiduciary determinations.

PACE includes:

• Plan Document and stop-loss policy “Gap Reviews” ensure compliance, eliminate coverage gaps, and ensure PACE readiness
• Advanced-level webinars exclusively for PACE clients
• Assessment of eligible final internal appeals via written directive as a fiduciary
• Unsurpassed legal analysis, clinical review and access to URAC-accredited IROs (and PACE covers all external review costs)

Beginning August 2019, we will also begin offering complimentary PACE Certification – whereby your organization can enhance your PACE business, improve your internal appeals processes, ensure regulatory compliance, and improve your business as a whole.

Chapter One of PACE Certification explores the ins and outs of self-funding; Chapter 2 takes a deeper dive into the laws and regulations applicable to self-funded health plans; Chapter 3 explains what PACE is, how it works, and how it can best be utilized.

PACE Certification

PACE Certification provides access to a multimedia educational program! Through videos and interactive knowledge materials, you will emerge educated and entertained! Once PACE certified, you will enhance your PACE business and increase revenues, improve your appeals processes, and assure regulatory compliance!

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 preemption to adverse benefit determinations and appeals.

Chapter Three: Explain what PACE is, what PACE does, and how it’s obtained, implemented, and utilized.

To learn more about either PACE or PACE Certification, please contact Tim Callender at 781-535-5631 or [email protected].

Phia Case Study: Independent Consultation & Evaluation (ICE) 

A client of The Phia Group’s ICE service approached our consulting team with an inquiry whereby an employee had accrued two weeks of paid time off (PTO) pursuant to the employer’s own internal policies, and that employee was about to take leave to deliver her first child. The inquiry was specifically regarding whether the employee could first take her accrued PTO for two weeks, and then begin FMLA leave, for leave totaling 14 weeks (two weeks PTO plus twelve weeks FMLA).

Our response focused on some guidance provided by the Department of Labor. In March 2019, the DOL was very specific in its mandate that once an employer knows that a leave of absence qualifies under FMLA, the employer must designate the leave as FMLA leave, regardless of any available PTO or other employer-approved leave.

In other words, the DOL requires the FMLA and PTO leaves to run concurrently; since the PTO totaled 2 weeks and the FMLA totaled 12 weeks, those first 2 weeks would have the leaves running concurrently, and then, if taken, there would be only ten additional weeks available of solely FMLA.

It’s important to mention in this context that employers have a wide berth to structure their own policies, grant leave, and other employment-type things – but continuation under the health plan should be pursuant to Plan terms, rather than only employer policies; this is important for many reasons, not the least of which being stop-loss coverage.

If the employer granted two weeks of continuation coverage in addition to the twelve guaranteed by FMLA, claims incurred in weeks 13 and 14 would likely not be covered by stop-loss, (since, again, the DOL requires that the two weeks of PTO be fully exhausted concurrently with the FMLA leave, resulting in twelve total weeks rather than fourteen). If the employer had offered those two additional weeks of continued coverage after the first twelve, it would have been neither FMLA nor PTO (i.e. it would have been a “favor” done by the employer), and therefore the stop-loss insurer could determine that it is not covered leave sufficient to invoke coverage under the stop-loss policy.

We therefore opined that allowing the employee to delay designation of FMLA for the purposes of extending coverage beyond 12 weeks would not only violate the DOL’s rules, but it may also result in issues with stop-loss reimbursement for claims incurred after the exhaustion of FMLA as proscribed by the DOL – both of which can carry serious repercussions.

While this issue deserves more analysis than what is described in this case study, this knowledge may have helped save the employer from violating federal regulations as well as potential stop-loss denials!

Fiduciary Burden of the Quarter: Following the SPD – Unless Inconsistent with the Law!

You may have heard of the so-called “greatest of three” rule with respect to out-of-network emergency services. This regulation – codified at 45 CFR 147.138(b)(3). This regulation, in a nutshell, requires that for out-of-network emergency services, self-funded health plans allow claims at the greatest of (1) 100% of Medicare, (2) the amount the plan would allow for non-emergent out-of-network claims (in other words, Usual and Customary, Maximum Allowable Charge, etc.), or (3) the median contracted rate for emergency services.

