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FEBRUARY 2013 NEWSLETTER
 
ISSUE# 37

 

"I just wanted to let you know how much we've enjoyed working with you and your staff. It's clear that providing exceptional customer service is a high priority at the Phia Group. Our transition was quick and seamless. Our inquiries are handled promptly and reports are delivered on time!

We continually hear from clients and staff about their positive experience. Thank you for your professionalism and assistance with subrogation and legal matters.

In less than a year, the Phia Group increased our recoveries."

 

Jacqueline Petersen

Vice President, Operations

Consociate Group Inc.

 

Dear Reader,
  
It's only February and I'm already getting sick of the snow. Thankfully spring training is underway and for the first time in years, my beloved Indians have a chance to win!  We here at The Phia Group want all of you to win new clients and increase your profitability and that's why our services are catered to you.  
  
The industry is going through much change and our expertise can and will guide you through the storms.  Our recent webinar on cost plus offerings was the highest attended to date and we expect to beat that number with our next two on how to convince employers that self funding is right for them.  Thanks for choosing us and happy reading.  
  

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Adam V. Russo, Esq.

CEO

   
 

CE Credits Now Available for The Phia Group's Webinar Presentations!  

 

Please contact Andrew Milesky at amilesky@phiagroup.com or by phone at 781-535-5636 for more information on which states qualify.

Passion For Subro & Self Funding Blog - New and Improved!

  

PassionNew
  

 
  
  
  
  
  
For all the latest industry news, please visit www.passionforsubro.com.
  
Letter from Editor
by Andrew Milesky

 

Well February has most certainly been an interesting month here in Boston. As some of you may have heard, we had a bit of a blizzard. Now, while I know I'm not impressing nor invoking any sympathy from our northern clients...I can tell you that even here in Boston, 2-3 feet of snow at your door is a little unexpected. I can still feel the back pain from shoveling...

 

In the midst of all this crazy weather, The Phia Group keeps pushing along. This month we had our most anticipated and highly attended webinar presentation to date. During this webinar, we covered the topic of Cost Plus pricing methodologies that have finally taken the industry by storm. (no pun intended).

 

In past entries of mine, I have mentioned that Cost Plus, Medicare Plus and other cost containment measures have become a hot hot topic this year - this month's webinar attendance further confirms this for me.

 

I think in the end, our message is simple - If you are going to do it, do it right. 

 

As the next few months move along so shall my travels. I will be visiting the lovely state of Texas for the TABA conference and hope to see all of my favorite Texans while there. 

 

 

 

Andrew Milesky

Director of Client Services

  
The Phia Group in the Community
Braintree Food Pantry 

 

Ron.PantryStarting 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

www.braintreefoodpantry.org

 

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.

 

PGC Issue of the Month - Final HIPAA Rules 

 

Most of our clients are concerned about the final HIPAA rules. Many feel that since the rules are now final - changes are required. Well good news!

 

The final rules did not significantly deviate from the proposed regulations issued in 2009.  From a practical standpoint, if the company's BAA had been updated after 2009, it should already be compliant.  Specific cites should be verified as some of the exact citations have moved/changed.  Also, if the prior BAA defines "breach," it may be updated as the definition of breach has been expanded. 

 

 

An Audit With No Appeal

by Ron E. Peck, Esq.

 

Many of the third party administrators (TPAs) and self-funded benefit plans (Plans) The Phia Group services have encountered a reoccurring issue.  In a nutshell, providers that are in-network either audit claims themselves or hire an outside firm to audit the claims.  These claims are often old (sometimes a few years have passed since they were paid), and they were paid by the applicable benefit plan utilizing (deducting) the PPO network discount from the total billed charges.

 

The audit identifies claims that were paid more than the PPO-contractual number of days (usually 30), after they were (in the providers' opinion and based on their interpretation of the PPO contract) submitted for payment; and thus, the claims were not "promptly" paid.  As a result, years after these claims were "paid late," the provider wants to recoup the PPO discount amount from the Plan.

 

We often hear about the following:  The PPO contract requires payment within 30 days of receipt of a clean claim for a covered service.  An in-network hospital treats a plan participant (for this example, let's say he suffered injuries in a car accident) and submits claims (that it believes per the PPO contract, are clean claims for covered services) on a certain date.

 

For this example, let's say the total charges are $100,000.00, and the PPO discount is 20%.  The provider expects payment of $80,000.00 within 30 days.  The TPA and Plan delay processing until they obtain an accident report / police report, to ensure that no exclusion applies (such as an illegal act or alcohol exclusion).  It takes 2 weeks (14 days) to get the report. The TPA and Plan pay $80,000.00 (the $100,000 charge minus the 20% PPO discount) within 30 days of receiving the report, but 44 days after the claims were first submitted.  Neither the Plan nor TPA hear any complaint.

 

The provider retains an auditor in 2013.  The auditor identifies the claim described above, and notifies the provider that the 20% discount was applied despite the claim being paid late; (not within 30 days).  The auditor on behalf of the provider notifies the TPA that it must pay the provider the discount amount (20% = $20,000.00) immediately, or they will file suit to recoup it.  Often they seek to add interest, for the years that passed as well; (adding insult to injury).

 

Unfortunately, the knee-jerk response from the TPA is usually the same.  They state that per the Plan Document and ERISA, "appeals" need to be filed within a certain time, and this demand for money arrived well after that deadline.  The auditor and provider respond, saying that the Plan Document and ERISA are irrelevant.  They are accusing the Plan and/or TPA of breach of contract.  The statute of limitations applicable to a breach of contract applies here; not the deadline to file an appeal.  Such a statute of limitations is often many years long. 

