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The Book of Russo - From the Desk of the CEO
Well, the fall is definitely upon us! Over in Boston, leaves are falling, changing to majestic landscapes, and the nights are getting cold; but The Phia Group is just heating up. We have so much information to share with you this newsletter from new service offerings to case law to regulatory changes. One of the things I wanted to share with you is the amazing conference I had the privilege to speak at this past weekend in Oklahoma City; the First Free Market Medical (FMMA) Association conference. It is rare that I am overwhelmed with new information, but this forum did the trick. The goal of the Free Market Medical Association is to bring together physicians, surgeons, providers, facilities, and support businesses to provide necessary resources to promote a successful industry. Its focus is to defend the practice of free market medicine without the intervention of government or other third parties.
I urge all of you to consider joining this amazing association as it truly brings innovation to those of us that want to lower the cost of health care and promote self funded employee benefit plans. You can learn more about the FMMA at http://marketmedicine.org/membership-benefits. I am sure that I will be returning next year as I have never been in a room where physicians, hospitals, employers, TPAs, and brokers are all on the same page - to make healthcare transparent and cheaper - amazing! I hope you enjoy the rest of this newsletter. Happy reading!
To read all of this quarter's newsletter, click here.
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Letter from the Editor
Change .... Everything is changing around us. In Baseball, the regular season has given way to the postseason. Summer and the sweltering heat and air conditioning of July & August has become fireplaces, blankets and hot cocoa. Lucky for us in the healthcare industry, change is constant, and we always have reform, compliance, and cost-containment to help keep us warm during the dark, dreary months. Every single day, healthcare costs are on the forefront of our minds, and The Phia Group is there to help drive change. Whether it's a change to your subrogation language, adjustments to your exclusions, or a decision to overhaul the whole system and take on a completely new claims pricing methodology, The Phia Group prides itself on being your partner. Reform is making us all take a look under the hood of our benefit plans, while you are in there, why not find all those areas you've been neglecting?
As the new Editor of The Phia Group's Quarterly Newsletter, I look forward to monitoring the industry and finding interesting happenings to keep you all apprised of. I hope you find this information, educational, useful, and of course, at least somewhat entertaining! Change is everywhere, and you are not alone. Let's get through it together!
To read all of this quarter's newsletter, click here.
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Stop the Presses
The Phia Group, LLC Announces The Release of its New "Phia Document Management" (PDM) Software
A first of its kind plan document drafting solution, Phia Document Management (PDM) was created to satisfy the needs of the entire health plan industry. PDM allows for instant population of an online template featuring The Phia Group's critically acclaimed plan language, while still ensuring customization to meet each client's unique needs.
For years, The Phia Group's clients have asked them to not only draft plan documents, but also review and revise documents prepared by others; including vendors' online templates and in-house efforts. The intent of such secondary review has always been to ensure that these plan documents are not only compliant, but forward thinking in areas of cost containment and the defense of plan rights.
To read all of this quarter's "Stop the Presses," click here.
The Phia Group, LLC Announced Exclusive U.S. Relationship with Jason Davis
The Phia Group LLC, one of the health benefit industry's leading cost-containment service providers, announces that we have agreed to a U.S. exclusive consulting agreement with Jason C. Davis. Mr. Davis will assist The Phia Group with sales and product development.
"We have grown so quickly in the last few years; we want to invest in both our existing products as well as business development infrastructure; with an eye toward future offerings," stated Adam Russo, CEO of The Phia Group. "Jason is here to help us reach the next level."
To read all of this quarter's "Stop the Presses," click here
Phia Takes the Lead !!!
The Phia Group takes pride in our position in the industry as not only your partner, but as one your most vehement advocates. We get involved in the issues plaguing our clients on a global scale so that we can foster change for all of our clients, while we are helping them each individually with their day-to-day issues. It should be of no surprise, then, that members of The Phia Group's team are taking position in some of the most influential organizations in the industry. Check out the latest appointments.