Many health plans and TPAs disregard this “greatest of three” rule, either by not containing the proper plan language or simply not following the regulation. In fact, in the performance of The Phia Group’s PACE service, we often need to ask our clients regarding their median contracted rate for emergency services – and we are sometimes informed that the TPA does not know.

They say “knowledge is power,” but in this case, “knowledge is compliance!” Without knowing each of those three elements, it is impossible to know which one is truly highest. This becomes especially dangerous for plans that pay out-of-network emergency claims based on Medicare rates; for such plans, it is incredibly common for the median contracted rate to be higher than the Plan’s chosen percent of Medicare – so knowing the median contracted rate can be the only way to compliantly adjudicate an out-of-network emergency claim.

There are two action items: first, make sure your SPDs are specific on this “greatest of three” rule, such that for non-contracted emergency claims, they are paid pursuant to this regulation – and second, make sure you are acutely aware of the median contracted rate for emergency services, since we have seen more and more providers raising this point in appeals of non-contracted emergency claims!

Success Story of the Quarter: The Balance-Billing “End Game”

A health plan had a member who was visiting some out-of-state relatives, and that member happened to sustain a non-emergent injury while playing frisbee with his family. He didn’t go to the emergency room, but instead (wisely!) visited a local Urgent Care facility, which referred him to a local ASC. The health plan of which this individual was a member utilized a small regional network in its home state, with Phia Unwrapped for non-network claims. Since neither the Urgent Care facility nor the ASC was not part of that regional network, this claim became subject to Phia Unwrapped, and was consequently priced at 165% of Medicare – a rate the health plan had chosen.

The ASC billed $17,000 for the eventual care provided, of which 165% of Medicare totaled around $7,500. The member was subsequently billed for the remainder.

The ASC was adamant that its billing was reasonable, and cited the fact that it had billed at only 375% of Medicare; when Phia’s balance-billing support team pointed out that 375% of Medicare is not a reasonable amount, the provider outright refused to negotiate its bill, and continued to bill the patient. The refusal to negotiate is a rare stance, but this ASC was so confident in its ability to collect that it felt it was appropriate.

Unfortunately for this ASC, the particular benefit plan and TPA had had enough with this type of provider mentality; after much discussion, the TPA and plan – with Phia’s assistance – engaged local counsel to file a lawsuit on behalf of the patient to challenge the provider’s billing as unreasonably high. Prior to that filing, we warned the ASC that if we were unable to settle, litigation would likely ensue, but the ASC balked in disbelief.

Fast-forward about two weeks: the very same day the complaint was served upon the ASC, we received correspondence indicating that the ASC would accept Phia’s prior offer of an additional $1,500 to close the claim.

New Service Offered by Phia: Patient Defender

The Phia Group is proud to introduce its “Patient Defender” program. For a small PEPM fee, every plan participant has access to legal representation against lawsuits targeting patients, or crippling balances being sent to collections, when efforts to amicably resolve these disputes fail, Patient Defender is the ultimate weapon in the battle against abusive balance billing tactics. 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 these increasingly aggressive tactics, Patient Defender will be there.

Patient Defender finally plugs the gap that has existed across the industry in relation to reference-based pricing programs and balance billing concerns. With Patient Defender, a small PEPM rate ensures that a trusted law firm is placed on retainer, ready and willing to assist the patient when balance-billing occurs. Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.

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].

Phia Fit to Print:

• BenefitsPro – Drug manufacturer coupons and out-of-pocket limits: What employers need to know – September 23, 2019

• Self-Insurers Publishing Corp. – Reference-Based Pricing: Pitfalls For A New ERA – September 3, 2019

• BenefitsPro – Universal health care: Comparing what looks nice on paper to reality – August 26, 2019

• Self-Insurers Publishing Corp. – How Self-Insured Health Plans Are Helping Employers Compete In A Challenging Talent Marketplace – August 5, 2019

• BenefitsPro – Blocking TV drug price disclosures: What's next? – July 31, 2019

• Free Market Healthcare Solutions - Senate Finance Committee Tackles Prescription Drug Prices – July 21, 2019

• Self-Insurers Publishing Corp. – Big Pharma Facing Big Losses Tied To Opioid Epidemic Fallout – July 4, 2019

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From the Blogosphere:

• Lots of Moving Parts. Put your Reference-Based Pricing knowledge to the test.

• Controversy Surrounds the Most Expensive Drug in the World. A drug designed to help kids that will bankrupt their parents.

