the phia group
The Phia Group, LLC Newsletter
In This Issue
Delay in Pay or Play
Testimonial
The Phia Group Forum 2013
Letter From the Editor
State Exchanges
Balance Billing
Participant Outreach & Support
Client Spotlight
New Business Outreach
Recovery Case of the Quarter
Employee of the Quarter
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Ensuring Cost Containment Success - Member Outreach & Support 

 

7/31/13 1-2PM EST

 

To Register Click HERE.

 

What's Good For the Goose is Good for the Gander? Analyzing BUCA-ASO PPO Agreements

 

8/20/13 1-2PM EST

 

To Register Click HERE.

 

2014 and Beyond - Reacting to PPACA's Volatile Evolution

 

9/25/13 1-2PM EST

 

Registration Coming Soon!

 

 

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Quarterly Newsletter
July 2013
gavel
Dear Reader,
 

 

It's been a crazy few months for the health insurance industry as you all know.  All I can tell you is that we are here for you with your questions and needs.  We attempt to stay ahead of the curve and I can tell you confidently that more changes are ahead, so be sure to tune into our webinars over the next few months.  

 

As always, thank you for your support of The Phia Group.  We promise to keep you informed so you can protect yourselves and your clients. Happy reading. 

  

Sincerely,

 

sign2 

Adam V. Russo, Esq.

CEO

 

 

Delay in Pay or Play - Considerations for Employers
Open Enrollment - Considerations for Employers
by Corrie Cripps

 

Plan B 

 

In an unexpected twist on July 2, the Obama Administration postponed the employer pay or play mandate of the Affordable Care Act (ACA) until 2015, delaying the assessment of any penalties or mandatory employer and insurer reporting requirements under the Internal Revenue Code. As a result, employers will not be forced to provide their full-time employees a plan which is considered affordable and meets minimum value coverage requirements. However, the individual mandate aspect of pay or play is still set to go in effect.

 

The Individual Mandate of Pay or Play

 

The individual mandate provisions of ACA, which require individuals to maintain minimum essential coverage each month or face pay a penalty, will begin on January 1. The Internal Revenue Service (IRS) issued Notice 2013-42 (http://www.irs.gov/pub/irs-drop/n-13-42.pdf) providing transition relief from the individual mandate. However, this transition relief is limited to employees who are eligible for an employer-sponsored group health plan that operates on a non-calendar year. 

 

The IRS will allow employees and their spouses or dependents who are eligible to enroll in a non-calendar year employer-sponsored health plan to avoid individual mandate tax penalties for the months between January 1, 2014 and the month that the employer's 2013-2014 plan year ends. With this new clarification, employees will not be required to enroll early in an employer-sponsored group health plan or to enroll in other health insurance coverage through the Health Insurance Marketplace to avoid individual mandate tax penalties.


Employers maintaining fiscal year plans may want to include information on this transition relief in their 2013 open enrollment materials or separate communications as this transition relief enables employees to retain their current elections until the next open enrollment period that takes place in 2014.

 

But what about the employees whose employer-sponsored health plan operates on a calendar year?

 

Employees who currently do not have health insurance coverage will need to make a decision: either enroll in the employer-sponsored plan or enroll in a plan on the Health Insurance Marketplace.

 

  • Open Enrollment on the Health Insurance Marketplace is from October 1, 2013 - March 31, 2014. In order for an individual to ensure he/has coverage on January 1 and to avoid a monthly penalty, he/she will have had to apply on or before December 15, 2013. (Source: http://www.mbaileygroup.com/blog/health-care-reform/how-will-enrollment-in-health-insurance-exchanges-work/)
  • Employers need to decide-will the employer-sponsored plan also provide a longer Open Enrollment period, to coincide with the Marketplace's Open Enrollment? If so, employers should include this information when they send out the required Exchange Notice. This information should also be included in the Open Enrollment materials.

 

Employees have more options now and will be looking for health plans that best meet their needs and are affordable to them. By providing some flexibility during Open Enrollment this will give them more time to research their options and to ask questions.

Automatic Enrollment

 

Another challenge employers will be facing is the potential future implementation of automatic enrollment, as outlined under ACA.

