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SEPTEMBER 2012 NEWSLETTER
 
ISSUE# 32
 

"I wanted to take this opportunity to share with you and any potential client the positive results we have experience with The Phia Group over the past several years. It is important to recognize business partners that perform above and beyond the normal expectation of service. The Phia Group's results have been rewarding for EBA&M, as well as the clients we serve."

 

Brad Gossen

Vice President of Marketing

Employee Benefits Administration & Management Corporation

 

Dear Reader,

 

Fall is in the air here in New England but the conference schedule is heating up earlier than ever for me.  I'm doing the nationwide tour and the focus from audience questions is on two areas - health care reform and self funding.  The same people who ask me about reform then follow up with whether self funding is a good move to lower their costs.  The interest in self funding is the highest I have seen in my life time so we here at The Phia Group will continue to preach the virtues of this option and how to make it work right. 

 

This Saturday I'lI be doing a 50 mile bike ride called the Tour de South Shore on 9/22/12 and all of the money raised will go to MS and Alzheimer's research.  Anything that any of you could donate to this cause will be truly appreciated.  You can go to the link below and donate.  I appreciate it.  Happy Reading!

 

http://www.firstgiving.com/fundraiser/adamrusso/TourdeSouthShore2

 

 

sign2 

Adam V. Russo, Esq.

CEO


  

Passion for Subro Blog


 

To get all the latest industry news, don't forget to visit www.passionforsubro.com. passion3

 

Want to get involved? Share your opinion with us and comment on any of our posts.

 
Click here to read a recent article.
Letter from Editor
by Andrew Milesky

 

The summer is officially over in my mind here in Boston... When the nights get too cold to leave the windows open, I'd say its fall. Along with the gorgeous foliage and cool nights, the fall means we are back on the road again.

 

This past week I traveled to Minnesota, where I was privileged to attend a conference that has been around almost as long as I've been alive. This year was the first year this particular conference added a claims track and we were honored to be picked as part of the presentation. Immediately following this trip, we headed directly to see our friends, Diversified Group Brokerage, where they celebrated their 45th anniversary in style at Mohegan Sun Casino.

 

Our CEO, Adam Russo was a featured speaker to discuss the benefits and challenges of self funding. You can see his presentation by clicking here. Congratulations to our friends on 45 years of excellence. We had a great time.

 

I plan to see many of you next month at SIIA to discuss your most pressing issues. If any of you would like to meet up while in Indy, please let me know.

 

In the meantime, I'll be recovering from watching my beloved New England Patriots lose yesterday and continue reeling from an otherwise miserable year of baseball for my Red Sox! As we have been brought up to day here in Boston, "There's always next year."

 

See you soon!

 

Andrew Milesky

Director of Client Services

 

Press Release - Inc 500/5000

 

For the Fourth Year in a Row, The Phia Group, LLC has been named to Inc. Magazine's List of America's Fastest Growing Private Companies

 

NEW YORK, August 21, 2012 -- Inc. Magazine ranked The Phia Group on its 31st annual Inc. 500|5000 list, an exclusive ranking of the nation's fastest-growing private companies. This is the fourth consecutive year that The Phia Group has made it to the list. The list represents the most comprehensive look at the most important segment of the economy--America's independent entrepreneurs. Companies such as Microsoft, Zappos, Intuit, Jamba Juice, Zipcar, Clif Bar, Vizio, Oracle, and many other well-known names gained early exposure as members of the Inc. 500|5000.

 

"It is an honor to be on this prestigious list for the fourth year in a row, and we are looking forward to year five! Our consistent growth and reputation is a testament to our staff's passion for savings in the health insurance industry." said Adam V. Russo, Esq. CEO, The Phia Group, LLC "Now, more than ever, we depend on Inc. 500/5000 companies to spur innovation, provide jobs, and drive the economy forward.  Growth companies, not large corporations, are where the action is," says Inc. Magazine Editor Eric Schurenberg.

 

About Inc.

Founded in 1979 and acquired in 2005 by Mansueto Ventures, Inc. is the only major brand dedicated exclusively to owners and managers of growing private companies, with the aim to deliver real solutions for today's innovative company builders.  Total monthly audience reach for the brand has grown significantly from 2,000,000 in 2010 to over 6,000,000 today.  For more information, visit www.inc.com.