• There’s a New Notice on the Block. On July 17, 2019 the Internal Revenue Service issued Notice 2019-45.

• Health Care “Cadillac Tax” Repeal Bill Passed by the House. This Cadillac Tax could hit your wallet and leave a mark.

• Network Contract Drafting: You’re Doin’ It Wrong. Watch you contract language!

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

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Webinars

• On September 17, 2019, The Phia Group presented, “2020 Renewal Season - Decisions Today, Uncertain Tomorrow,” where we discuss important issues impacting plan renewals, address known roadblocks, and perform an assessment of the candidates’ positions on healthcare – with an eye toward what we should be doing today to prepare for an uncertain tomorrow.

• On August 21, 2019, The Phia Group presented, “Back to School: 2020 Renewals,” where we provide the education needed to help you meet your obligations and keep your business safe – and provide the information you need to earn a “passing grade” during renewal season!

• On July 23, 2019, The Phia Group presented, “Trump’s Executive Order on Transparency: How it Will Effect Each Segment of Our Industry,” where we discuss the executive order point by point; they’ll touch on what they like and don’t like about it, and – more importantly – what this all means for you.

Be sure to check out all of our past webinars!

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Podcasts:

Empowering Plans
 

• On September 18, 2019, The Phia Group presented “Politics! Politics! Politics!,” where our hosts, Ron Peck and Brady Bizarro, discuss Obamacare, the state of health care versus health insurance, and the political environment as we move toward the 2020 election.

Face of Phia

• On September 4, 2019, The Phia Group presented, “Crunching Numbers with Desmond Campbell,” where our host, Ron Peck, sits down with Desmond Campbell, the man, the myth, the legend.

• On August 16, 2019, The Phia Group presented, “The Fine Fan Club!,” where our hosts, Adam and Ron, learn more about the life and background of Andrew Fine, Phia’s Lead Intake Specialist.

• On August 1, 2019, The Phia Group presented, “The Magical Kingdom!,” where our hosts, Adam and Ron, interview Mattie Sesin, our Director of Recovery Services.

Tales From the Plan

• ON September 23, 2019, The Phia Group Presented, “A Vision for Savings,” where Adam Russo and Michael Vaz sit down to discuss his experience with The Phia Group’s health plan and how he was able to save money for the plan and get rewarded for doing so.

• On July 17, 2019, The Phia Group presented, “Direct & To The Point!,” where The Phia Group’s VP of Legal Recovery Services, Chris Aguiar, Esq., discusses his experiences before and after becoming a happy participant in Direct Primary Care.

• On July 8, 2019, The Phia Group presented, “Mrs Peck, It’s Cancer…,” where our host, Ron Peck, tells us about his family’s battle against cancer, and lessons we can all learn from their experience.

Be sure to check out all of our latest podcasts!

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The Phia Group’s 2019 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 2019 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 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.

Back to School

Our friends from the Boys & Girls Club of Brockton are going back to school, and the Phia Family wanted to send them some school supplies to go back to school with. The Phia family donated a total of 3,500 school supplies/backpacks and $1,700 in monetary donations. We hope all of the amazing children are enjoying their new school supplies!

Volunteer Day

The Phia Family was out and about a few months back, celebrating our annual volunteer day at the Boys & Girls Club of Brockton. There were a variety of activities for the kids to participate in, between archery, rock climbing, basketball, hiking, and so much more. In addition to partaking in activities with the kids, we all got to see the new pavilion that was donated by The Phia Group. Next year, we are planning on decorating the pavilion for the kids. That being said, we are already looking forward to next year!

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The Stacks

Reference-Based Pricing: Pitfalls For a New Era

By: Jon Jablon, Esq. – September 2019 – Self-Insurers Publishing Corp.

How many times have you read an article or listened to a sales pitch about how great reference-based pricing is? RBP can add a lot of value, and many of us have seen that first-hand. But that is not the purpose of this article. As a consultant in the self-funded industry, The Phia Group has lots of opportunities to review and assess reference-based pricing plans and various claims situations. We have seen plans experience a great deal of RBP success – but we have also seen many RBP failures.

As many of you reading this have found out the hard way, and often unexpectedly, there are certain ways that RBP can go poorly and cause harm to an employer’s health plan, employee base, or even business reputation.