 

The automatic enrollment provision requires employers with more than 200 full-time employees to automatically enroll any new full-time employees into the employer's group health plan. This automatic enrollment will be subject to any applicable waiting periods (i.e. not to exceed 90 days beginning in 2014). This regulation also mandates that employers provide proper notice and the opportunity for an employee to opt out of any coverage for which the employee was automatically enrolled.

 

This requirement will add complications for employers already trying to revise and modify their plans to comply with ACA's upcoming 2014 provisions. Further, this creates confusion for employers trying to define "full-time" since the employer mandate provision has been delayed.

 

Large employers are now questioning: will the "full-time" definition from the employer mandate apply to employers? If I have a non-calendar year plan, how will the employer mandate affect my plan on January 1, 2015? What if the mandate goes into effect mid-plan year and "full-time" is defined as 35 hours and not 30 hours under my plan? Do I have to amend my plan now or can I wait until open enrollment for 2015? And most importantly, how will I coordinate this with the Marketplace's Open Enrollment?

 

However, there is good news for employers. A Technical Release (2012-01), issued in February 2012, reported that the automatic enrollment regulations will not be effective by January 2014. Thus, employers are not required to comply with the automatic enrollment provision until final regulations are issued and effective. This delay should alleviate the stress of additional administrative burdens by implementing such an expansive provision.

 

In summary, the delay of the employer mandate should not be treated as an opportunity to put the topic of employee benefits on hold. Individuals will still be required to obtain health coverage, meeting the requirements of ACA, in 2014. Thus, employers should carefully consider whether, and to what extent, they will help their employees access this coverage. It is certainly very possible that once an employee leaves the employer plan and accesses the exchange, he/she will not come back to the employer plan in 2015.

 

 

Client Testimonial
"From the point of contact forward, The Phia Group has been an excellent partner to work with.

 

They embrace the role of subrogation with vigor, enthusiasm, and thoroughness. They are very complete and timely with their reporting, up to date with the latest technology in electronic claims data capturing, and subsequently have realized a greater amount of recoveries for our clients than previous vendors with whom we have worked.

 

They are always accessible and respond quickly to any inquiry, and are extremely thorough in their investigations. They have worked with us to customize their services for both our needs and the needs of our clients. They are always there to help, no matter how large or small the issue may be. We look forward to continuing a growing relationship with the Phia Group."

 

Mary Gousev

Director of Operations

CDS Group Health

The Phia Group Forum 2013 - Real Challenges, Real Solutions

 

This year, we found ourselves at a crossroad. PPACA's constitutionality was upheld and those that support its implementation maintain their majority in our government. A seemingly never-ending barrage of statute-driven reform is on the horizon, and much is already at our doorstep. Threats from the NAIC have placed stress on the stop loss industry and puts employers at risk of not having the ability to self-fund. Claim pricing methodologies using reference based pricing such as Medicare Plus have taken our industry by storm as we try to find innovative ways to tackle the ever growing problem of the cost of healthcare.

 

During our forum, we tackled many of these issues and more. As always, we try to host a number of guest speakers that can offer insightful discussion to our meeting. This year was no exception. With the addition of Professor Mark A. Hall, we wanted to do something that others do not - bring the opposition to the table. We think his exposure to us at the very least, provided him with a clearer view into the looking glass of the self funded industry.

  

As always Mike Ferguson shared his latest views and insight into SIIAs efforts to thwart the efforts of regulators across the county and Dr. Keith Smith of the Surgery Center of Oklahoma impressed us all with his simple solution to the high cost of healthcare and price transparency - post prices online. In addition to our guest speakers, our legal team members, Jennifer McCormick Esq., Shauna Mackey, Esq., and Chris Aguiar shared our PPACA updates and their knowledge of regulatory changes and legal cases effecting plans rights to reimbursement 

 

To see ALL the slides from our forum please click HERE.

 

Our clam bake dinner on Spectacle Island was a huge success as the majority of you joined us in a traditional Boston LOBSTAAA DINNA! The weather held up and many of you were able to enjoy a beautiful view of our cityscape at sundown. I am attaching a picture for your enjoyment. We hope you had some great memories - we certainly did. You can view additional pictures from our event by clicking HERE.

 

We thank everyone who was involved for their passion and dedication to our industry.

 

 

 Letter From the Editor - Quarterly Newsletter

by Andrew Milesky

 

Uncertainty these days seems to be the only thing that is certain. Every quarter seems to bring new challenges, but it also seems to carry with it, delays from old ones.

