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In addition to the large increase in savings, we have found their staff to be exceptionally professional, courteous, and prompt. Our TPL recovery rate with Phia increased to 700% when comparing their recovery amounts for the last 6 months with our prior carrier's last 6 months. This savings is passed on to the schools of California in the form of lower premiums."
Dr. Russel Bigler
Chief Executive Officer |
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Dear Reader,
Its April - spring is here and baseball has already started, so what could be better than that? Well maybe if my Cleveland Indians wouldn't already have such a bad record, but I guess I am used to it...
There is so much going on right now. I will speaking to our clients across the country and people are wondering what will happen with the Summary of Benefits Coverage ("SBCs"). Will is be postponed? Will it go away if health care reform is overturned? The bottom line is we have to act as if everything will move full steam ahead. Otherwise, we may find ourselves in a tough situation at the end of this year.
My biggest concern is the current trend we are seeing whereas states are fighting hard against the stop loss industry. Last week, a bill was amended in the California State Legislature that would effectively take away the ability of smaller employers in that state to operate self-insured health plans - by restricting access to stop-loss insurance. SB 1431 now prohibits the sale of stop-loss policies to employers with fewer than 50 employees that do any of the following:
Contains a specific attachment point that is lower than $95,000; Contains an aggregate attachment point that is lower than the greater of one of the following:
- $19,000 times the total number of covered employees and dependents;
- 125% of expected claims;
- $95,000
Similar acts are occurring in New Jersey and other states. We need to fight back as more and more states and legal scholars want to make self-funding a thing of the past. Their hope being that all of these employers will have to shift to the exchanges in 2014. Self-funding is too successful for many government officials that need employers in the exchanges.
Don't ignore this and instead, lets fight back. Happy reading!
Adam V. Russo, Esq. CEO |
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Passion for Subro Blog
To get all the latest industry news, don't forget to visit www.passionforsubro.com.
Want to get involved? Share your opinion with us and comment on any of our articles.
Click here to read a recent article. |
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Letter From the Editor From the Editor
 | | The Alamo |
Last month I talked about my various upcoming trips around the country. As you can see from the picture to your right - I was visiting the legendary Alamo in San Antonio, Texas. I think our industry must feel like we are defending ourselves in our own little Alamo these days!
For those Texans reading this, I truly enjoyed visiting the city of San Antonio, and found its history intriguing and its Riverwalk beautiful. But what I found most interesting was the information a number of local TPAs shared with me during my visit.
In our industry you always hear people say, "When you've met ONE Administrator, you've met ONE Administrator." That may be true in a number of ways, but one thing I am seeing is that all these "different" administrators are starting to face many of the same challenges that the current landscape presents them. (Believe it or not, I'm not just referring to the SBCs!)
As I travel across the country from SPBA this month to HCAA in the summer I hope that many of you share the issues that you are currently facing with me. My goal is to bring this information back to The Phia Group where we spend our days constantly searching for new ways to fight the issues that plague our clients. With your help we will continue to find exciting new ways to help our industry market self-funding to the masses.
If you have any issues that you would like to share with me, I urge you to reach out to us - share your experience so that we can continue to learn and continue to fight on your behalf!
Sincerely,
Andrew Milesky
Director of Client Services
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Client Spotlight of the Month - SISC III
This month we would like to place a spotlight on the Self-Insured Schools Of California "SISC". SISC has been a client of The Phia Group since 2005 and we have enjoyed one of our most sucessful relationships since then.
"Although Self Insured Schools of California, SISC, Joint Powers Authority, JPA, has been contracting with The Phia Group for a relatively short time, we are pleased to report that our relationship with them has exceeded our expectations.
In addition to the large increase in savings, we have found their staff to be exceptionally professional, courteous, and prompt. Our TPL recovery rate with Phia increased to 700% when comparing their recovery amounts for the last 6 months with our prior carrier's last 6 months. This savings is passed on to the schools of California in the form of lower premiums."
Dr. Russel Bigler
(Previous)Chief Executive Officer
About SISC
SISC III is one of the largest school focused health care purchasing pools in California. This size means we have tremendous bargaining leverage with health care providers. We use this leverage to negotiate the lowest rates and best services for our members.
SISC III offers a wide range of health benefits. This allows member districts to assemble benefit packages that will meet their budgetary needs while providing employees with quality health care coverage. The medical providers under our umbrella of plans cover every corner of the state.
If you would like to learn more about SISC III, please visit http://sisc.kern.org/.
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Consulting Issue of the Month
An administrative services agreement (ASA) is a very important agreement for a TPA to have in place with its employer.
An administrative services agreement (ASA) is a very important agreement for a TPA to have in place with its employer group plans. It is even more important to ensure that this ASA is both accurate and complete - or issues can be sure to arise.
