the phia group
The Phia Group, LLC Newsletter
In This Issue
Tragedy in Boston
Testimonial
A Victory for Subrogation
Letter From the Editor
TX HB 1869
PGC Issue of the Quarter
Recovery Case of the Month
Employee of the Quarter
Client Spotlight
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2/25/13 1-2PM EST

 

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Quarterly Newsletter
April 2013
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Tragedy in Boston

 

skylineBoston 

As you have no doubt heard by now, on April 15, 2013 - two bombs were detonated just before 3 P.M. Eastern Standard Time in the Copley Square area of Boston, MA. 

 

Since the news broke, many of you have reached out to us to ascertain our situation and confirm our wellbeing.  I am pleased to advise you that our entire team is whole and healthy.  The outpouring of support from you, our industry partners, has been moving. 

 

Thank you once again for your care and support.  It is appreciated. If you would like to support the victims of this horrible tragedy please visit https://teespring.com/staystrongboston.

  
Phia Blood Drive
  
A day after the event, The Phia Group participated in a blood drive with The American Red Cross. Many "Phians" took time out of their busy days to donate blood for a great cause.We are always finding new ways to get involved in the community and we vow to continue those efforts.
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Client Testimonial
"Starline Group has used The Phia Group for claim subrogation over the past ten years. I would not hesitate to recommend Adam Russo and his team as a professional claim recovery firm. The Phia Group blends an aggressive recovery approach, encyclopedic knowledge of collection and subrogation law, and the latest in computer technology into a dynamic force for recovery. The results have been extraordinary and we are more than pleased with the follow-up and reporting."
 

Craig C. Schmidt

Director

Star Line Group

It's been a wild ride for all of us in the self funded community for many reasons.  From the Time Magazine article by Steven Brill - if you haven't read it, the link is HERE - to the NAIC and various states such as Utah and Colorado attempting to limit the ability to self fund, we have many major battles ahead.  We here at The Phia Group are here for you to deal with the PPACA complexities and your constant battles with the networks and facilities on excessive charges.  Whatever the need, we want to be your one source for solutions.

 

On a different note, I am running in the 2013 MuckFest MS Boston on April 27.  I would love for you to donate to my cause for MS research on behalf of my family, which has been personally affected by this terrible disease.  Any donation would be helpful.  Please see the link below if you can donate to my cause:

 

http://main.nationalmssociety.org/site/TR/General/FLNMUCKEvents?px=11795093&pg=personal&fr_id=21243

 

 

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Adam V. Russo, Esq.

CEO

 

A Victory for Subrogation...and a Focus on Plan Language
Tuesday, April 16, 2013, the U.S. Supreme Court released its decision regarding the matter of US Airways, Inc. v. McCutchen Et Al., 569 U. S. ____ (2013), No. 11-1285.  For those of us whose lives are dedicated to the viability of health benefit plans, this decision represents both a great victory, as well as a reminder.  Self-funded benefit plans administered in accordance with the Employee Retirement Income Security Act of 1974 ("ERISA") may enforce the terms of their benefit plan document - as written, however, the Supreme Court also reminds us that a plan's rights are only as strong as its terms.  Benefit plans will fail when scrutinized if their plan document provisions are not air-tight.  Indeed, in this case - as in so many others - less than perfect plan language led to the use of "equitable" rules as gap filler.

  

Please visit our official blog, www.passionfosubro.com, for a complete analysis of this important case.  As in many other cases, the Supreme Court determined that where plan language is silent, equitable rules may be used as "gap filler."  This, then, reinforces a message The Phia Group has been delivering for more than a decade... 

 

Had U.S. Airways' plan document featured The Phia Group's plan language, they would have not been ordered to reduce their reimbursement.  In light of this newest decision, we encourage everyone to examine their plan documents and ensure there are no "gaps" which the Courts would be happy to fill with equitable remedies.  As always, our team of plan document experts are ready, willing, and able to close those gaps using the best language available.  Please contact our director of client services, Andrew Milesky, at amilesky@phiagroup.com or 781-535-5636 anytime to discuss these and other services available.

