The Book of Russo:

Halloween is my favorite holiday of the year, though my reasoning has evolved over time. Back in the day, I used to love wearing a cool costume and going trick or treating in my neighborhood. Could anything beat the combination of free candy, time with friends, and fresh air? Today, however, Halloween is no longer about serving myself, and rather, is about bringing joy to my own children and our neighborhood kids. That passion to serve others drives me to – according to my wife – go a little too far. Each year I basically build a haunted house in my front yard, for the entertainment of the hundreds - yes I said hundreds - of kids that stop by and care to be spooked by my many scary decorations and animatronics…

It's gotten to the point that people from other neighborhoods come to mine just to see what I have in store that year. At this point, you may be asking what this has to do with The Phia Group, health insurance, benefit plans, or any of the other pressing topics and innovative services that Phia has to offer. I mean, election day is upon us, laws are changing, litigation is pending, regulations are evolving… At first blush, you’ll say my story is unrelated… but you’d be wrong. Watching hard work translate into joy; investing time and effort into serving others; it all boils down to one important thing – passion.

Just as my passion for Halloween has expanded and grown to include a larger community, so too has my passion for this industry expanded and evolved. Moreover, a passion for serving others is paired with a passion to compete! I'm out there trying to outdo the neighbors. I need to have the coolest set up in town with the latest items and features. The same can be said for The Phia Group as well. Yes; we are focused on reducing the cost of care while improving quality outcomes, but we also want to be the best at what we do. We are passionate about every service, every feature, every new piece of technology and we want to share it – both our services and our passion – with the industry. Just like I want to share my love of Halloween with my neighborhood. What a treat!!! Well I hope you have lots of children dressed up and ringing your doorbell this October 31st. I can't wait to see the creativity in some of the costumes just like you all enjoy the creativity of our plan documents.

It's a great time of year - happy reading.

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

Wrap networks? More like Cr-- well, they’re not great, anyway. Instead of that antiquated and widely despised fallback for OON claims, Phia Unwrapped is a better, smarter, more cost-conscious way to manage those claims. 

Powered by the expertly crafted Phia Ignite Repricing Engine, Phia Unwrapped boasts best-in-class claims repricing and comprehensive patient-centric balance billing support with the full weight and skillset of The Phia Group behind it. 

If you haven’t used, seen a demo of, or heard great things about Phia Unwrapped, we urge you to email [email protected] today. (Your bank account will thank you.)  

Enhancement of the Quarter: SoPhia  

The Phia Group’s great consulting and technology minds have continued to refine our artificial intelligence (AI) tool, SoPhia, which is expertly trained using documentation curated explicitly for SoPhia. This is unique in that SoPhia is trained exclusively with Phia’s own consulting expertise and carefully curated third-party sources in order to maximize the quality of SoPhia’s responses. 

We're excited to announce that two of our clients are now participating in the beta testing phase, exploring how SoPhia can streamline tasks and disseminate information in a helpful way. 

We’ve engineered SoPhia to help improve the ICE service for all users, whether directly or indirectly, and the beta testing program is a step toward broader usage. We look forward to expanding SoPhia’s capabilities and we’re eager to eventually roll it out to all our ICE clients!

Phia Case Study: Third Opinions  

Note: this is not one single case study, but a conglomeration of many similar ones. 

Medical reviews have become an integral part of claims and appeals adjudication, and with good reason: employers are not clinicians (. . . unless the group is literally a group of clinicians). But what happens when a medical review is performed on an initial claim and yields one result, and then a different medical review is performed on appeal and yields the opposite result? Does the plan necessarily have to trust the second opinion? If it differs from the first opinion, who’s to say that the second one is more correct than the first? 

The answer depends on the circumstances, but like so many things, the plan has to make sure that it’s being reasonable in its administration of this type of issue. For instance, some plans continue to rely on an initial medical review (which supports the benefit exclusion) through the entire appeals process, but that’s likely a violation of the appeals regulations that require a new review on appeal. Other plans seek a second medical review on appeal, and operate based on the second, more recent medical review. Other plans still look for a “tiebreaker” medical review when the initial two conflict; the process has to end somewhere, after all. 

Though we are generally of the opinion that either of the second two options is compliant (that is, rely on the later medical review on appeal, or rely on the “tiebreaker” when the initial two conflict), we can say with confidence that relying on a single medical review that supports the claim denial throughout the entire appeals process is not compliant. 

This is one of the draws of The Phia Group’s Plan Appointed Claim Evaluator (PACE) service: whenever there’s a clinical question, we have a new medical review performed, so you never need to worry that you’ve relied on the same review the whole way through the process!  

Fiduciary Burden of the Quarter: Aligning the SPD with Network Contracts

Too many times, Phia’s consulting team has encountered Plan Documents that say in no uncertain terms that all claims payments will be limited to some sort of U&C-based amount. That’s fine, of course, but only if it’s accurate! Unfortunately, if a claim is subject to a network contract, that U&C limitation can’t be applied, and the SPD language becomes accidentally incorrect. 