Adam Russo - SIIA Board of Directors
Ron Peck
TPAAA - Board of Directors
SIIA - Government Relations Committee
Jason Davis - SIIA Healthcare Committee
Whether it's in the back room of your operation, or on the front lines of your disputes, The Phia Group has your back!
For more information about The Phia Group, LLC, please contact Michael Branco at 781-535-5618 or via email at mbranco@phiagroup.com.
To read all of this quarter's "Stop the Presses," click here.
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The Stacks
Texas C.P.R.C. c. 140: The New Standard for Subrogation Rights
Texas health plans seeking reimbursement via subrogation, are now forced to deal with new guidelines. C.P.R.C. c. 140, governing subrogation, went into effect January 1, 2014; enacting H.B. 1869, which was passed months prior; but the finer points are still being explored.
Who Does This Affect & What's Changed & What Should You Do?
To read all of this quarter's "The Stacks," click here.
ERISA-Man ... Not Coming to the Rescue
By Adam Russo, Esq.
In the continuing celebration of ERISA's 40th birthday, I wanted to focus on the power of ERISA preemption for private self-funded employee benefit plans, the avenues that employers use to lose ERISA protection, and then look to a mythical "ERISA-Man" to find ways to save the day. The bottom line is that ERISA cannot save you from yourself. This article will outline the ERISA language within a typical plan document and how plans give away these rights when they sign agreements outside the protection of the plan document. Finally, we will cover many cases where state and federal laws collide, most of which end with the ERISA plan being on the losing end of things.
To see excerpts of this article and get information on how to subscribe to the publication visit us at "The Stacks," click here.
A Prescription for Savings
By Ron E. Peck, Esq.
The cost of healthcare in the United States is, by all accounts, excessive. To date, apparent efforts to "contain costs" have in fact focused more on "who" is paying than "how much" is being paid. Reasons for out-of-control prices range from the costs faced by medical service providers in securing malpractice insurance and defending against lawsuits, to inefficiencies on the part of payers and payees alike. While the truth is almost certainly a mix of these, including known and heretofore unknown causes, the fact remains that the actual price paid by consumers of healthcare, their benefit plans, and the employers that sponsor them, is too high to remain financially viable.
In an effort to meet both the requirements of the Patient Protection and Affordable Care Act ("PPACA"), as well as offer the most robust coverage for the lowest cost, health plan sponsors and administrators alike, are examining cost containment options not considered in the past. A new focus on things like coordination of benefits with other insurance plans (such as workers' compensation and auto-insurance), as well as subrogation and claims recovery from liable third parties, has garnered more attention. Likewise, the use of fee schedules to cap amounts payable, the use of data to setup reference based pricing mechanisms, enhance narrow networks, execute direct provider arrangements, or even implement a cost-plus mechanism in lieu of networks, as well as wraps and carve-outs, is gaining popularity.
One area of particular concern for so many plan administrators, however, and the topic we address here is the issue of prescription drugs.
To read all of this quarter's "The Stacks," click here.
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3rd Quarter Case Study
Claims Recovery Services - Stop-Loss Claims Analysis, Subrogation and Appeals
This case involved a motor vehicle accident where a state government official's daughter was a passenger in a car, whose driver was found to be at fault for a serious accident. Both the passenger and driver died due to the severity of their injuries (over $600,000 in related claims paid).
The passenger's benefit plan was self-funded and its TPA had an in-house subrogation department. They conducted research and spoke with several attorneys until they came to the conclusion that due to applicable State law, no recovery could be made.
In 2008, the stop-loss carrier, having paid over $500,000 in claims relating to this incident, forwarded the matter to The Phia Group's attention. The stop-loss carrier also suggested that the TPA have The Phia Group represent its interests as well. Within six months The Phia Group was able to secure a recover on behalf of the stop-loss carrier and the benefit plan.
