Prior to our decision to partner with The Phia Group, we were processing claims relying on the claim staff's ability to identify a subrogation situation. GISC has substantially increased the return of recouped funds on behalf of our clients using your expertise. Your IT departments' ability to identify potential recoveries by "washing" our data regularly is impressive and has proven very beneficial.
The reports supplied are timely and clear and concise. Communication between our two offices is exceptional."
Karen J. Sealund
Treasurer & CEO
Group Insurance Service Center, Inc
The elections are over and regardless of who you voted for, the fact remains that PPACA is here to stay. While many of you have been utilizing our firm to assist in your compliance needs, we have never publicly announced that our team of experts can assist your organization with Regulatory Compliance issues until now.
Our experts navigate the complexities of regulatory law as they relate to the health care industry. So, regardless of whether your inquiry relates to State or Federal regulation; issues involving State Insurance Departments, the NAIC, HHS, CMS, and DOL, our complance team can handle it.
Happy Thanksgiving everyone and make sure you work off those extra pounds in some way!
Adam V. Russo, Esq.
Letter from Editor
by Andrew Milesky
Happy Thanksgiving to all of our readers! My goodness, can you taste the delicious food already? I can. I must admit that this is a time of year when my mind sort of checks out of reality and checks into truck loads of food that await me. Hopefully most of you can relate.
With that said, there is still much work to be done and most of the time we feel like we are always working up-hill. For once, I'd like to focus on what we as an industry have to be thankful for.
Its November 2012, Healthcare Reform has been deemed constitutional, Obama has been re-elected and guess what? We all still have jobs! I put that as a "W" in the win column. Lets be thankful for that. (for now :))
In the end, as it pertains to this industry, what I am thankful for above all is innovation. This is something we should all be thankful for. Even if you aren't doing everything, the ability to be innovative is at your fingertips. From the ability to customize your plan documents to the various levels of service you can offer, this is your strength. Use it.
So, as your week winds down and you need something to be thankful for at work, be thankful you are working in the self-funded industry at a time where our innovation and our flexibility is something others sorely lack.
See you soon!
Director of Client Services
"Phia Group Consulting Addresses Regulatory Compliance"
Braintree, MA - For years, The Phia Group's team of consultants have been dealing with various regulatory inquiries. In response to the impending influx of regulation bound to follow the recent election and rollout of PPACA's most complex provisions, The Phia Group announced this week the official formation of its Regulatory Compliance team.
The Time for Procrastination is Over
"Let's face it..." The Phia Group's CEO Adam V. Russo, Esq. stated, "The Patient Protection and Affordable Care Act is here to stay. The only question we need to ask is whether we will rise to the challenge, or collapse under the regulatory burden."
The floodgates are open and a tidal wave of mandates is fast approaching. The Supreme Court has deemed PPACA to be constitutional, and we now know that it will not be repealed. Now that PPACA is the law of the land, the freeze on regulatory activity is at an end. The DOL, HHS, CMS, and NAIC are about to bombard us with rules pertaining to items such as Transitional Reinsurance Programs, Essential Health Benefits, Self-Insured Health Plan Rights Reconsidered, Defining Self-Insurance and Stop-Loss' Roles, and more...
If you administer health benefits and haven't addressed these and other pressing compliance issues, you're not alone. Phia Group Consulting's Regulatory Compliance team has been assembled to assist all members of the industry in their effort to comply with applicable laws for a fraction of the cost traditional law firms will charge.
"Uncertainty seems to be the only certainty these days..." The Phia Group's Sr. Vice President and General Counsel remarked; "When it comes to all of these regulations, mandates, and acronyms... it's a nightmare to keep track of. We've compiled a team whose mission is to make sense of the mayhem."
Customized Compliance Support
With an ability to customize their services, The Phia Group will provide timely compliance support tailored to their clients' specific needs. Entities impacted by these forthcoming regulations are encouraged to contact The Phia Group's Director of Client Services:
Director of Client Services
The Phia Group, LLC
163 Bay State Drive
Braintree, MA 02184
Phone (781) 535-5636
Fax (781) 848-1154
E-Mail [email protected]
Phia Group Consulting Case of the Month
by Chris Aguiar
In another interesting case hammering home the need for clear plan language and consistent administration of plan terms, a court ruled that a third party administrator's decision to pre-authorize claims, when paired with certain representations made within the plan terms, could serve as a determination of medical necessity by the Plan.