 

The provider argues that the contract language is very clear regarding how much needs to be paid, and when it needs to be paid.  The contract, they say, speaks for itself and can be enforced without looking at the Plan Document or ERISA.

 

This type of "appeal" is a big issue for many clients right now, and another reason they are looking at alternatives to PPOs.  Regardless, dealing with such an issue involves (1) analyzing the language of the applicable PPO contract, (2) having a clear and concise explanation of why the delay or reduced payment took place, and (3) a willingness to negotiate with the provider, to avoid litigation.  This last requirement is important, as many Courts (particularly State Courts, which would oversee a breach of contract claim), lack the understanding of self-funding necessary to analyze the network arrangement in light of the Plan Document.  Many judges will only consider the PPO contract, in a vacuum, and enforce the terms of said contract without regard for the Plan, the Plan Document, or the "reasons" why the Plan breached the PPO contract.

 

 

Recovery Case of the Month

by  Sean Hegarty


 

We received this case one morning and the client called just 20 minutes after we received the case to check up on it so we knew right away that this was a priority case for them. A quick review showed that this was a, workers compensation case where the member said she was hurt at work, fairly standard stuff.

 

A closer review showed that this was in fact a Minnesota workers compensation case where the state appoints a mediator to help the case along. I knew in these cases The Phia Group would need to file an intervention to protect the plans interest, and I immediately did so. We contacted the Members attorney and workers compensation attorney and placed them on notice of the plans interest, and had a list of all the related claims made and sent to them. The case quickly progressed and soon the workers compensation attorney contacted us with a proposed settlement offer of 25% of the plans claims that were paid. The reduction they explained was due because there happened to be questions about the nature and source of the injury.  Among the many reasons the workers compensation attorney cited were; other lien claimants,  the workers compensation denied that they were primarily responsible for the injuries incurred, the medical records indicated a spontaneous onset of the injury, the claimant did not file at the time of the injury, the patient allegedly returned to work at her second job, and finally the IME determined that there was no evidence of a true injury and that if there were an injury there was no way it could have occurred from the description given.

 

With this information in hand we thought it best to settle for a reduction but certainly not the initial amount offered. We advised the attorney that the plan was a self-funded employee benefit plan and it called for a 100% of funds. With that we were able to secure a refund for 50%, more than what the member received after attorney's fees had been deducted.

 

Department of the Month -Information Technology

 

Too often, organizations forget to recognize their Information Technology department who act as the silent warriors of a company. Most of us don't care how something works, but rather that it does.

 

At The Phia Group, our dedicated team of IT specialists quietly ensure that we are able to successful serve our clients on a daily basis. As the need for new technology increases as does our reliance on IT.

 

As our subrogation clients can attest to, our recovery numbers often meet and exceed expectations. It is our proprietary Phia System that drives this function of our company. As much as we'd like to think it runs all by iteself, it is the good work of our technology team that makes it all possible.

 

With the changes looming in our industry The Phia Group is constantly adding new services and features to answer the call of the industry we serve. As we create new services and provide more in depth cost containment schemes, we must look to them to provide the support we require in order to deliver exceptional products and service.

 

So this month we'd like to tip our hats to The Phia Group's Information Tecnology Department who go about thier day so quietly but have such loud performance.

 

 

 

Spotlight Employee -  Chinmay Kulkarni

  

ChinmayChinmay joined The Phia Group in 2012 as Data Analyst/Developer. Over the last year, Chinmay has become a trusted a reliable source within our IT department. Chinmay is always willing to help out our staff without question and his selflessness is precisely why he has earned the spotlight this month. 

 

Chinmay obtained his Masters in Computers Science from State University of New York. He received his bachelors in Business Administration and AS in Computer Information Technology from Dutchess College NY. Chinmay has also received a Diploma in Animation. 

In his spare time, Chinmay likes to spend time with his family and visit different places. He also enjoys exercising, biking, hiking and cooking.

Client Spotlight  - Consociate Group

 

This month we would like to place a spotlight on our friends in the midest, Consociate. We have been partners since November 2006 and have enjoyed a wonderful subrogation, and consulting relationship with them ever since. We hope to continue that partnership for many years to come.

 

Overview

 

Consociate Dansig, a Third Party Administrator and Insurance Brokerage since 1972, has built a proven reputation for providing exceptional and custom benefits and insurance solutions to individuals, corporations and employers in 48 states. Consociate Dansig embraces two sides of the insurance and benefits industry:


Consociate - a Third Party Administrator, administering employee benefit plans for large employers while focusing on healthcare cost management and maintaining employee productivity.

Dansig - a full service Insurance Brokerage with professionals providing cost-effective solutions for large companies, small businesses and individuals.

We are a group of skilled benefits and insurance professionals who will be your partner in managing insurance costs, reducing risk, and keeping employees productive. 

 

 

To learn more, please visit http://consociategroup.com/.

 

In This Issue
CE Credits
PassionForSubro
Letter from the Editor
The Phia Group in the Community
An Audit With No Appeal
RecoveryCase of the Month
Department of the Month
Spotlight Employee
Client Spotlight

 

 Upcoming Webinar
 
 
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Our next webinar will be March 13, 2013 @ 1pm EST

 

Getting Employers To Self-Fund In The PPACA Era - Keep Existing Clients Self-Funding... Get New Employers To Self-Fund...

 

To register, click HERE. 

 

 

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