Though it’s unlikely that anyone will complain about a technical SPD violation when the provider and patient are both happy because a claim is paid at the network rate instead of the lower rate specified in the SPD, it’s nonetheless a breach of the fiduciary’s duty to fail to not administer the plan strictly in accordance with the SPD – not to mention that stop-loss carriers generally don’t reimburse claims paid at amounts higher than the SPD allows, regardless of the fact that the employer has separately agreed to make the higher payment via its network contract. 

Luckily, there’s a simple fix for this: to make sure the SPD remains accurate with respect to contracted claims payments while keeping its strong cost containment for non-contracted claims. Our preference is something simple, such as defining the payable rate as “a negotiated rate, if one exists,” and then falling back to the other cost containment methods if there’s no negotiated rate. 

It’s very important for a fiduciary to do exactly what the SPD says – so we urge employers and those who service them to be diligent about making sure the SPD language is accurate with respect to claims payments.

Webinars:

• On August 19, 2024, The Phia Group presented “Don't Be Surprised - Phia's Keys to Success with The No Surprises Act and Appeals Management,” in which we discussed our unique, battle-tested processes for handling NSA claims and appeals. 

• On July 16, 2024, The Phia Group presented “The Impact of Provider Trends on Stop-Loss and Plans,” in which we discussed how to counterbalance rising prices as well as navigate increasingly complex interactions with stop-loss.

Be sure to check out all of our past webinars!

Podcasts:

• On September 27, 2024, The Phia Group presented “Senator Sanders: “Stop ripping us off,” in which our hosts, Brady Bizarro and Andrew Silverio, discussed senate committee hearing on GLP-1 drug pricing and strategies that self-funded employers are using to manage the extreme costs of these drugs while we wait and hope for congressional action. 

• On September 12, 2024, The Phia Group presented “Diving Into the Parity Pool: MHPAEA’s Latest Updates,” in which our hosts, Jennifer McCormick and Bryan Dunton, discussed several critical considerations for plans as renewal season approaches. 

• On September 5, 2024, The Phia Group presented “Recognizing Our Blind Spots” in which our host, Adam V. Russo, was joined by our special guest, Dr. Marty Makary. Listen in as they discuss his new book, Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health. 

• On August 29, 2024, The Phia Group presented “Summer Regulation Rundown,” in which our hosts, Kelly Dempsey and Nick Bonds, discussed some of the big rules we’re looking forward to as the clock gradually runs out on the Biden administration and the challenges they may face. 

• On August 15, 2024, The Phia Group presented “Healthcare on the Ballot,” in which our hosts, Nick Bonds and Corey Crigger, discussed the impact that each administration could have on the self-funded industry and the country. 

• On August 1, 2024, The Phia Group presented “The Concerns About PBMs and the Demand for Reform,” in which our hosts, Jon Jablon and Kendall Jackson, broke down the consequences of PBM steerage. 

• On July 18, 2024, The Phia Group presented “Exploring Claims Processing Models,” in which our hosts, Andrew Silverio and Cindy Merrell, delved into the pros and cons of the pay and chase versus pend and pay models of claims processing. 

• On July 2, 2024, The Phia Group presented “SCOTUS Decisions: Harrington and Loper's Impact on Healthcare,” in which our hosts, Brady Bizarro and Corey Crigger, broke down two of the most significant Supreme Court cases just decided this term – the Harrington case and the Loper case.

Be sure to check out all of our latest podcasts!

Back to top ^

Phia Fit to Print:

• Worklife News – From ‘Tinder Leave’ to Pet Insurance, Employers Get Creative with Benefits – September 2024 

• Medium – Driving Disruption: Adam V Russo Of The Phia Group On The Innovative Approaches They Are Taking To Disrupt Their Industry – September 2024 

• Dorchester Reporter – ‘Dot kid done-good’ funds a scholarship at Suffolk – August 2024

Back to top ^

From the Blogoshpere:

• What the Overturning of Chevron Means for Healthcare. Learn about the Supreme Court’s 1984 decision in Chevron U.S.A., Inc. v. Natural Resources Defense Council. 

• Health Over Wealth. It has become fairly common practice for PE firms to acquire a struggling healthcare facility or physician practice, one desperately in need of capital and management expertise. 

• Healthcare in Rural America. Healthcare inequality is a glaring problem across our nation, but the issue is particularly acute in rural America where folks grapple with a perfect storm of factors restricting access to medical facilities. 

• Section 1557 Final Rule: Where Do We Stand? The implications of the Section 1557 Final Rule are currently in flux since the Final Rule was issued on April 26, 2024. 

• The First Ten: Medicare Unveils Inaugural List of Negotiated Drug Prices. Will drug prices be coming down in the near future?

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

Back to top ^

The Phia Group's 2024 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 2024 charity is the Boys & Girls Club of Metro South.

