Phia Group

Title: House Republicans’ Proposal Related to HSA-Qualified HDHPs

On January 24, 2025
As we close out the first month of 2025 with a new administration, the vast number of new proposals related to reducing government spending is unsurprising. Only a week ago, two documents were leaked related to House Republicans’ “Spending Reform Options,” which provided insight into their policy objectives.

The Invisible Truth of Healthcare

On January 24, 2025
When you’re shopping for a new car, you expect that shelling out more money will correlate with a more high-powered, fancier, and durable vehicle. The same logic – that price and quality run parallel to one another – would seemingly apply to flat screen TVs, smartphones, stereo systems, laptops, vacuum cleaners, snowblowers, and every other item that Americans race to the stores to purchase on Black Friday. It is human nature to assume that a higher price equates to higher quality . . . unless information is provided to the contrary. As savvy shoppers are well aware, there are user reviews online that could potentially reveal that the higher cost vacuum or TV is no better than (and is sometimes worse than) a lower cost alternative. As such, price transparency on its own may be harmful as people gravitate to the higher cost item based on an assumption that it is better; however, when price transparency is combined with quality metrics, consumers can truly make the most enlightened and informed decisions.

First to Market

On January 13, 2025
Unfortunately, there has long been a widely held perception that the healthcare industry is largely antiquated and riddled with inefficient processes. Perhaps that can explain why last week’s announcement – that Machinify, a provider of artificial intelligence (AI)-powered software for streamlining the healthcare claims lifecycle, will become an integral part of the company recently formed through the merger of The Rawlings Group (“Rawlings”), Apixio’s Payment Integrity business (“Apixio PI”), and VARIS – was deemed particularly newsworthy. That this new conglomerate, to be named Machinify, will be leveraging next generation technology and a wealth of data to further automate and enhance healthcare administration processes has apparently captured the imagination of healthcare stakeholders worldwide, and struck a chord with those that believe the healthcare industry must do more to leverage new technologies and catch up to other innovative industries.

An App for What Ails You

On January 13, 2025
This is the future presaged by “PDURS” (Prescription Drug Use-Related Software). One of the sillier acronyms to grace the healthcare industry in recent memory, PDURS are defined by the FSDA as “software disseminated by or on behalf of a drug sponsor that accompanies one or more of the sponsor’s prescription drugs, including biological drug products.” Essentially, most patients will encounter this software as an app, paired with marquee prescription drugs, that is designed to “assist” patients and healthcare providers in the prescription and use of the medication.

Why Wesco v. BCBSM Matters (A Lot)

On January 8, 2025
Back in November, Wesco, a 55-year-old privately-held gas station chain, and the benefits fund for the Utility Workers Union of America filed a class action lawsuit, alleging that Blue Cross Blue Shield of Michigan (BCBSM), an insurance carrier serving over six million Midwesterners, engaged in an anticompetitive practice by charging an additional PEPM (“per-employee, per-month”) fee to any group that opted to use a stop-loss carrier other than BCBS. For BCBS of Michigan, the fee represents a fairly standard industry practice for charging a plan extra if it opts to use a non-preferred stop-loss carrier; conversely, for the aforementioned plaintiffs, the constantly escalating PEPM fee represents a means for inflating costs for the already cash-strapped covered groups as well as driving smaller stop-loss carriers out of the market. Looking ahead, how this case plays out in federal court in Michigan will have a monumental impact on not just the stop-loss marketplace but also the self-funding industry in its entirety.

No Extension for HDHPs and Telehealth

On January 6, 2025
It’s not the news any of us wanted to hear, but 2025 has arrived with no extension to the telehealth services safe harbor for high deductible health plans that are HSA-qualified. As such, the safe harbor officially expires for plan years starting on or after January 1, 2025. There were numerous reports that an extension was included in early drafts of the bill to keep the government funded in December, but the bill passed and signed by President Biden on December 21, 2024, did not include this extension.

Anthem Blue Cross Blue Shield’s Major Reversal

On December 26, 2024
Earlier this month, as the healthcare industry was receiving an inordinate amount of unwanted public attention and scrutiny, there was actually a positive development stemming from one of the country’s largest health insurers. Indeed, lost in the shuffle amidst the chaotic aftermath of the murder of UnitedHealthcare CEO Brian Thompson was Anthem Blue Cross Blue Shield’s reversal of its initial decision to stop paying for anesthesia care in certain states if the surgery or procedure extends beyond a particular time limit. Had such a titan of the health insurance industry proceeded in not paying for medically necessary anesthesia services, tens of thousands of Americans – many of whom are of limited financial means -- would have been at risk of getting cut off from a life-saving service.

