"We have been working with the outstanding staff at The Phia Group for over a year, and continue to appreciate their unprecedented level of support and solid industry knowledge. They have simplified the process of obtaining Third Party Recoveries for our clients, at a most advantageous rate. On more than one occasion, we have also used them to educate our staff on the eccentricities of this industry, as well as intercede on our behalf with the entities. I am very pleased with the service we have received and would recommend them to other TPAs. "
Debra A. Nephew
Vice President of Operations
I cannot believe that New Year's Eve was over 2 weeks ago - where have these days gone? Time certainly seems to fly by when I keep myself busy working to ensure that all of you are protected this year. I have been spending much time researching the options available to employers in 2014. Where will they go? Will they decide to self fund or will they join the exchanges?
The fact is that most employers do not understand their options or the benefits of self funding. We here at The Phia Group want to be your resource when it comes to educating your clients and prospects. Well, that's my mission this year and I am looking forward to sharing the details with you once I am done. Enjoy this month's article and stay warm!
I also wanted to again mention my best friend Robert Pokorski or as I call him - Staga - who was diagnosed with Non-Hodgkin's Lymphoma.
You can make a contribution to the Robert Pokorski Irrevocable Trust, which will help support Staga and his family with their medical expenses. Donations can be made online at: http://www.giveforward.com/stagaswartheneighborhoodfightsback
Adam V. Russo, Esq.
CE Credits Now Available for The Phia Group's Webinar Presentations!
Please contact Andrew Milesky at firstname.lastname@example.org or by phone at 781-535-5636 for more information.
Letter from Editor
by Andrew Milesky
Happy New Year to all of our readers! While I am not one for New Year's resolutions, I may have to start this year and I'd like many of you to join me.
The reason I am not a fan is because too often we set goals for ourselves that are out-of-reach or at least we think they are. For example, we go to the gym for two months and when we don't look like Arnold Schwarzeneggeror Jane Fonda (I'm an 80's kid), we give up. Its all about immediate results.
Unfortunately, much like fitness, our business actions cannot always produce instant results. However, just like we know that lifting weights and working out will yield results that will make us more fit, we know that certain business practices that we can implement will ultimately produce positive results.
So why wait to get started? Start what you are likely thinking. Let me digress...I am speaking about making additions to what you have done in years past. I am referring to finally updating your plan documents. You know the ones I am referring to - the plans that have a thousand amendments. That one.
With Healthcare Reform here to stay, its as good as time as any to address not only the barrage of compliance issues you are facing, but also the matter of your plans strength. As we continue to innovate and address issues to contain costs, the opposition is waiting in the background playing catch up. Our goal as an organization is to always keep you two steps ahead. Let them play catch up and let us keep innovating.
If your even thinking about trying an alternative claims payment methodology, run it by us, we're happy to provide consultation. Let's do it right.
If you are worried about plans moving to the exchanges let's work hard to show the brokers and plans why they should stay self funded. Let's show what we can do and market the heck out of ourselves!
So there's my pitch for a New Year's resolution. Let's stop talking about it and be about it.
See you all in my travels.
Director of Client Services
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.
This past month, The Phia Group participated 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 adopted 20 children this year.
On January 9th, we headed back to the pantry to serve dinner to thier patrons and we will be heading back again on March 6th! This has been an amazing exercise for our staff and we will continue to serve our community to the best of our ability.
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.
"Is There a Place for Preferred Provider Organization ("PPO") Networks In Today's Health Benefits Marketplace?"
by Ron E. Peck, Esq. & Shauna Mackey, Esq.
Modeern employee benefit plans are exploring alternatives to Preferred Provider Organizations. ("PPO's). To understand why, we must understand the history of the PPOs. Only by identifying the value once created by PPOs can we subsequently identify when and why this money-saving resource for benefit plans has apparently ceased to be so. We must then explore the alternatives with an open mind, understand that alternatives - why resulting in cost savings for the benefit plan - are not cost free. Indeed, the cost may be more than some benfit plan sponsors are willing to bear.
A Brief History of PPOs
PPO's were originally developed so that select providers of healthcare services ("providers") could offer services at discounted rates to benefit plans in exhange for steerage. Early PPO networks were effective beacause the discounts were significant and were applied to charges generally deemed to be usual, customary, reasonable, and appropriate....
PGC Issue of the Month - "Pay or Play?"
by Christina Farrington
As the PPACA timeline gets closer to completion, another important decision will need to be made by the nation's employers - do I play or pay?
What exactly is play or pay you ask? That's easy to answer, employers with 50 or more full-time employees are required to offer medical coverage or pay a penalty. Sounds easy enough, however, employers are left with the difficult decision that consists of financial, legal and competitive implications that need to be considered carefully. This requirement is only a little more than a year away but the decision to pay or play isn't as cut and dry as it may seem.
Some employers are fearful that the play or pay mandate will raise their costs and they will be forced to make cutbacks. Due to these fears, the most logical answer would be to eliminate their health care coverage altogether and simply pay the penalty of their full-time employees. Right? The "pay" option may be worth considering, however, there are some strong reasons why employers should carefully consider all of their options and then decide which option is best for them in the long run.
Specifically, the issues are: lost tax advantages, reporting burdens, recruitment and retention challenges, employee counts, coverage cost adjustments, financial implications and plan designs.
Employers will have to consider whether or not the tax break cuts will be worth it or not. They risk their current employees demanding more pay in order to be able to afford buying their own insurance policy and potential recruits declining the position for better opportunities which could lead to talented individuals accepting another job.