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

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

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

Silent Auctions at SIIA National

At this year’s SIIA National event, Phia auctioned off a stunning painting by Rich Hunt, our Facilities Manager. The auction saw competitive bidding over two days, and Heather Schiappacasse emerged as the final winner. Additionally, Kelly Russo’s painting was auctioned off at our cocktail party, which was won by Danny Schwarz. The paintings raised over $1,300, with all proceeds going to support the Boys & Girls Clubs of Metro South. A big thank you to everyone who participated!

2024 Volunteer Day

The Phia Group had the opportunity to visit the Boys & Girls Clubs of Metro South to participate in some fun activities for the kids! With over 100 kids to entertain all day, we had plenty for people to do. Temporary tattoos, tie-dye, face painting, hiking, and so many more activities filled the day with so much joy and left us with so many memories. We are looking forward to next year’s Volunteer Day!

2024 Louisville Volunteer Day

Our Louisville team was out and about this past summer, volunteering at The Boys & Girls Club of Kentuckiana. They hosted a Water Wonderland event for the kids that included face painting, a water slide, sprinklers, water balloon/cannon games, and more. We hope you all had a great time and can’t wait to do it all again next year!

Backpack & School Supply Drive

We just wrapped up our annual backpack & school supply drive with The Boys & Girls Club of Metro South. Our staff collectively donated items and/or money to purchase supplies for 150 kids (ages 5-18). In total, we donated over 3,000 items . . . 3,304 to be exact.

Leukemia & Lymphoma Society

As a tireless supporter of the Leukemia & Lymphoma Society, The Phia Group, behind Chief Legal Officer, Ron E. Peck (Mission Award Winner – Research), was extremely proud to be a leading sponsor of this year's Boston Metro Visionary of the Year campaign. We are also thrilled to report that Ron's efforts placed him in the top five all-time fundraisers for this campaign and were a major reason why this turned out to be a record-breaking year. We look forward to continuing this wonderful partnership for many years to come.

Back to top ^

Phia News: 

Phia On Fire at SIIA National

The Phia Group brought incredible energy to this year’s SIIA National event! If you were there, you likely heard the buzz of cowbells coming from our booth. We had it all: hot sauce tastings, live painting sessions, and live demos of our new software. It was an exciting, interactive experience, and we can’t wait to do it all again in 2025!

Phia’s New Software 

The Phia Group was proud to showcase four innovative software demos at the SIIA National Conference in Phoenix, AZ. These demos highlighted the latest tools designed to optimize healthcare cost containment and plan management: 

• Care Empowered Pricing (CEP): Revolutionizing cost savings through smarter pricing strategies. 

• Phia Appeals Management System (PAMS): Streamlining the appeals process for better efficiency. 

• SoPhia: A sophisticated platform for actionable insights and automation. 

• Phia Unwrapped: A cutting-edge service for unbundling and identifying hidden costs. These tools demonstrate Phia’s commitment to leading innovation in the industry. Check out our new demos, here: https://vimeo.com/1018445477/91a84ffba1

Phia on the News

The Phia Group’s CEO, Adam V. Russo, appeared on Boston 25 News to discuss the incredible partnership with The Boys & Girls Club of Metro South. He shared his personal story of his involvement with the club as a child and expressed how meaningful it is to give back to the organization that helped him in his youth.

Get to Know Our Employee of the Quarter: Alex Houle

Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. 

The Phia Explore team unanimously agrees that there is no one more deserving than Alex Houle to be recognized as The Phia Group’s Employee of the Quarter for Q3 of 2024.

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

Job Opportunities:

• Sr. Claims Recovery Specialist 

• Office Assistant (Accounting) 

• Claims Recovery Specialist – Mass Tort 

• Case Investigator

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

Promotions

• Bill Parlee has been promoted from Claims Recovery Specialist IV to Sr. Claims Recovery Specialist. 

• Nicholas Walsh has been promoted from Case Investigator to Sr. Claims Recovery Specialist 

• Jessica Grande has been promoted from Team Lead, Project Coordinator to Manager, Projects & Operations

New Hires

• Kendall Felici was hired as a Project Coordinator 

• Brad Hall was hired as a Sr. Claims Recovery Specialist 

• Bradley Lynch was hired as a Case Investigator 

• Ben Chute was hired as a Salesforce Consultant 

• Samantha Canestraro was hired as a Claims Recovery Specialist 

• Hannah Coffey was hired as a Case Investigator 

• Immanuel Allen was hired as a P/T Office Administrator 

• Lakshmi Sreenevasan was hired as a VP, Data Services, Analytics and Automation 

• Justin Forton was hired as a Client Success Account Executive 

• Tamika Virgil was hired as a Customer Service Rep 

• Keri Potter was hired as a Customer Service Rep 

• Julie Wisch was hired as a Customer Service Rep 

• Tabyrius Baldwin was hired as a Sr. Claims Recovery Specialist 

• Brianna Sullivan was hired as a Customer Service Rep

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.

Back to top ^