 

About the Inc. 500|5000 Conference

Each year, Inc. and Inc.com celebrate the remarkable achievements of today's entrepreneurial superstars--the privately held small businesses that drive our economy. The Inc. 500|5000 Conference & Awards Ceremony brings together members of the Inc. community, both a new class of Inc. 500|5000 honorees and the list's alumni, for three days of powerful networking, inspired learning, and momentous celebration. Please join us October 3-5, 2012, at the JW Marriott Desert Ridge Resort & Spa in Phoenix, Arizona. For more information about the 2012 Inc. 500|5000 Conference & Awards Ceremony and to register, visit www.inc500conference.com or call 866-901-3205.

 

More about The Phia Group, LLC

The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. The Phia Group's overall mission is to reduce the cost of plans through its recovery strategies, innovative technologies, legal expertise, and focused, flexible customer service.

 

True to its motto "A Revolutionary Passion for Savings," The Phia Group has become one of the most innovative and fastest growing cost containment firms in the nation, and is a pioneer setting the highest standards in the health care marketplace.

 

 

Protecting TPAs from Illegal Provider Billing Practices


SIIA filed an amicus brief with the Texas State Supreme Court on July 27, 2012 in the case of GPA Holdings, Inc. v. Baylor Health Care Systems. This brief supports GPA's request that the Supreme Court reverse an adverse judgment issued by the Fifth District Court of Appeals concluding that third party administrators (TPAs) can be held financially liable for health care services incurred by self-insured group health plans.

 

SIIA's brief, drafted by attorneys Adam Russo and Ron Peck of The Phia Group, LLC., argues such legal interpretation dictates that TPAs would necessarily be deemed as plan fiduciaries, which clearly conflicts with the Employee Retirement Income Security Act (ERISA). More broadly, SIIA contends that the Appeals Court decision threatens the existence of TPAs in Texas and elsewhere, and in turn, would greatly compromise the viability of self-insured group health plans for most employers.

 

 

 

Client Spotlight  - EBA&M 

This month, we would like to place a spotlight on eba&M. EBA&M  

 

EBA&M has been a client of The Phia Group since 2004. For the last 8 years we have enjoyed a successful partnership and hope to share many more years with our friends on the west coast. 

About EBA&M
From our commitment to customer service, claims handling and technology and cost management, to our full suite of services, we remain focused on providing our clients the tools to best manage their health care dollar.

Customer Service

Customer service is a primary focus at EBA&M. Our hands-on
teams are committed to continually improving the service and
programs we offer. Learn more

 

Technology & Cost Management

Implementing the latest technology and innovative cost
management strategies allows us to best manage our client's
healthcare dollars. Learn more

 

Claims Handling

Strict attention to claims handling assures the greatest efficiencyand accuracy in the claims process. Learn more

PGC Legal Issue of the Month

by Chris Aguiar

 

I have recently  taken to the pages of the The Phia Group's monthly newsletter to notify everyone of the recent chink in the armor of private self funded, ERISA qualified, employee benefit plans brought about the 3rd and 9th Circuits.   Now, I am back this month to remind everyone that despite the recent decisions in, all is not lost.  The rulings in the 3rd and 9th Circuits currently represent a minority opinion in the country.  Most circuits that have ruled on the issue have allowed qualified benefit plans to apply the terms as set forth in the summary plan description.  Is there a better way to show that that the "the kids are alright" then to have a recent decision that goes back to the basics and reminds us that a benefit plan's equitable rights are still strong, albeit a bit weakened?

 

In Smithey v. Tyson Foods, Inc.,  the Plan participant was involved in a motor vehicle accident and received a mediated settlement of $17,500.00.  The Plan had advanced over $53,000.00 in benefits on behalf of the plaintiff.  Though the plan participant refused to reimburse the Plan, she did hold the funds in trust and filed a declaratory action and eventually a Motion for Summary Judgment that the monetary reimbursement to a health insurance plan was not considered "equitable" under ERISA.  If you are thinking to yourself, "this sounds familiar"; well, that's because it is.  The Plaintiff was attempting to assert the age old argument that the Supreme Court resolved for us back in 2006 when it used Sereboff v. MAMSI to clarify its decision in Great West v. Knudson  that a plan could was entitled to an equitable lien or equitable remedy as long as it sought to recover funds in actual on constructive possession of, rather than impose personal liability on the plan participant. 

