Phia Group

The Social Impact of Mental Health Parity Testing

On March 24, 2025
Unknown to many of us, celebrities suffer from mental health and substance use disorders just like anyone else. Recently, country music megastar Luke Combs openly discussed his struggles with obsessive compulsive disorder (OCD). Combs hopes that his discussion of the topic will reduce stigma that often comes with a mental health diagnosis. Taylor Swift has previously discussed her own struggles with an eating disorder for similar reasons. Before Robert Downey Jr. became Iron Man on the big screen, he suffered from substance use disorders for years before seeking treatment, ultimately becoming sober and remaining so to this day.

Pancreatic Cancer Vaccine May Be on the Horizon

On March 17, 2025
Chances are that cancer has touched the lives of nearly every American. Maybe it’s a suspicious mole that turns out to be a carcinoma, an old high school friend’s social media post raising awareness of the need for mammograms after a scare, or a grandparent who battled lung cancer after years of smoking. As the years go by, studies show that the frequency is increasing. The National Cancer Institute estimated that last year alone, more than two million Americans were diagnosed with a form of cancer, and 600,000 lost their fight. This can be compared to a diagnosis rate of 1.9 million in 2022. Statistics show that the most common types of cancer remain breast, prostate and lung cancer, but one stands out above the rest as having the lowest survival rate.

Struggling to Breathe

On February 26, 2025
For well over a century, medical oxygen has been used for treating patients with an assortment of medical needs, most notably respiratory issues such as pneumonia, as well as those undergoing surgery, experiencing heart failure, and receiving maternal care. Utilized by over 370 million medical patients worldwide, medical oxygen was, in fact, added to the World Health Organization’s Essential Medicines List in 2017. And yet, according to a recent report published in The Lancet medical journal, well over half of the world’s population does not have access to safe and affordable medical oxygen services; unsurprisingly, this segment of the population is largely comprised of those living in lower-income and developing nations where it is more difficult to access facilities that offer basic oxygen services of reasonable quality.

Journavx: Is Relief on the Way?

On February 11, 2025
Every year, tens of millions of opioid prescriptions are written for Americans experiencing searing pain caused by broken bones, burns, procedures, and wounds. In most cases, the medications produce efficacious results without causing patients to become overly dependent and ultimately addicted. Still, there is a relatively small percentage of users (numbering in the tens of thousands) who develop severe – and sometimes fatal – addictions, hence the well-chronicled national opioid crisis that has descended on humanity this century.

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.

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.

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