 

How much time was spent thinking about, planning for and educating ourselves for "Pay or Play"? I can say from personal experience, countless hours were spent learning and eventually teaching about the regulation.

 

Here we find ourselves, July 2013 and suddenly pay or plan has been delayed another year. But wasn't the penalty cash going to help fun the exchanges? So what happens now?

 

It has often been said by some of our speakers that if the government is running it, it is certain to fail in some way. I feel that vindication is on the horizon for our comments.

 

With Pay or Play on the sidelines for now, what is our focus? As I see it, the growth of self funding by ceasing the opportunities that have been afforded to us with ACA influencing employers to seek flexibility and freedom within the world of self funding is our mission.

 

After the last 4 months on the road, I have consistently heard one thing, my TPA clients are seeing a majority of their new business coming from the large carrier world. This shift in culture has also brought something else to light, the carrier and health plan world are getting in on TPA business by starting their own TPAs. The effect of this is hard to say. But what is clear is that self funding is the answer.

 

The deep hot summer is upon us and with it comes a small break in my travel. I plan to use this time to follow up with many of you on your concerns as it relates to your organizations. However, should any new questions or concerns every arise, do not hesitate to contact me directly. I am always here to assist.

 

I wish you all an amazing last few months of summer and look forward to seeing you all in the fall.

 

Andrew Milesky

State Exchanges: How will it impact self-funded Plans?

by Sharryn Gedeon

 

Patient Protection and Affordable Care Act a/k/a Affordable Care Act a/k/a Obamacare is the top of discussion in the Healthcare industry and news concerning the employer mandate which has been delayed until January of 2015. The major component of the health care reform law is the new Exchanges. Notices regarding the Exchanges must be distributed by the employers to their employees by October 1st the date of open enrollment for the Exchanges.

 

Many employers select self-funding in order to control and to save. In the control aspect of self-funding, it provided employers the opportunity to have control over their plan's design, components, and administration. Self-funding is known as the most cost-effective structure, provides coverage for healthier than average employees and low claims equal low costs. Larger companies lean towards self -funding and appreciate it, especially if many of their employees are young.  

 

The health care reform contains many mandates that are applicable to both insured and self-funded plans. In the result of health care reform, self-funded plans face increased requirements and fees, moreover, will still be able to maintain greater flexibility in their benefits than their insured counterparts. For instance, self-funded plans will continue to be exempted from the often costly state mandates and state premium taxes due to ERISA. In general, this will provide freedom to employers to offer the same uniform health plan in multiple states, as they are not required to offer tailored benefits to each state dependent upon the existing state mandates.

 

Time is essential for the State Exchanges and with the delay many feel that health care reform will run smoothly and precisely. Many states already decided to establish State Exchanges and six of these states: Maryland, Colorado, Oregon, Massachusetts, Washington and Utah were approved from HHS for their State Insurance Exchange plans. On the other hand, many states have decided not to set up their own Exchanges but instead let the federal government do it for them.

 

Health care reform will continue to have a significant effect on all health plans, regardless if they are fully insured or self-funded. The self-funded plans will experience an increase in administrative responsibilities and fees as a direct result of health care reform. Nevertheless, the law will still allow increased flexibility and some relief to employers in a position to maintain a self-funded plan.

 

Balance Billing - Unconsciousable Yet Enforceable

by Ron E. Peck, Esq.

 

balancebill 

 

As the cost of providing robust health benefits to employees continues to soar, employers are faced with a difficult decision - redirect precious resources towards maintaining their plan, cut back on benefits, or drop their program. 

 

Employers that discontinue coverage or allow benefits to fall below mandated minimum coverage will be forced to pay penalties in accordance with the Patient Protection and Affordable Care Act's ("PPACA") 152(f)(1) when and if employees enroll in the forthcoming exchanges and obtain a premium subsidy.

 

In an effort to maintain their benefit programs at levels that will not expose them to penalties, employers are cracking down on excessive spending.  Among other things, they are diligently applying exclusions, performing eligibility audits, and applying fee schedules with price caps based upon numerous parameters - such as cost, MSRP, AWP, and Medicare pricing. 

