The Dialysis Carve-Out: The Phia Group was asked to review and revise a client’s plan document.  Based on prior conversations with the client, The Phia Group proposed a dialysis carve-out. The Phia Group went to task determining how claims are currently set up, confirming there were not any contradictory network agreements, etc. With consideration toward various parameters including but not limited to Medicare reimbursement rates, The Phia Group was able to assist in the design of a plan that would ultimately save the plan roughly $50,000 per month on dialysis based reimbursement, arising from a single dialysis recipient receiving monthly treatment.  In addition, upon weathering some provider pushback, it has become clear that the carve-out could not have proceeded without The Phia Group’s full spectrum revision.  Many such carve-outs fail, resulting in payment by the benefit plan in full, plus damages.  Thanks to The Phia Group, the capped rate is not only paid in accordance with the terms of the plan document, but the carve out is defensible in the face of appeal.

 

Plan Exposure:		$75,000 per month, per case
Phia Intervention Saved:		$55,000 per month, per case

The No-Network Plan: As it relates to the implementation and administration of a non-PPO, alternative-pricing system, The Phia Group has provided advice and drafting services regarding language and layout of SPDs, ID cards, EOBs, correspondence to members and providers on behalf of a self funded plan administered by a TPA.  Phia has been a key contributor to the apparent market shift in cost-containment services focusing on fee schedule based carve-outs, narrow networks, or even no-network reference based reimbursement models.

 

In all cases, we’ve found that the solutions lie in preparation, not reaction.  If you negotiate with providers before they treat patients, add language to plan documents and ID cards before claims are incurred, and educate clients and their employees, your results will be much better than if this is “sprung” on everyone post-service. Phia advised in this area and provided plan guidance of the “do’s and don’ts” of non-network arrangement implementation.

 

Our capabilities in this regard related to document and correspondence drafting, guidance when dealing with situations on a case by case basis, attempting to resolve balance billing disputes that cannot be resolved in-house, and providing reference to litigation counsel (if necessary) when a conflict cannot be resolved without legal action.  After one year of implementation of this reimbursement methodology one such plan covering approximately 100 lives has experienced a reported savings of nearly $200,000 for the first year of the program.

 

Plan Exposure:		More than $200 PEPM
Phia Intervention Saved:		Exceeding $200,000

Plan Provision Revision and Harmonization with Vendor Program: In the process of securing a subrogation reimbursement, one of The Phia Group’s claims recovery specialists noticed that the SPD contained a particularly short definition of Usual and Customary, and referred it to our consulting department mainly. We contacted the TPA and informed it of the definition, with the knowledge that the TPA used a claims auditor with which we deal very closely; it was immediately clear that the SPD’s language did not actually permit the Plan to reduce claims based on the claims auditor’s determinations. Aside from potentially wasting money using an auditing firm whose calculations were not usable by the Plan, the Plan Administrator technically breached its fiduciary duty because Plan language didn’t support such reductions, it only supported reductions based on the prevailing charge in the area. We worked with the TPA to formulate language suited to the claims auditor program, and we ensured that moving forward the Plan Administrator was permitted to make the claims determinations that the claims auditor suggested. The total Plan savings is unknown, but it is substantial, and the Plan Administrator was saved from a costly litigation thanks to a reinforced ability to counter pushback and defend plan decisions, thanks to solid plan provisions and supporting documents.

 

Plan Exposure:		Hospital Single Claim Amount in Excess of U&C = $117,000
Phia Intervention Saved:		Exceeding $200,000

The Gap-Free Analysis: The Phia Group had been working closely with a TPA for a long time when The Phia Group was made aware of a certain plan provision that one of the TPA’s client groups wanted to change within its SPD. The Phia Group was privy to which stop-loss carrier the group utilized, and The Phia Group was well aware of the language in this particular stop-loss carrier’s policies. The group’s proposed SPD language set off a red flag, and The Phia Group cross-referenced the carrier’s current stop-loss policy against that language, and it was revealed that there would be a significant “gap” in coverage – in other words, the Plan would be paying claims that the stop-loss carrier would exclude under its policy.

 

The Phia Group offered to complete a Gap-Free Analysis to compare the SPD and the stop-loss policy, and its analysis exposed over a dozen specific language issues that the group subsequently changed to eliminate “gaps” in coverage between the Plan and its stop-loss policy. The group subsequently informed The Phia Group that it had previously been denied stop-loss benefits from this carrier because of its poor language in the past – and the carrier and group alike were grateful for our assistance in informing the group where it needed to be changed for its own cost-containment as well as to avoid future “gaps.”

 

Plan Exposure:		Amounts in Excess of Specific Deductible
Gap Free Analysis:		$600
Phia Intervention Saved:		Amounts in Excess of Specific Deductible

A client approached us requesting assistance with an important new group that was committed to its current plan document structure. The group’s plan document had not been updated in several years and included multiple amendments. The client wanted to ensure that the group’s plan document was compliant with current applicable law and to integrate Phia’s cost containment provisions while still maintaining the existing plan document structure. The Phia team completed an update of the existing plan document, incorporating the group’s amendments, making modifications in accordance with current applicable law, and integrating Phia’s cost containment provisions. The Phia team then participated in an active review with the client, providing explanations of the changes and preparing the client for an in-depth discussion of the plan document with the group. With Phia’s guidance, the client was able to achieve their goal of obtaining a compliant, cost-conscious plan document while still meeting the group’s goal of maintaining their current plan document structure.