Insurance Claim Negotiation & Wrap Network Replacement

A TPA referred two claims to The Phia Group to utilize its Claim Negotiation & Signoff service, totaling $221,000. This particular TPA specialized in administering narrow network health plans, but this particular claim was incurred at an out-of-network hospital. The benefit plan had no history with this provider, and the Plan’s language did not contain adequate cost-containment language.  The Phia Group’s attorneys discussed the claim extensively with the provider, leveraged the best data and resources available, and were ultimately able to have the hospital agree to accept a negotiated payment of 150% of the Medicare allowable. The TPA has subsequently updated its template Plan Document with The Phia Group’s recommended cost-containment language, after the TPA witnessed first-hand the problems faced by narrow network health insurance without proper support and protection.

 

Plan Exposure:		$221,000
Phia Intervention Saved:		$179,000

A TPA began to utilize The Phia Group’s “Phia Unwrapped” service in order to help control exposure for out of area insurance claims. Previously, one health plan administered by this TPA offered no out of area insurance coverage, due to exposure that was faced in the past. The plan, however, desired to take better care of its employees and provide options aside from their narrow network – so the plan elected to utilize Phia Unwrapped and chose 150% of Medicare as it allowable amount, in an attempt to ensure that providers were paid only what the plan determined to be reasonable and customary healthcare fees.

One claim in particular was billed at what the provider proclaimed to be its own usual and reasonable fees, but was over 1,500% of the Medicare allowable. Furthermore, the provider proclaimed that it had a standing policy of refusing to engage in any health care direct contracting. The Phia Group, however, leveraged certain factors such as the provider’s reported cost-to-charge ratio in an attempt to demonstrate that the billing was egregious, and that the payment tendered by this self funded health plan was reasonable and constituted the plan’s own usual and customary fees. Ultimately, the provider agreed to accept an additional 40% of the Medicare allowable to settle the claim – along with a stipulation that the agreement would remain confidential.

Plan Exposure:		$83,000
Phia Intervention Saved:		$72,000

The Phia Group was engaged by a captive insurance company to provide assistance with a medical provider that had been paid its full billed charges in error This particular captive manager was given The Phia Group’s name by a mutual partner, after the captive manager expressed a desire to engage a firm of experienced health care attorneys. In this case, the captive manager sought to utilize our medical bill negotiation service with respect to out of network insurance benefits provided by a non-ERISA plan, governed by state law. This particular plan utilized a narrow network, but any provider not covered by that network was subject to benefits based on Medicare based pricing – a form of reference based pricing. The health plan calculated its usual, customary & reasonable fees at a level approximately 30% of the provider’s billed charges. The captive manager’s concern was that if the plan had to pay more money to settle the claim on the back-end, the captive would be on the hook for anything denied by stop-loss in this particular arrangement.

 

The Phia Group engaged the medical provider. The provider argued that its usual & customary fees were exactly the amount that it had billed and received – and that the amount of benefits that the plan had re-calculated was not supported by the Summary Plan Description or the Summary of Benefits & Coverage – and accordingly, that this self-insured health plan was unreasonably trying to force the provider to refund its reasonable and appropriate healthcare fees. The Phia Group countered these arguments with arguments based on fair market value, health plan limitations, and potential balance billing issues the provider would face if it chose to pursue the patient. The Phia Group, after weeks of arguments back and forth, made it clear to the provider that what it had billed was inappropriate, and what it accepted as payment was incorrect. The Phia Group came to an agreement with the provider; for accounting purposes, the provider would refund the entire amount paid, and the plan would then re-issue a certain agreed-upon level of benefits, to complete the overpayment request.

 

Plan Exposure:		$71,000
Phia Intervention Saved:		$57,000

A self-funded benefit plan, which had historically secured a 10% discount with an ambulatory surgical center for services involving implants, referred a $91,000 medical implant claim to The Phia Group.  The Phia Group’s health benefits attorneys leveraged cost data and innovative arguments, and The Phia Group ultimately secured a negotiated payment of only $22,000, amounting to a net 76% in savings, with no balance-billing.

 

Plan Exposure:		$91,000
Phia Intervention Saved:		$69,000

A TPA referred claims to The Phia Group that various participants of one of its client plans had incurred at a certain provider whose pricing was particularly egregious. The TPA had suggested the prospect of contracting with the provider moving forward, but the provider had been unwilling to entertain that discussion. The Phia Group discussed the claims with the provider, and explained to the provider that its billing suffered from certain coding and logic errors.

 

By employing expert legal and clinical reasoning, The Phia Group’s experienced health care lawyers negotiated a contract where the provider agreed to accept 200% of the Medicare allowable (or equivalent) for all claims moving forward, and 225% of the Medicare allowable for the claims already incurred, calling this “usual and customary fees.” To this date, the provider has been satisfied with the steerage, and the Plan has been satisfied with its greatly reduced payments.

 

Plan Exposure:		$470,000 (and counting)
Phia Intervention Saved:		$335,000 (and counting)