Recently, a TPA was confronted with an issue relating to certain language within their ASA. While the actual "intent" of the language in the ASA may have been clear, the specific language in the ASA was ambiguous. This created a dispute over the ASA terms. Among other responsibilities, this ASA outlined the responsibility for payment of certain tax and surcharge assessments.
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Legal Issue of the Month
A plan participant was seriously injured (and injured her husband as well) when she flipped the vehicle she and her spouse were riding in. Police on the scene found alcohol containers in the vehicle, and detected a heavy smell of alcohol on the participant's breath.
After airlifting the participant to the hospital, blood tests revealed alcohol levels double the legal limit. The participant was treated as an inpatient for many days, and medical expenses were substantial. The applicable plan document included an exclusion, prohibiting payment by the benefit plan for claims arising from or occurring during the commission of an illegal act. The exclusion specifically mentioned driving under the influence of alcohol as an excluded event. The plan administrator accordingly denied the claims.
Sometime later, for reasons unknown, the applicable district attorney chose not to prosecute the participant. The participant retained counsel, who appealed the Plan's denial, arguing that the Plan could not deny claims as being the result of an illegal act, when the participant was not convicted of an illegal act. The plan administrator, wishing to confirm that no conviction had (or might) occur, contacted The Phia Group for help. We explained to the administrator that a conviction is irrelevant when considering the denial of claims.
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Case of the Month
The following story is about a workers' compensation case. The patient was a federal employee but had also opted to be a dependant under her husband's Self Funded Employee Benefit Plan offered through his employer: an interstate dairy farming company whose companies stretched out over upstate New York, Vermont, and New Hampshire.
The Plan paid approximately $100,000 in claims for treatment of injuries which unbeknownst to the Plan were sustained in a motor vehicle accident. At the time of the accident, the patient was driving a vehicle provided to her from the federal government for traveling purposes. The patient also happened to have been returning home from a music festival in upstate New York.
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Department of the Month - Claims Analysis & "The Phia System™"
The Phia Group developed proprietary software to increase case identification by a greater rate than any other service provider, resulting in our industry leading recovery statistics.
The Phia System™ captures all recovery opportunities by thoroughly analyzing claims data. The result is an efficient process leading to faster and higher recovery totals for benefit plans. Identifying cases with true recovery opportunity is the key to optimizing savings. The Phia System™ finds cases with real value and eliminates those with no savings opportunity. The system allows us to analyze data using various logic techniques in order to project client savings and operating needs before we even open a single case.
The Phia System™ is a sophisticated application that provides step by step analysis throughout the recovery process. Key application features significantly increase efficiency and productivity, substantially enhancing recovery opportunities and maximizing savings for our clients. Each claim is analyzed utilizing up to five digit diagnosis codes, including secondary and tertiary codes.
Learn More... |
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Spotlight Employee of the Month - Meagan Leard
 | | Meagan Leard |
This month we would like to place the spotlight on Meagan Leard.
Meagan joined the Claims Analysis Department in April 2008 and she has since expanded her role as a Distribution Liaison. One of Meagan's primary roles as Distribution Liaison is to provide our clients with assistance for any and all of their correspondence needs. In addition to this, Meagan oversees all distribution of our "Phia Letters". She has been a large part of her teams increased production in this area.
Meagan attended Clark University in Braintree, MA where she earned a certificate in Multimedia Communications.
An avid health enthusiast, Meagan is very active and partakes in many activities that promote a healthy lifestyle, such as hiking, bicycling, and running 5K races. She also enjoys watching movies, playing pool, and spending time with her boy friend Bob in their new home.
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Upcoming Webinars
May Webinar
"Working with the Networks - An Analyis of PPO and PBM Arrangements"
May 16th 1-2PM EST Benefit plans and their TPAs are contemplating alternatives to classic networks in response to rising costs. Many, however, are tied to their networks or simply feel alternatives aren't viable. It is imperative that these plans implement best practices to contain costs while operating within the network's parameters. Join The Phia Group as we analyze PPO and PBM contractual terms, offer suggestions to revise these agreements, and reveal strategies to limit costs; all without breaching your contracts. To register click here! |
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Where in the World is Phia?!?!
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Riverwalk - San Antonio, Texas |
Do you have a picture of yourself, or someone else representing The Phia Group in a fun or exotic place? If so, submit your photo to , and you may be selected as our quarterly prize winner! |
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Presentations
 To view any of our past presentations, please click here.
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©2000-2012, The Phia Group, LLC | 163 Bay State Drive Braintree, MA 02184 | Phone: 781-535-5600 | Fax: 781-535-5656 |
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