Recovery Case of the Month
by Angela Johnson
The case of the month for this issue is a unique and interesting case. The patient was injured on an acquaintances boat when it exploded while the patient was working on it. The accident took place in the responsible party's residential garage. The patient had sustained burns over 30% of their body and required extensive treatment, leaving permanent scarring on their face, arms, and legs.
This case had been sent over to Phia by our client because the patient had offered the client $50,000 of the $100,000 policy limits of the boast insurance. Phia immediately contact the patient to obtain more accident details and to see if there may be any other avenue for recovery other than the $100,000 boat insurance policy as well as making the adjuster aware of the Plan's reimbursement interest. Phia was advised by the adjuster that any negotiations needed to be made with the patient instead of themselves.
With the cooperation of the patient, we contacted their own boat insurance carrier to see if there may be any type of medical payments coverage available to the patient, but unfortunately was informed that this was not a possibility. We also tried to obtain contact information for the responsible party from the patient was informed that they did not that information. Phia also used a legal program that is able to search by someone's name and the state of residence for contact information, but to no avail. The reason why Phia tried to obtain this information was to see if there may be any coverage on the responsible party's home owner's insurance policy, since the accident took place at a residential garage.
The Phia Group used the Plan Document to the best of our abilities when negotiating with the patient. The Plan had paid over $107,000 in claims and there was only $100,000 being offered. We took into consideration the patients out of pocket expenses such as medical bills and lost wages. The patient was well versed in his duties as an insured and knew that the Plan had a right of reimbursement, making it easier to negotiate a higher amount than the $50,000 that was already offered.
In the end, Phia was able to negotiate with the patient and secure a recovery of 2/3 of the policy limits or $66,666.67, leaving over $33,000 for the patient to take care of their medical bills, lost wages, and pain and suffering, allowing the patient to put this horrific accident in their past.
California Imposes New Fees on Worker's Compensation
by Chris Aguiar
The State of California recently enacted Senate Bill 863 as Labor Code Section 4903 which imposes new rules and fees on lien claimant's filing liens with the worker's compensation appeals board. This law may have implications on plan's who actively pursue recovery from worker's compensation. Basically, plans may now be required to pay a fee to file a lien. While this law was just recently enacted, it also provides that an activation fee be paid on any lien filed pursuant to § (b).
As if that weren't enough, plans holding liens may now be required to appear at all hearings related to the lien. The attendant must have settlement authority. In addition, the administrative law judge assigned to the case may require a representative be available at other hearings not covered under §5502(e) of the labor code. For parties that are subject to this law, noncompliance can result in complete dismissal of the plan's lien.
While some types of plans may be exempt, including some self funded plans, there are conflicting labor codes that add confusion. This is apparent where some judges are unclear on exactly how to interpret and execute the law. As usual, The Phia Group, LLC is reviewing this law and will be hosting a webinar
at 4PM EST on January 23rd to go over this law, what implications it may have on you and you clients, and how we can help.
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@example.com
Spotlight Employee - Jennifer M. McCormick, Esq.
Jennifer M. McCormick, Esq. joined The Phia Group, LLC as corporate counsel in 2008. She is admitted to the Bar of the Commonwealth of Massachusetts and holds the Certified Subrogation Recovery Professional (CSRP) designation.
As an attorney with The Phia Group, Jen concentrates on a variety of healthcare and regulatory issues facing employee benefit plans and their administration. In addition, she focuses on health plan document design and drafting matters affecting employers, third party administrators, stop loss carriers, and health carriers. She is a constant contributor to The Phia Group's webinars and other educational media.
Jen earned her J.D. from the Syracuse University College of Law, with certificates in Estate Planning and Family Law, and her B.A. in both Psychology and Criminal Justice from Indiana University, graduating with distinction as a National Dean's List Scholar. While attending Syracuse, Jen served as an Intercollegiate Director of the Moot Court Honor Society and as a Student Attorney in the Low Income Taxpayer Clinic where she counseled clients on state and federal tax matters and the US Tax Court appeals process.
In Jen's spare time she likes to practice yoga, spend time with family and friends, and relax with a good book.
Client Spotlight - Advantek Benefit Administrators
This month we would like to place a spotlight on our friends over on the west coast, Advantek. We have been partners since November 2009 and have enjoyed a wonderful subrogation relationship with them ever since. We hope to continue that partnership for many years to come.
Advantek Benefit Administrators, located in Fresno, California, is a private corporation licensed to provide claims administration services. We are committed to providing excellent customer service, optimization for each client and quality equal to none. Advantek is a division of Santé Health System, which has been in business since 1989. Advantek's goal is simple-with our staff of professionals, we provide high quality administrative services to self-funded employer groups.
We are confident that we can significantly reduce the frustrations you and your employees currently experience with the healthcare system. Our teams of highly dedicated individuals receive on-going training to ensure the best possible quality and service. In short, we want your business and will work hard to prove ourselves as the most appropriate choice for delivering this service.
- Extensive experience in EPO, PPO and managed care administration
- Highly trained, experienced team of professionals with a vast background in claims administration
- Comprehensive, customizable reporting package
- User friendly, on-line resources including employee enrollment
- Banking flexibility
- On-site clinical staff that includes full-time Medical Director and nursing staff
- Knowledgeable staff available to assist with employee education and meetings
To learn more, please visit http://www.advantekbenefit.com/.
Our next webinar will be January 16, 2013 @ 1pm EST
"The State of the Subro-Union Address "
To register, click HERE.
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