Life After Helene: The Ever-Widening Health Disparity in Appalachia

On December 2, 2024
Well before Hurricane Helene, one of the deadliest storms in modern American history, ripped through Western North Carolina earlier this autumn, decimating scores of residences and businesses and washing away entire neighborhoods, the largely impoverished Appalachian region was grappling with a precarious healthcare infrastructure. To this day, Asheville, North Carolina, and its surrounding mountainous communities have never fully recovered from the devastation of the Great Recession of 2008, resulting in a grave health disparity among other societal ills. And, yes, the recent ferocious tempest of which Western North Carolina bore the brunt has only exacerbated the region’s already fragile healthcare system.

New Requirements Under the Mental Health Parity and Addiction Equity Act (“MHPAEA”)

On November 20, 2024
The deadline to comply with several of the new final rules regarding the Mental Health Parity and Addiction Equity Act (“MHPAEA”) is quickly approaching. On September 9, 2024, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released new final rules that updated existing regulations to provide additional clarity for plans and their vendors on what is required and what will be considered compliant and non-compliant for parity purposes when performing a nonquantitative treatment limitation (NQTL) comparative analysis.

Navigating Balance Billing and Post-Payment Disputes: Solutions for TPAs and Self-Funded Employers

On November 14, 2024
As rising healthcare costs continue to challenge employers and third-party administrators (TPAs), Reference-Based Pricing (RBP) has emerged as a powerful strategy for cost containment. However, RBP, while promising, is not without its pitfalls. Chief among them is balance billing, in which providers charge patients for the difference between their billed charges and the RBP plan’s payment. Additionally, the No Surprises Act (NSA) has introduced Open Negotiations and Independent Dispute Resolution (IDR) processes, which, while protecting patients, expose employers to post-payment disputes. Addressing these concerns effectively requires comprehensive tools, support, and strategic implementation.

Having NSA Problems? Better Call The Phia Group

On October 31, 2024
The Independent Dispute Resolution (“IDR”) process was designed to be a cornerstone of the No Surprises Act (“NSA”), a means for resolving claims for payment for out-of-network items and services and a vital mechanism for buttressing the NSA’s protection for plan members against potentially devastating balance billing expenses. Unfortunately, since the NSA took effect on January 1, 2022, things have gone awry on many fronts.

Cobenfy: A Potential Game-Changer for Schizophrenia Patients – But at What Price?

On October 9, 2024
As you’re reading this blog, millions worldwide are suffering from the horrors of schizophrenia, one of the most complex, debilitating, and stigmatized mental disorders inflicted on humanity, the symptoms of which typically manifest themselves in early adulthood, though they are not always so easy to detect. Those afflicted by this condition are desperately trying to manage an array of frightening symptoms (hearing voices, delusions, memory lapses to name a few) while carrying on with their lives. In this country alone there are approximately 2.8 million Americans living with schizophrenia; tragically, many of those 2.8 million Americans won’t be living much longer as there is a particularly acute rate of suicide among people battling schizophrenia. Meanwhile, so many others suffering often experience prolonged bouts of homelessness and/or run afoul of the law. And for decades, pharmacological innovation has moved at such a glacial pace that treatment has largely yielded inadequate improvement in symptoms and/or intolerable side effects during therapy that many have felt inclined to discontinue usage.

Healthcare and Politics… Ugh. Old News!

On September 27, 2024
Donald Trump recently stated that while he will never give up on repealing the ACA, he also said that he was not running on terminating the ACA. This is likely a smart decision, given that a recent Kaiser Family Foundation (KFF) poll revealed that for Republican voters, repealing Obamacare was an important issue for a very small percent of respondents. Is this demonstrative of a more widespread loss of interest in health care as a political talking point?

The First Ten: Medicare Unveils Inaugural List of Negotiated Drug Prices

On September 16, 2024
Last month, while many of us were busy vacationing or doing last-minute back-to-school shopping, the Biden administration announced that it had reached an agreement with the titans of the pharma industry to lower prices on the 10 costliest prescription drugs under Medicare, thus bringing to fruition Democrats' decades-long push to allow the government to negotiate directly with pharmaceutical manufacturers. While individual plans had previously been able to haggle over prices with Big Pharma, this development marks a seminal moment as it is the first time that Medicare used its clout to be able to negotiate for the program as a whole.

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