 

And so, the court in Smithey ruled in favor of the benefit plan because the plan participant was in possession of the funds, and the Plan was trying to recover a particular fund from the plaintiff, not simply impose personal liability, and therefore was seeking a valid equitable remedy.

 

It is sometimes beneficial to go back to basics and view the forest through the trees.  I use this case today to illustrate a bigger point, the Sereboff decision is still the controlling law of the land as it pertains to a plan's ability to impose an equitable remedy; and until the Supreme Court rules on the case of U.S. Airways v. McCutchen, many Federal jurisdictions agree that a plan can have an equitable lien by agreement and will defer to plan terms, rather than reform the terms of the plan and impose equitable limitations on a plan's recovery rights.  It is always, however, very important to remember that one cannot build a house without a foundation.  Comprehensive plan language is absolutely necessary to ensure that a plan can circumvent equitable doctrine.  No matter where in the country you are located, insufficient plan language will almost always lead to reduced recoveries. Additionally, a proactive recovery strategy is undoubtedly the most effective means of maximizing recovery opportunities.  As long as you have the foundation in place, and capable representatives on the ground, you can be sure that you have the tools you need to maximize your recoveries.  Hopefully, the Supreme Court sides with the majority and helps us re-establish a full right of reimbursement.

 

 

PGC Issue of the Month - SBC Regulation

by Shauna White

 

By now, most everyone is aware of the regulations requiring health plans to issue Summary of Benefits and Coverage (SBC). Over the last few months, we have fielded many questions regarding what information needs to be included in the SBC.   As we get closer to deadline, the prevailing question has shifted from "What needs to be in the SBC?" to "What are the rules for distributing the SBC?" If you need the answer to the latter question, please see the information below, courtesy of the DOL:

 

The final regulations require that the SBC be provided in several instances:

 

  • Upon application. If a plan (including a self-insured group health plan) or an issuer distributes written application materials for enrollment, the SBC must be provided as part of those materials. For this purpose, written application materials include any forms or  requests for information, in paper form or through a website or email, that must be completed for enrollment. If the plan or issuer does not  distribute written application materials for enrollment (in either paper or electronic form), the SBC must be provided no later than the first date on which the participant is eligible to enroll in coverage.

 

  • By first day of coverage (if there are any changes). If there is any change in the information required to be in the SBC that was provided upon application and before the first day of coverage, the plan or issuer must update and provide a current SBC no later than the first day of coverage.

 

  • Special enrollees. The SBC must be provided to special enrollees no later than the date on which a summary plan description is required to be  provided (90 days from enrollment).

 

  • Upon renewal. If a plan or issuer requires participants and beneficiaries to actively elect to maintain coverage during an open season, or provides them with the opportunity to change coverage options in an open season, the plan or issuer must provide the SBC at the same time it distributes open season materials. If there is no requirement to renew (sometimes referred to as an "evergreen" election), and no opportunity to change coverage options, renewal is considered to be automatic and the SBC must be provided no later than 30 days prior to the first day of the new plan or policy year.

 

  • Upon request. The SBC must be provided upon request for an SBC or summary information about the health coverage as soon as practicable but in no event later than seven business days following receipt of the request.

 

We will be sure to keep you all posted of any changes or updates to this important regulation.

 

 

 

Recovery Case of the Month

by Tianna Pagan

 

This month's case was a single motor vehicle accident. Initially, we were informed by the claimant's mother that they were a passenger in a vehicle where the driver simply lost control of the vehicle. No other information was given willingly.

 

We investigated this matter further and were able to locate a police report which painted a very different picture. The police report indicated that the patient was the driver and may have been under the influence of alcohol and well over the legal limit. Naturally we contacted the police department and were told that charges were pending following the results of a toxicology report. We were also informed that the member had two other pending charges reckless endangerment, as he had a passenger in the vehicle and driving without proof of insurance.

 

We contacted the auto carrier and verified that at the time of the accident the patient did not have valid insurance. Therefore was no first party coverage available, which resulted in a lack of subrogation potential.