 

As employers and plan administrators continue to cap costs and consequently push for consumerism in the healthcare marketplace, participants will be thrust into the fray like never before.  Regardless of network status, whenever an adverse benefit determination occurs, the participant is exposed to the threat of balance billing. 

 

Why is this?

 

A benefit plan administrators' first responsibility is to prudently manage plan assets in accordance with the terms of the benefit plan document, and protect the plan membership.  Often, this duty is at odds with the interests of an individual participant.  For instance, if a benefit plan excludes claims for cosmetic surgery, and a participant receives cosmetic surgery, the plan administrator must deny the claims despite the fact that the participant will be balance billed; so too in the case of excessive charges. 

 

We know that plan administrators still wish to protect such participants from balance billing.  In an effort to both enforce the terms of the plan and protect the participant, many plan administrators will seek to "settle" balance billed amounts with providers.  If and when a provider agrees to accept a plan payment as payment in full, the participant is protected from balance billing. 

 

There are times, however, when a plan administrator cannot resolve a balance billing dispute; there are times when a provider will simply not accept anything less than an amount prohibited by the plan. 

 

Where settlement cannot be achieved absent payment by the plan blatantly in excess of allowable rates, the plan must step away from the matter and allow the participant to be balance billed.

 

At this point, you're probably saying... "WHAT?!?!  ALLOW BALANCE BILLING?!?!  No way...  I think balance billing is illegal, if they take my plan's money; right?"

 

Wrong.

 

The only way to stop balance billing is by contract.

 

I can't reiterate this sentiment enough.  Whether the contract is a PPO agreement, a settlement agreement, or some other contract... the only way to stop balance billing is by contract.

 

Too often, our clients make the mistake of thinking that if they pay a "fair" amount... and amount they think the provider "should" accept as payment in full... then the provider won't balance bill the patient.  Sadly, this is not the case.

 

Imagine you walk into a fancy boutique clothing shop.  You spy a pair of pants that would look great on you.  You check out the price-tag; $750.00.  For most of us, that is an excessive price for pants.  Despite that fact, you know that if you walk over to the register, hand over $200 (an amount that you think is more than fair), and leave the store with the pants, you will be arrested for shop-lifting.  The only way to pay $200 and not be "balance billed," would be if you were able to negotiate the price with the shopkeeper.  This negotiation (settlement) is a form of contract.  Absent that "meeting of the minds," you can't unilaterally enforce your will - no matter how reasonable you think your position may be - upon the seller of goods or services.

 

This, then, is the crux of an issue I frequently encounter.  Payers think that by forcing a fair payment down the provider's throat, they can also prevent balance billing.  When the participant is balance billed, despite the provider accepting the payment from the benefit plan, my client is shocked. 

 

In other words... If you're shocked that the provider doesn't share your good sense, and appreciation for fair market value, don't be so surprised.

 

In our opinion, we need to take action before the claims are incurred; not to "prohibit" balance billing (because, as you already know, we can't stop balance billing absent a contract)... but rather... to disincentivize it.

 

It's true that I can't stop a provider from balance billing... but the provider can't stop me from limiting assignment of benefits to only those that agree to accept it as payment in full. 

 

Assignment of benefits represents a lessening of risk on the part of the provider.  It represents peace of mind, in the form of payment by the plan (deep pockets) versus from the participant (good luck pursuing that money).  Providers don't want to be in the collections business; but until we threaten exactly that, they have no reason not to demand their cake (assignment and payment from the plan) and eat it too (balance bill the remainder). 

 

The bottom line?  I'm not here to say that the provider can't balance bill.  I'm here to say that it can't accept assignment and balance bill.  It can accept assignment or balance bill.

 

Assuming some providers will opt to balance bill, we need to next address how this is handled...

 

Too many benefit plan sponsors suffer from split-personality disorder.  On the one hand, they are the meanest, toughest, tight-fisted, most gosh-darn cost-effective plan administrator south of the Mason-Dixon!  They set rock-hard limits on what the plan will pay, and anybody that dares to charge more than that amount can go ahead and balance bill the patients... 'cause this plan ain't payin' one more red cent!  Yet... the same plan sponsor also gets bent out of shape when their employee complains that they are receiving notifications from a collections agency or hospital, regarding that $50 Tylenol (of which the plan only paid $10... GASP!)...