 

We also want to remind you about our upcoming webinar.  Please visit: REGISTER FOR THE PHIA GROUP WEBINAR!

  

We will be discussing this case during that presentation as well... DON'T MISS IT!

 
 Letter From the Editor - Quarterly Newsletter

by Andrew Milesky

 

As you may have noticed, The Phia Group's newsletter has changed from a monthly to a quarterly edition. After much deliberation, we decided we could provide greater and more entertaining information by allowing a few months to pass between editions. With this new format, we promise you'll find our newsletter filled with articles on many of the topics you are hoping to hear about. With that said, it has been an exciting first quarter here at The Phia Group. With a growing need for assistance in the area of benefit plan compliance, The Phia Group has expanded its regulatory offerings. Our team navigates the complexities of regulatory law as it relates to the health care industry. Regardless of whether the inquiries relate to State or Federal regulation, issues involving State Insurance Departments, the NAIC, HHS, CMS, and DOL are all being handled by our Regulatory Compliance Team.

 

In addition to an increased presence from our  legal team, we have placed major importance on the technology that drives us. This year kicked off the implementation of several new technologies aimed at increasing our productivity from a claims recovery standpoint and new tools to allow for a greater level of client communication.

 

As the second quarter approaches, so does an onslaught of industry travel that we look forward to each year. Our CEO, Adam Russo, was honored last month to be part of the opening act at this year's SIIA Conference in Palm Springs, CA where he was on a panel to discuss the industry's most pressing matters alongside Ernie Clevenger of CareHere, LLC and Larry Thompson of BSI Strategic Consulting. As the spring moves along, we will be enthusiastically hitting the road and look forward to seeing all of you at the various industry events across country
TX HB 1869 / SB 1339 - A Brief Overview and Commentary
by Ron E. Peck, Esq.
  

What is TX HB 1869?

 

TX HB 1869 is a bill (a proposed law) presently being considered by the State's legislature, which would seriously impact the subrogation and reimbursement rights of those health benefit plans and health insurance policies that are regulated by State law.  Its purpose is threefold:

 

(1) Implement a statutory common fund doctrine;

 

(2) Implement a statutory made whole rule;

 

(3) Prohibit recovery from "1st party" policies.

 

Who is Impacted?

 

Private, self-funded health plans enjoy what is called "Federal preemption" of State law, thanks to the Employee Retirement Income Security Act of 1974, ("ERISA").  ERISA states that State law cannot limit or control a private, self-funded health plan's ability to implement and manage its health plan.  As long as the plan is in compliance with Federal law, the single plan will be enforced in accordance with the terms of its plan document, nationwide. 

 

Self-funded municipal plans and self-funded plans managed by houses of worship are exempt from ERISA.  While this results in many benefits, it does also nullify the Federal preemption described above; meaning that these self-funded plans are regulated by State law.  As such, if HB 1869 were to become law, these types of plans would need to comply with it.

 

Finally, insurance (programs where an insured pays a premium to an insurer, and the insurer takes on the responsibility of paying claims) are also regulated by State law.  As such, anyone who purchases insurance rather than self-fund their benefit plan, will be impacted by HB 1869.

 

What is Subrogation?

 

Subrogation occurs when a benefit plan or insurance carrier pays medical bills, but later discovers that a third party caused the injury or illness.  If another entity (such as another insurance program, workers' compensation, auto insurance, or negligent third party) is actually

 

Subrogation recoveries are an important factor in calculating the cost of premiums (if you buy insurance) or contributions (if you fund a self-funded plan).  HB 1869 places significant limitations on a health plan's ability to coordinate benefits and ensure the responsible party pays the claims, which will likely increase health insurance premiums and limit how many employers can afford to purchase coverage for their employees.