 

However, the Plan had already paid $7,000.00 in medical bills with $145,000.00 pending a subrogation review. We informed the Plan of this information and informed the Plan that depending on the results of the toxicology report they could retract the payments and deny the pending claims. This of course was based upon the Plan's General Limitations and Exclusions Language which excludes payment of claims for injuries that were the result of illegal acts, including but not limited to felonies and misdemeanors, and regardless of whether the offense resulted in an arrest.

 

The Plan was well within their right to deny $145,000 in pending claims and recover the $7,000 payments pursuant to the Plan's Illegal Acts Exclusion. The Plan agreed we would wait for the results. After 2months of constant communication with the Sheriff's department, we were finally able to obtain the toxicology results. We recovered the Plan's $7,000.00 and saved them another $145,000.00.

 

Department of the Month - Claim Investigation

 

Here at The Phia Group, we are always evolving. Culturally, we believe that we can always be better. As a result of that thinking, we find ourselves constantly developing new ways to become more productive, more focused and recover more dollars on behalf of our clientele.

 

Recently, we have added a new department to The Phia Group - Claims Investigation.

 

The purpose of Claims Investigation is to uncover the true value and validity of a case. As you can imagine, every new case that walks through our door or is discovered through our claims auditing processes is not necessarily delivered with all the information we require.

 

Instead of utlizing precious time from our recovery specialists efforts throughout the day, we have a dedicated team with one simple goal - aquire the necessary details and dollars involved to puruse a claim.

 

With this team in place since June, we have already seen amazing results. The Claims Investigation team has uncovered a total of 604 active cases with true recovery potential that are now being settled with our Claims Recovery Specialist team and 305 cases that have deemed "unrecoverable". These 305 cases would have previously been investigated by our specialists. 

 

The team is still quite new but with the positive results we have seen in such a short time, we are sure they will continue to be an intergral part of our recovery process.

The Phia Group in the Community
Greater Boston Food Bank Volunteer Day 2012

GBFB

As an annual tradition, The Phia Group dedicates at least one day per year, where we close our office completely and participate in a charitable event. This July, our staff spent the day at The Greater Boston Food Bank, where we sorted and organized food for distribution, as well as made a donation from our entire team.

 

The Greater Boston Food Bank provided us with statistics based on our days work: 

 

Total pounds of food sorted: 12,574

  • Total pounds of food salvaged: 10,059
  • Pounds of food sorted per Volunteer: 173

Total Meals made possible: 7,714

  • Meals made possible per volunteer: 133

We are very proud of our staff's accomplsihment and vow to continue to donate our time each year to making a difference in the community.

 

If you are interested in learning more or donating to the Greater Boston Food Bank please click here

Employee Spotlight of the Month - Lisa Decristofo 

 

 LisaD

Over the years Lisa has become a Jack or "Jill" of all trades at The Phia Group. She started in May 2010 as a member of the Customer Service Department. Since then she has transitioned to Case Evaluation, and is now a valued member of the Claim Investigation team.

 

Lisa enjoys spending her spare time with her 2 year old Pit Bull, Zeek. She rescued him from a local animal shelter where he had been abandoned by his previous owner. Aside from being an avid dog lover, Lisa enjoys spending time with her niece, watching movies, attending car shows & cooking. Lisa was a member of the winning team in the June 2012 Phia Cooking Competition.  

 

 

 
In This Issue
Passion for Subro
Letter from the Editor
Article Headline
Article Headline
Client Spotlight
PGC Legal Issue of the Month
PGC Case of the Month
RecoveryCase of the Month
Department of the Month
The Phia Group in the Community
Employee Spotlight
 
 
Upcoming Webinar
 
 
webz 

Our next webinar will be September 19, 2012 @ 1pm EST

 

"Doing it For Ourselves!" - Examining the impact of the Supreme Court decision on PPACA, and developing methods to improve the system internally

 

To register, click HERE. 

 

 

Where in the World is Phia?!?!

 

AniaSpain 

 

Do you have a picture of yourself, or someone else representing The Phia Group in a fun or exotic place? If so, please submit your photo to info@phiagroup.com
 , and you may be selected as our quarterly prize winner!   
 
 
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Presentations

  

AVR.DAC 
 To view any of our past presentation, 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