In, Sanctuary Surgical Center v. UnitedHealth, 2012 WL 5199611 (S.D. Fla., Oct. 22, 2012), the court ruled that summary judgment was inappropriate because the Plan's definition of medical necessity was ambiguous. Where it was ambiguous and the Plan terms suggested that pre-authorization would serve as a determination of medical necessity, there was sufficient question as to whether the Plan could then utilize its discretionary authority to later deny claims on the basis of medical necessity.
The Court also suggested that the provider may have standing to bring a claim for breach of fiduciary duty by way of the assignment of benefits.
This is just another example illustrating the need for clear plan language creating clear guidance for the third party administrator and a an understanding of plan intent so as not to undercut a plan's discretionary authority.
For more on this case ... please contact Chris Aguiar at [email protected].
PGC Legal Issue of the Month
by Chris Aguiar
If you have not heard about the 3rd Circuit case that is taking the subrogation world by storm then you must have been spending your time living under a rock, hibernating early for the winter, or perhaps even training to beat Felix Baumgartner as the first person to actually jump from outer space and plummet towards the earth all the while setting three world records. Luckily, I am far too afraid of heights to even jump out of bed, let alone dive from over 120000 feet. On November 27th, the Supreme Court of the United States will review the case of U.S. Airways v. McCutcheon and finally decide whether a court sitting in equity can force a plan to apply equitable limitations to its reimbursement interests despite clear plan language disclaiming those limitations.
For the past few months we have been pouring over the case law and creating methods to debunk the arguments that are being made. This past week, I traveled across the country and made a quick stop in Las Vegas, but I didn't hone my skills at poker, or black jack, Nor did I press my luck and put it all on red; instead I was obtaining more knowledge that I can now impart to you, today!
A few promising cases have come out since the 3rd and 9th Circuit put some doubt into the rights of self funded ERISA plans. For example, in K-VA-T Food Stores, Inc. v. Hutchins, the Western District of Virginia ruled in favor of the Plan and awarded attorney's fees. The court distinguished the case from McCutcheon because, were in McCutcheon a full recovery by the plan would have lead to a starkly inequitable result where the plan participant would have been left in a worse position than if he had not brought a claim at all, Mr. Hutchins still got a significant award and after deducting the Plan's lien of $191,948.75 from his $850,000.00 settlement. Where he was still receiving $460,635.88, the Plan was able to recover. The court even went on to admonish him for the overt actions he took to avoid reimbursing the Plan and went on to award the Plan attorney's fees, as well.
Further, the 11th Circuit has once again come out with a decision favorable to the Plan in this arena. In Schwade v. Total Plastics, Inc. 2012 U.S. Dist Lexis 37091 (M.D. Fla. Feb. 22, 2012), a federal court denounced the McCutcheon decision as a "broad, judicially manufactured alteration of ERISA based on a little-explained reading of several narrow Supreme Court decisions". The Court even pointed that this manufacturing amounted to revision of the plan over the objection of the Plan administrator on behalf of one beneficiary rather that in conformity with the interests of all the other plan participant and was sure to increase the cost to all the other participants.
Suffice it to say that the sense at the National Conference was that many people with intimate involvement in the case are cautiously optimistic that the Supreme Court will rule in the Plan's favor in this case. Many organizations have submitted briefs supporting both sides of this issue and it is sure to be an interesting and eventful few months as we await the outcome of this case.
If anyone would like copies of the cases or more information as developments happen, I can be reached at [email protected]. Or, feel free to call me at 781-535-5633.
Recovery Case of the Month
by Pamala Parette
Our investigation established the Plan participant was a passenger in a vehicle traveling on a two lane highway, one lane in each direction. As the driver passed a large mail truck the truck executed a left turn. The two vehicles collided causing the participant to suffer extensive injuries. Medical bills considered by the Plan were in excess of $250,000 with future anticipated medical treatment of an estimated $60,000.
The participant obtained the services of an attorney to represent her interests. The attorney secured an offer of $100,000 policy limits from the driver of the participants' vehicle and contacted our office in an effort to gain consideration for an equitable reduction of the Plan's interest.
The Phia team reviewed all file information and contacted member's attorney to discuss other potential sources of recovery. Participants' attorney advised no additional sources of recovery from any source. We discussed the negligence of the mail truck driver. Participant's attorney advised his investigation into the negligence of the mail truck driver was determined to be minimal and, as the result, no claim for damages had been made. We advised counsel that participants' injuries resulting were due to the combined negligence of both drivers, that the mail truck driver likely had significant liability limits, and the state the accident occurred had joint and several liability. We asked the participants' attorney to review his file for consideration and provide his findings so the Phia team could monitor his actions for complete handling.