 

Read On

 

PGC Issue of the Quarter - Vermont First to Unveil Health Insurance Exchange Rates

by Rebecca Meyrick

 

This past Monday, Vermont became the first state to unveil the insurance exchange rates. This preliminary look allows Vermonters to gauge how the health insurance overhaul will impact their wallets come January 2014, under the Patient Protection and Affordable Care Act.

 

The Vermont Health Connector, as Vermont's exchange is known as, will open this coming October 2013 for enrollment. Vermont's exchange was designed primarily to offer coverage for individuals without access to employer-sponsored health care.

 

According to the Associated Press, a family of four making $32,000 per year will pay $45 per month out-of-pocket and a single person making $40,000 per year will pay about $317 per month out-of-pock et.

 

Vermont's insurance exchange will be supported by two insurance companies (1) MVP Health a third party administrator based out of Schenectady, New York, and (2) Blue Cross Blue Shield of Vermont.

 

The long term goal of Vermont's state legislature is to be the first state in the United States to have a single-payer health care system from which the government pays all of the residents' medical bills and virtually nullifying the need for private insurance companies in the Green Mountain State.

 

Single-payer health care systems are currently in place in Australia, Canada, and Taiwan. This progressive plan was passed into law in 2011 with hopes of having full implementation by 2017.

 

The question to be considered as Vermont moves towards the single-payer system is what could this mean for self funded health plans in Vermont?  

Recovery Case of the Quarter

by Mary Burkhalter 

 

The case of the month for this issue is not your typical motor vehicle accident or slip and fall. This case involved a patient who sought treatment due to a faulty hip replacement.

 

This case had been sent over to The Phia Group by our client because the client was aware that there was a class action brought by many individuals against the manufacturer of the equipment used in hip replacement surgeries.

 

The Phia Group immediately placed all parties on notice of the Plan's subrogation interest. After many months of litigation, the case settled with the manufacturer. Unbeknown to The Phia Group, the patient contacted the client directly requesting that the plan waive its subrogation rights. The client then contacted The Phia Group advising us that they had been contacted by the patient. We contacted the attorney and advised that because the patient was represented by counsel, all future communication and issues needed to be addressed by their law firm and The Phia Group.   Based on the limited amount of settlement funds of $200,000.00, the unpaid medical expenses and the other liens the attorney received, the attorney requested that the Plan accept $32,000.00 in satisfaction of the Plan's subrogation claim in the amount of $90,000.00.

 

The Phia Group referred to the group's Plan Document, case law and the circumstances arising out of this incident and with the cooperation of all parties (including the approval of our client), The Phia Group was able to seek a recovery of $55,000.00.

Employee of Quarter -  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 - StarLine Group
StarLine
  

 

 

This Quarter we would like to place the spotlight on our very first MGU client, StarLine Group. StarLine is not only a company local to us here in Boston, but holds a special place in our heart as the organization that got us involved in the reinsurance market place.

 

About StarLine Group

 

A specialty underwriting management company with the passion, the people and the products to help your business succeed. StarLine Group does not pull risk solutions off the shelf or pop them out of a can. We sit down with each and every client and listen. What are your issues and goals? What are the challenges of the marketplace? Then we discuss. We probe. We make suggestions. We play devil's advocate. We work diligently to understand you and your company. In the end, we do what we do best: we tailor a customized risk solution.

 

Where does all this passion come from? Our people. From senior leadership down through the entire team, everyone carries a sincere and tireless desire to help each and every client. Our industry professionals reflect a valuable blend of insurance experience including underwriting managers, multi-national carriers, national and international brokerage houses and third party administrators. Their passion directly benefits you by way of prompt claim payments, simplified administration, competitive pricing and highly attentive customer service.

 

Our areas of expertise include Specialty Benefits, Stop Loss, and Managed Care.

 

StarLine Group also offers you the peace of mind in knowing we only partner with A-rated insurance companies. We admit it. We are passionate about managing risk. And our clients wouldn't have it any other way.

2000-2013, The Phia Group, LLC | 163 Bay State Drive Braintree, MA 02184 | Phone: 781-535-5600 | Fax: 781-535-5656