 

Suddenly, that budget conscious plan wants to hire someone to "stop the balance billing."  Remember what I said above?  This is easier said than done...

 

In addition, the attitude is that the plan can hire a "patient advocate" on the plan participant's behalf.  Again - this is a tricky concept.  Let's first digest the relationships before proceeding further...

 

The Phia Group is retained by benefit plan administrators to assist in the drafting of plan language, identification card language, explanation of benefits language, and disclaimers accompanying payment.  In addition, The Phia Group drafts template correspondence to be used by plan administrators when notifying participants and providers of the limits set by the benefit program upon payable rates.  In totality, these endeavors - along with applicable case precedent - protects benefit plans from losing battles with participants and providers seeking additional payment from the benefit plan. 

 

"Patient Advocacy," meanwhile, implies legal representation of the patient.  It implies a vigorous, all encompassing effort on the participant's behalf.  A patient advocate would therefore both have to mount a defense against the provider's balance billing efforts, as well as pursue a bad-faith claim against the benefit plan.  In other words, if you truly represent the plan participant, you should leave no stone unturned when fighting for them.

 

Often, entities retained by and working on behalf of the plan, resolve disputes in the name of the plan... and thereby eliminate the balance billing as a side effect.  These entities (all of whom are fantastic), are deemed to have acted as "patient advocates" due to the fact that their efforts resulted in the participant avoiding balance billing.  The truth is, however, that while they helped the participant, they represent the plan.

 

The bottom line?  A true patient advocate must only have their client (the patient's) interests in mind, even if it means turning against the benefit plan.

 

The Phia Group does not promote itself as a patient advocate.  The Phia Group does undertake efforts on behalf of its clients - the benefit plans - to resolve disputes with providers; thereby resulting in the participant enjoying the fruits of our labors as well.  In these cases, the participant is a beneficiary of efforts taken on behalf of the plan, not the participant. 

 

The Phia Group also seeks to provide support to participants facing balance billing.  By this we mean that The Phia Group can assist the benefit plan in explaining why the payments were capped, describing the appeals process in detail, and providing the patient (and their advocate if applicable) with arguments they can raise against the provider.  This type of participant education, entitled Outreach and Support, will invariably reduce the number of claims filed by participants against their plans, and hopefully enable participants to successfully combat balance billing efforts by providers.

 

Our goal is to contain costs and fight for the plan's rights.  Regardless of how you choose to proceed, please make sure you are protected from the types of conflicts I reference above.  If you feel like leaving the highway we've all been cruising to date, because the tolls are just too high, be prepared for a bumpy road, regardless of what the GPS tells you.

 

Participant Outreach & Support

dice 

INTRODUCTION:

 

As the cost of providing robust health benefits to employees continues to soar, employers are faced with a difficult decision - redirect precious resources towards maintaining their plan, cut back on benefits, or drop their program.

 

Employers that discontinue coverage or allow benefits to fall below mandated minimum coverage will be forced to pay penalties in accordance with the Patient Protection and Affordable Care Act's ("PPACA") 152(f)(1) when and if employees enroll in the forthcoming exchanges and obtain a premium subsidy.

 

In an effort to maintain their benefit programs at levels that will not expose them to penalties, employers are cracking down on excessive spending. Among other things, they are diligently applying exclusions, performing eligibility audits, and applying fee schedules with price caps based upon numerous parameters - such as cost, MSRP, AWP, and Medicare pricing.

 

As employers and plan administrators continue to cap costs and consequently push for consumerism in the healthcare marketplace, participants will be thrust into the fray like never before. Regardless of network status, whenever an adverse benefit determination occurs, the participant is exposed to the threat of balance billing.

 

REPRESENTING THE PLAN:

 

The Phia Group is retained by benefit plan administrators to assist in the drafting of plan language, identification card language, explanation of benefits language, and disclaimers accompanying payment. In addition, The Phia Group drafts template correspondence to be used by plan administrators when notifying participants and providers of the limits set by the benefit program upon payable rates. In totality, these endeavors - along with applicable case precedent - protects benefit plans from losing battles with participants and providers seeking additional payment from the benefit plan.