Click here to read the rest of this article

How Self-Insured Health Plans Are Helping Employers Compete In A Challenging Talent Marketplace

By: Philip Qualo, J.D. – August 2019 – Self-Insurers Publishing Corp.

Prior to joining The Phia Group, LLC, an experienced health care cost-containment company specializing in self-insured plans, my knowledge and experience with the self-insured industry could fit on the tip of my pinky. My previous work experience was exclusively in the fully-insured sector, where I quickly learned that uttering the words “self-insurance” was considered almost offensive. On a more personal level, I had been covered under various fully-insured health plans since my very first job after graduating law school. From the start, my experience with fully-insured plans jaded my perception of health benefits. I eventually accepted that medical insurance was a necessary evil that I would have to learn to live with. Although my employers genuinely cared about the well-being of their employees, the ability to offer comprehensive medical benefits became increasingly difficult due to the monumental annual increases in the cost of fully-insured coverage.

Click here to read the rest of this article

Big Pharma Facing Big Losses Tied To Opioid Epidemic Fallout

By: Sean Donnelly, Esq. – July 2019 – Self-Insurers Publishing Corp.

In 2017, a total of 70,237 people in the United States died from a drug overdose. A staggering 67.8% of those deaths involved the use of opioids, a startling escalation that has been classified as a national epidemic. Deaths attributed to synthetic opioids have become increasingly prevalent, accounting for 59.8% of all opioid overdose deaths.

Every day, an average of 46 people in the United States die from overdoses specifically involving prescription opioids. The highest prescription opioid-involved death rates in 2017 were in West Virginia, Maryland, Kentucky and Utah. According to the National Institute on Drug Abuse, drug overdose deaths involving opioids that were prescribed rose from 3,442 in 1999 to 17,029 in 2017.

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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Phia’s 2019 Speaking Engagements:

• 1/9/2019 – FMMA Conference – Austin, TX

• 2/27/2019 – Sunlife 2019 MVP Academy – Denver, CO

• 3/8/2019 – UnitedAg Conference – Anaheim, CA

• 3/19/2019 – SIIA Self-Insured Health Plan Executive Forum – Charlotte, NC

• 3/21/2019 – CGI Business Solutions Seminar – Woburn, MA

• 3/26/2019 – HFTA Broker Meeting – Tyler, TX

• 4/3/2019 – BenefitsPRO Broker Expo – Miami, FL

• 4/5/2019 – Pareto Conference – Nashville, TN

• 4/7/2019 – Captive Symposium – Cayman Islands

• 4/8/2019 – National Beer Wholesalers Association Legislative Conference – Washington DC

• 4/12/2019 – FMMA 2019 Annual Conference – Dallas, TX

• 4/23/2019 – Johns Hopkins Industry Education Series – Baltimore, MD

• 4/24/2019 – Sunlife 2019 MVP Academy – Kansas City, MO

• 4/25/2019 – BevCap’s Best Practices Workshop – Orlando, FL

• 4/26/2019 – Society of Professional Benefit Administrators Annual Conference – Washington, D.C.

• 5/2/2019 – MassAHU Benefest 2019 Conference – Westborough, MA

• 5/14/2019 – Cypress Unversity – Las Vegas, NV

• 5/30/2019 – Contrarian Captive – Austin, TX

• 6/11/2019 – Leavitt Conference – Big Sky, MT

• 7/16/2019 – HCAA TPA Summit – Dallas, TX

• 7/31/2019 – 2019 MVP Academy – Wellesley, MA

• 8/20/2019 – Pritchard & Jerden Employee Benefits Forum – Brookhaven, GA

• 9/17/2019 – WebTPA Annual Conference– Dallas, TX

• 9/19/2019 – Employee Benefits Planning Association Conference– Seattle, WA

• 9/30/2019 – SIIA National Educational Conference & Expo – San Francisco, CA

• 10/27/2019 – 2019 Annual NASP Conference – Washington DC

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Get to Know Our Employee of the Quarter:
Lyneka Hubbert

Lyneka is a truly dedicated case handler for the Provider Relations department. She has a vast knowledge of the most proficient and effective ways to work each file. Perhaps even more importantly, she is a great communicator with our clients. One of the most important aspects of this role is to keep our clients updated and confident in the work we are doing. We need to present a clear understanding of where our files stand while providing our clients with multiple options on how we can proceed. Lyneka does a fabulous job of communicating these types of things to our clients in a timely manner. She is persistent with the providers when trying to get a balance written off or a settlement reached. She explores all possible arguments with the providers so that she can have optimum success with her files.