Participants' attorney concluded his findings and immediately made a claim to the mail truck driver ultimately securing full recovery for the benefit of the participant.
From Plan consideration of an equitable share of $100,000 to full recovery of paid and future medical bills The Phia Group experience makes an amazing difference!!
Department of the Month - Phia Group Consulting
Regulatory Compliance Services
Our experts navigate the complexities of regulatory law as they relate to the health care industry. Regardless of whether your inquiry relates to State or Federal regulation; issues involving State Insurance Departments, the NAIC, HHS, CMS, and DOL are handled by our Regulatory Compliance team.
The Time for Procrastination is Over - PPACA is Here
The floodgates are open and a tidal wave of mandates is fast approaching. PPACA is the law of the land and the freeze on regulatory activity is at an end.
Customized Compliance Support
With the ability to customize our services, we can provide timely support tailored to your specific needs. Our Regulatory Compliance team will assist you for a fraction of the cost traditional law firms will charge, while addressing topics regarding but not limited to:
- Stop-Loss Regulation at State and Federal Levels
- Benefit Plan Status and Rights
- Internal Investigation
- Human Resource Compliance for Employers
- Licensure Compliance
- Federal and State Law
- The Public Health Services ActAlternative Risk Sharing Models
- Legislative Entities and Their Mandates
Contact The Phia Group's Director of Client Services, Andrew Milesky today. The Phia Group's Regulatory Compliance Team can be reached toll-free at 888-986-0080, directly at 781-535-5636, and via e-mail at [email protected].
The Phia Group in the Community
Braintree Food Pantry
Starting this October, The Phia Group began a partnership with The Braintree Food Pantry located down the street from our office.
Once a month, Phia Group employees dedicate time after work to serve dinner to patrons or organize food in the pantry for hours. We feel this is a worthy cause and one that we vow to continue indefinitely.
About The Braintree Food Pantry
Located in the First Baptist Church on 594 Washington St., Braintree
In an average month they purchase and distribute more than a ton of food and supplies Some food is provided by GBFB and a small grant from Project Bread, all other food and monetary donations are from organizations, community, etc.
Next Month The Phia Group will be participating in their "Adopt-A-Child" program. Every year, children sign up to received Christmas gifts. They make a list of things they want and things they need. The Phia Group is hoping to "adopt" at least 20 children this year.
Employee Spotlight of the Month -Ashley Enyeart
Ashley Enyeart has been with The Phia Group since 2007, after graduating from Marist College in Poughkeepsie, New York and receiving a Bachelor's degree in both Criminal Justice and Psychology. It's been a great five years, during which she has handled a variety of cases, expanding her knowledge of the industry and is now the paralegal to our Sr. VP and General Counsel.
When Ashley isn't helping the company run smoothly, she enjoys spending time with friends, traveling to different countries (her favorite so far is Australia) and being an active leader in the youth group at her church. Ashley also loves to visit her hometown of Stillwater, in upstate New York, whenever the time (and weather) allows for it.
Client Spotlight - Group Insurance Service Center, Inc.
This month, we'd like to place a spotlight on our old friends right down the street from us, Group Insurance Service Center, Inc. "GISC" has been a client of The Phia Group since August 2002. This was at a time where many of you would not have recognized us. They have been a wonderful client and loyal friends for the last 10 years and we hope for many more.
About Group Insurance Service Center, Inc.
Group Insurance Service Center, Inc., is dedicated to the effective Program Management of our clients' benefit programs. This section contains information on our company and some of our team members.
Group Insurance Service Center, Inc. was re-established in 1995, but its' roots go back to 1972, as a professional third party employee benefit administrator.
GISC specializes in the administration of employee health, dental, life, AD&D, and short-term disability insurance and is an approved claim payment facility for major A+ insurance carriers.
GISC operates a state-of-the-art computer and claims processing system. Our employees are professional, courteous and knowledgeable. Our management personnel are members of both local and national industry associations and stay up-to-date with the rapid changes in benefits, government regulations, employee expectations and recruitment demands. We maintain memberships on important committees of the Society of Professional Benefit Administrators and local Chambers of Commerce and will keep our clients up to date with government and industry developments.
GISC's clients nationwide have come to rely on our professional guidance, our cost-effective partnership in employee benefit plans and rapid, responsive service. You will, too!
Visit http://www.giscinc.com/index.html to learn more.
Our next webinar will be December 12, 2012 @ 1pm EST
"Looking forward to 2013 - The Phia Group Looks Back at 2012 and Forward to 2013"
To register, click HERE.
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Where in the World is Phia?!?!
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 [email protected] , and you may be selected as our quarterly prize winner!
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