 

Enforcing the benefit plan's ability to pay the amount set forth by the plan terms is                The Phia Group's mission

 

ASSISTING THE PARTICIPANT:

 

A benefit plan administrators' first responsibility is to prudently manage plan assets in accordance with the terms of the benefit plan document, and protect the plan membership. Often, this duty is at odds with the interests of an individual participant. For instance, if a benefit plan excludes claims for cosmetic surgery, and a participant receives cosmetic surgery, the plan administrator must deny the claims despite the fact that the participant will be balance billed; so too in the case of excessive charges.

 

Yet, plan administrators still wish to protect such participants from balance billing. In an effort to both enforce the terms of the plan and protect the participant, many plan administrators will seek to "settle" balance billed amounts with providers. If and when a provider agrees to accept a plan payment as payment in full, the participant is protected from balance billing.

 

There are times, however, when a plan administrator cannot resolve a balance billing dispute; there are times when a provider will simply not accept anything less than an amount prohibited by the plan.

 

Where settlement cannot be achieved absent payment by the plan blatantly in excess of allowable rates, the plan must step away from the matter and allow the participant to be balance billed.

 

PATIENT ADVOCACY:

 

"Patient Advocacy" implies legal representation of the patient. It implies a vigorous, all encompassing effort on the participant's behalf. A patient advocate would both have to mount a defense against the provider's balance billing efforts, and pursue a bad-faith claim against the benefit plan. Often, entities retained by and working on behalf of the plan, which resolve disputes and thereby eliminate balance billing, are deemed to have acted as patient advocates due to the fact that their efforts resulted in the participant avoiding balance billing.

 

A true patient advocate must only have their client (the patient's) interests in mind, even if it means turning against the benefit plan.

 

OUTREACH AND SUPPORT:

 

The Phia Group does not promote itself as a patient advocate. The Phia Group does undertake efforts on behalf of its clients - the benefit plans - to resolve disputes with providers; thereby resulting in the participant enjoying the fruits of our labors as well. In these cases, the participant is a beneficiary of efforts taken on behalf of the plan, not the participant.

 

The Phia Group seeks to provide support to participants facing balance billing. By this we mean that The Phia Group can assist the benefit plan in explaining why the payments were capped, describing the appeals process in detail, and providing the patient (and their advocate if applicable) with arguments they can raise against the provider. This type of participant education, entitled Outreach and Support, will invariably reduce the number of claims filed by participants against their plans, and hopefully enable participants to successfully combat balance billing efforts by providers.

 

BE SURE TO REGISTER FOR THIS MONTH'S WEBINAR WHERE WE WILL DISCUSS PARTICIPANT OUTREACH AND SUPPORT. YOU CAN REGISTER NOW BY CLICKING HERE.

 

Client Spotlight - CDS Group Health
This Quarter we would like to place the spotlight on CDS Group Health.  CDS has been a client of The Phia Group's since February 2005 and we have enjoyed a strong business realtionship ever since. We feel that CDS employees are not only our colleague, but our friends.  

 

 

About CDS Group Health

 

As a full-service third-party administrator, CDS partners with self-funded employer groups and their broker consultants to customize plans that meet the specific needs of employers and their members. Our team of dedicated experts can meet the needs of any employer group including benefit plan design, medical management, open enrollment tools, reporting capabilities, out of area network solutions and specialized claims processing.

An affiliate of Saint Mary's Health Plans, CDS Group Health is a member of Catholic Healthcare West (CHW) and is the largest third-party administrator (TPA) in northern Nevada. We provide a comprehensive continuum of health insurance products and services in multiple markets delivered by a compassionate, effective, customer-focused team. Our affiliation with CHW brings added strength to a major managed healthcare program and allows us to be a leader in healthcare management. 

 

New Business Outreach Program [for existing Phia Group clients]

Notice to existing Phia Group Clients:

The Phia Group's Client Account Management Department is undertaking an audit of groups for which we provide our services. To help facilitate this audit, they will be conducting a bi-annual survey of any new groups that your organization has obtained.  This will be conducted as part of our New Business Outreach Program.

We want to be sure that we are maximizing our ability to save your plans both time and money by including the corresponding claims in the scheduled extract, along with the regularly scheduled data feed.  It is to everyone's mutual benefit that we facilitate the following recovery efforts for all applicable groups: 
  • Full Subrogation Services - We identify opportunities by analyzing the claims data for incidents with potential Third Party Liability.
  • Case by Case Referrals - Cases are referred to The Phia Group as your organization becomes aware of them.
  