She is also a great team member and is always willing to go above and beyond what is expected of her. Whether this means staying late, helping a team member catch up on work, or executing tasks not normally assigned to her, she is always there to step up with a positive attitude.

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

Phia News

PACE® Certification Has Arrived!

The PACE Certification program educates 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
Explain what PACE is, what PACE does, and how it's obtained, implemented, and utilized.

The PACE Certification program is free of charge and creates 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.

Additionally, the PACE Certification program provides education on self-funding in general, claims and appeals regulatory education, and overall best practices surrounding fiduciary duties, claims, and appeals.

Please see this video for more information.

Please contact Michael Vaz ([email protected]) for more information and to sign up today!

Team Building

After a fun day of volunteering with the children from the Boys & Girls Club of Brockton, the Phia Family took the remainder of the day to work on some good, old-fashioned team-building exercises. Throughout the day, the Phia Family was split into groups and faced with a variety of different tasks. After all of the exercises were complete, the Phia Family felt closer than ever. Check out the picture below to see how exciting the games were!

Our Louisville, KY Office is Now Open

The Phia Group, LLC is pleased to announce the opening of a new office in Louisville, KY. Under the leadership of the newly appointed Vice President of Operations and Total Quality Management, Scott Byerley, Esq., this new location strengthens The Phia Group's presence in the central United States - just as it did in the west with its Boise, ID, office - continuing to allow The Phia Group to identify, recruit, and hire the most talented professionals, nationwide.

With a focus on subrogation and claims recovery, as well as other cost containment activities, the Louisville team shares the same passion as the entirety of the "Phia Family," to deliver robust yet affordable health benefits to as many hard working Americans as possible. " We're very excited to bring The Phia Group to Louisville. This is a continuation of year after year growth for The Phia Group," remarked Mr. Byerley. "The Phia Family made this happen with their dedication and passion for everything cost containment and reducing the costs of healthcare."

Cornhole Tournament and Phia BBQ

It has become tradition at The Phia Group to celebrate the last day of summer with great games, food and conversations. This year we invited all Phia employees to enter into our cornhole tournament. As you can see, we had a great turnout. The winners of the cornhole tournament were Harry Horton and Jeff Hannah. Congrats on the win, it was a close game!

Job Opportunities:

• Health Benefit Document Drafter

• Health Benefits - Case Investigator I

• Claim and Case Support Analyst

• Client Intake Specialist

• Overpayments Care Representative

• Customer Care Representative

See the latest job opportunities, here: Our Careers Page

Promotions

• Kelly Dempsey, Esq. has been promoted from Director, Independent Consultation and Evaluation Services to Director, Consulting and ICE Services

• Dylan Fry has been promoted from Marketing & Accounts Intern to Claim Recovery Specialist

• Dante Tylerbest has been promoted from Customer Service Representative to Overpayment Recovery Assistant

• Denise Swienc has been promoted from Customer Service Representative to Case Investigator

New Hires

• Crystal Cascante was hired as an Intern

• William Lovejoy was hired as an IT Systems Administrator

• Craig Malcolmson was hired as an Intake Specialist

• John Shearer was hired as a Health Benefit Plan Admin - Attorney I

• Shauna Mackey was hired as an Associate General Counsel

• Brian Wentworth was hired as a Claims Specialist II, Provider Relations

• Dillon Fosa was hired as a Marketing & Accounts Coordinator

• Larice Booker was hired as an Overpayments Recovery Specialist

• Brittney Willoughby was hired as a Sr. Claims Recovery Specialist

• Elizabeth McAlister was hired as a Sr. Claims Recovery Specialist

• Melanie Brown was hired as an Intake Specialist

• Ashley Jancaterino was hired as an Intake Specialist

• Cornelius Mance was hired as an Attorney I

• Ervin Morice was hired as a Case Investigator I

• Jason Pence was hired as a Sr. Claims Recovery Specialist

• Heather Breckenridge was hired as a PACE Client Intake Coordinator

• Allison Britton was hired as a Case Investigator I

• Aditya Sukumar was hired as a Business Analyst

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