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PACE® - Protection Against Fiduciary Liability Arising from Final Level Appeals

Reduce Your Risk and Take Back Financial Stability and Confidence

The Phia Group ensures that all relevant materials from plan documents to stop-loss policies align for maximum clarity and regulatory compliance with PACE®.

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The Number of Appeals Is Doubling Year-Over-Year

Appeals are expensive. The average cost of an external appeal to an IRO is $1,000 with the amount at stake per appeal growing by nearly 100% each year.

Appeal Topics by Percentage

Graphical represenation of percentage breakdown

navy - graph legend No Medical Necessity

36%

dark blue - graph legend Experimental and Investigational

35%

blue - graph legend Off-Label Use of RX

15%

light blue - graph legend Other Exclusions

14%

The Phia Group Appeals Technology and Expertise

The Phia Group utilizes PATS, our proprietary state-of-the-art appeals technology, to ensure that nothing is overlooked in the decision-making process. Our subject matter experts provide:

  • Objective Oversight of Appeals
  • Coordination Between Entities
  • Clinical Review
  • Access to URAC-Accredited IROs
  • Document Analysis
Reduce My Risk

What You Can Expect with The Phia Group

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Plan document review to ensure compliance and PACE® readiness.

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Assurance that claims are processed in accordance with plan terms.

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Multifaceted implementation to ensure awareness and seamless utilization.

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Review of all relevant stop-loss policies and network contracts.

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Advanced-level webinars, presented exclusively for PACE® clients.

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An administrative PEPM for any TPAs facilitating PACE® services.

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Unsurpassed legal analysis, clinical review, and access to URAC-Accredited IROs.

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Appeals management with objective and dedicated oversight by experienced professionals.

Your Days of Unchecked Claim Denials Are Over

The Phia Group is here to help you reduce your financial risk and take back stability and confidence with PACE®.

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"At Cobalt Benefits Group, we are fixated on cost, quality and member experience. And The Phia Group, through their PACE® product, is fundamental to having protections in place for the customer and their bottom line, as well as individual exposure to the health insurance market. They are experts, and they provide a layer of protection for our customers that we think is a market differentiation for us.”

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Bill Meehan

President and CEO
Cobalt Benefits Group

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The Phia Ecosystem

Our services work together—or individually—to help you recognize your full cost containment potential.

ICE

Your Partner for B2B Compliance and Business Solutions

Subrogation & Recovery Services

The Key to Unlocking Your Full Recovery Potential

PACE®

Industry-Renowned Protection Against Fiduciary Liability Arising from Final Level Appeals

Phia Unwrapped

Comprehensive and Technology-Driven Out-of-Network Repricing

Care Empowered Pricing

Next Level Reference-Based Pricing with Quality Care and Fair Pricing Done Your Way

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Partner with The Phia Group for:

  • Compliance Peace of Mind
  • Plan Document Language
  • Claims Issue Resolution
  • Vendor Review
  • Technology-Powered Solutions
  • Access to Legal Expertise
  • Out-of-Network Repricing
  • Maximized Claim Recovery
  • Self-Funded Plan Advice
  • The Highest Level of Care

PACE® FAQs

PACE® is a service whereby you receive an objective review and guidance on final appeals, share fiduciary liability with a third party, and receive indemnification against damages arising from fiduciary breach. The Phia Group thereby assumes fiduciary responsibility for final-level internal appeals, so plan administrators, TPAs, and brokers don’t have to.

All plan designs are compatible with PACE®. From reference-based pricing plans to traditional PPO plans to “skinny” plans, all self-funded plan administrators have fiduciary duties, and will face difficult appeals.

Unfortunately, not every administrator is compatible with PACE®, but the vast majority of administrators are. This would be assessed on a case-by-case basis.

If a claim deemed deniable by the PACE® becomes subject to review by an Independent Review Organization, The Phia Group will both pay for the full cost of the IRO review and provide any assistance necessary during the external review to defend the decision.

Absolutely nothing. The Phia Group’s PEPM fees for the PACE® service are paid by the individual plans that utilize the service rather than by the TPA or broker. In fact, TPAs and brokers even have the opportunity to add a new profit center through their administration assistance with the PACE® service.

As part of the PACE® implementation process, The Phia Group will convene with you to determine the best way to market PACE® to groups. The Phia Group prefers to hold this meeting on-site, but it can also be done remotely. During this meeting, co-branded marketing, sales, and implementation strategies will be outlined and a thorough plan for success will be created to suit your unique book of business.
Tomasz + Family

Joined The Phia Group in 2013

When Plans Win, So Do Families

We believe that everyone should have access to high-quality and justifiably priced care.

Contact us today to get started.

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