Recovery Case of the Quarter

by Matthew Woods

  

Mr. Staton, our plan member was involved in a multiple vehicle accident on April 20, 2012.  On this day, he was riding his motorcycle on his way to work.  Suddenly, before he knew it, he was struck head on by a car driven by an 89 year old woman.  The accident left him with multiple injuries.

 

The woman that struck Mr. Staton had her car insured through Allstate Insurance.  On the positive side, the auto carrier accepted liability without hesitation and had every intent to cooperate.  On the contrary, their insured only carried $50,000 of bodily injury coverage for this loss, and the medical expenses had soon passed that mark. Our client, paid a total of $36,203.79 for injuries related to this loss.  Mr. Staton also accrued a number of out-of-pocket expenses as well as over $3,000.00 in past due bills from additional medical treatment.  To add insult to injury, Mr. Staton did not carry underinsured motorist coverage on his auto policy through Progressive Insurance.  In addition, he did not possess any medical payments coverage under his insurance umbrella either.  On top of that, compensation for pain/suffering hasn't even been factored in at this point.  To say the least, the member was in a bind. 

 

Allstate Insurance offered their policy limits to Mr. Staton as a means of settling their liability claim.  The issue at hand was now how to get the health insurance reimbursed for their paid claims as well as being compensated personally.  Due to the nature of the file and cost comparison, it was determined by the member not to seek legal representation in this situation.  Mr. Staton knew that it would cost him more to be legally represented by council than to try work something out with his health carrier.

 

Mr. Staton submitted a written request to our client asking that the rights of subrogation for the $36,203.79  be waived.  The request was submitted to respectfully compensate him, personally and financially, for the losses he amassed throughout this ordeal.  With complete understanding of this situation, our client replied respectfully denying the member's offer.  With that being said, this particular Plan had a right to 100% of any settlement issued for this loss.  However, the health carrier was more than willing to find a common ground to aid in the benefit of both parties.  Being that the plan is a self-insured ERISA plan, they simply could not deny their losses in this accident.  They offered the member a 50/50 split of the total settlement in efforts to satisfy both sides of the table.  Unfortunately, Mr. Staton was dissatisfied with this counter offer and wished to stick by his original stance.  At that time, Mr. Staton decided that he would rebut our client with a follow up letter to back up his initial request. 

 

Our client responded to the member with a looser belt.  They offered to accept 1/3 of the total settlement to satisfy the member's request, reassuring him that the offer is simply being made in good conscious.  The member, still dissatisfied with our clients rebuttal, tried to reason with the carrier by submitting another written request for the Plan to accept a total of $2500.00 as reimbursement for the paid claims.  The client reviewed the member's request, and again, respectfully denied.  They again decided to reduce their figure for reimbursement, this time to $10,000.  The member reviewed their offer understanding that they could not completely waive their lien.  He decided to try his luck one last time as a means to have the Plan increase their reduction further.  He requested a final figure of $7500.00 be accepted to satisfy the Plan's reimbursement obligation.  It would seem that the member's persistence paid off as the amount of $7500.00 was accepted by the carrier. 

  

Employee of Quarter -  Regina Cattel

reggy.jammy

Regina Cattel in Montego Bay, Jamaica

  

Regina Cattel has been an employee of The Phia Group since January 2008. She was hired to be a part of our Case Evaluation Department. During her first year at The Phia Group, Regina was able to learn the seemingly limitless variables of what can make a case have "subrogation potential".

 

As a graduate of many of our Phia University classes, she was filled with the knowledge required to excel at her job. She currently is an integral part of our Claim Investigation team.

 

Throughout her Phia career, Regina has been a key figure in organizing the fund raisers for our community work.  We are very proud of her efforts.

 

Regina is a true "concert junkie" and can often be found in the front row of a Justin Timberlake concert near you.  

 

In addition to her love of music Regina also loves to  travel. Regina considers Hawaii and Grand Cayman her two favorite travel destinations. 

 

Regina attended Bridgewater State College where she studied graphic design. 

 

We hope to continue to see Regina grow here with The Phia Group and consider her an important piece to our success as a company.

 

Congratulations Regina on being the Employee of the Quarter!

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