Plan Exposure: $700,000
Phia Intervention Saved: $400,000
To read all of this newsletter and other industry news, please visit our blog.
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Get to Know... The Employee of the Quarter!
Amanda Grogan began working for The Phia Group in 2007. She began her career at Phia as a part-time employee in our file room and has been working in our Case Evaluation department for several years. Because of her dedication and skill set she has recently moved into our Claim Investigation unit. She now spends her days investigating and uncovering all available paths to recovery for The Phia Group's clients.
Her managers and other employees comment that "Her prior experience in CE has proven to be a major contributor in her ability to identify cases with and without recovery potential in the CI Department. She is a no nonsense employee, and stays focused on the task at hand throughout the day." And "Amanda has absolutely blossomed in her new role. It is clear from her work that she really thinks about the most efficient way to get the best information and takes it."
To read all of our quarterly newsletter, click here.
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Phia News
Phia Gives Back
As is our tradition for the past several years, The Phia Group partners with a local charity where we invest our time, money and support to ensure a successful program. We not only make monetary donations, but also collect needed items and have a company-wide day off so that our employees can volunteer their time and efforts to the cause. This year we have chosen to work with Jewish Family Service of Metrowest (JFS).
JFS provides vital social, health, and community services to alleviate suffering, enhance lives, and support people in need. The program that The Phia Group is involved with is the Reducing Achievement Gaps program (RAG). RAG is a comprehensive system of interventions to address the academic and social needs of poor children of immigrant families in Framingham, Massachusetts, located 30 miles from our office in Braintree.
RAG is based at the 550 student Woodrow Wilson Elementary School, located in Framingham's poorest and highest-crime neighborhood. RAG gives Framingham's most economically and educationally challenged school age children and their families the help and resources they need to succeed in school and in life. Please click on the link to this video to learn more:
https://www.youtube.com/watch?v=p4eowvE4kLw
Summer Event: In July, The Phia Group spent a day at Woodrow Wilson Elementary School for our annual volunteer day. We spent the day helping the school with various tasks such as: planting and expanding the school vegetable garden, fixing the concrete school yard by repainting lines, a US map, and other recess games, enhancing the playground by purchasing and installing additional equipment, and interior painting of classrooms and the gym.
We would love to be able to provide the students of Woodrow Wilson Elementary School with everything they need, and would greatly appreciate any donation from you. If you would like to make a donation you may do so by visiting: http://www.jfsmw.org /JFS_giving.html action_donateReport=1&partner=networkforgood&ein=04-2730898, or by mailing a check made payable to JFS of Metrowest to The Law Offices of Russo & Minchoff, 123 Boston St., 1st Floor, Boston, MA 02125
Phia in the Industry
In Case You Missed It ...
7/30 - EBMS - Employer's View: Cost Containment
8/28 - Sun Life - Self Funding ... The Future
9/10 - Pequot - "Curiosity Saved the Healthcare Budget"
9/16 - Sun Life - Self Funding ... The Future
9/17 - Sun Life - Self Funding ... The Future
9/25 - CDB - "Affordable Care Act: What's in the cards?"
9/26 - Free Market Medical Association - The Perfect Self Funded Plan
Coming to a Conference Hall Near You!
10/06 - SIIA - Best Practices & Cautionary Tales of Reference Based Pricing for TPAs & Employers
10/15 - SPBA -Controlling the Hidden High Costs of Drugs Through Your Plan Design
10/23 - HealthFirst - The Perfect Self-Funded Plan
10/28 - Delaware Captive Insurance Association - "Best In Class Self-Insured Group Health Plans - What Captive Insurance Professionals Needs to Know!
11/11 - NASP - Reform & Recovery - Not the Type of R&R You Needed!
New Faces at Phia
Angela Grande - Legal
Lisa Tamulynas - Recovery
Talise Rivers - Case Support
Joseph Huddleston - Case Support
Moving On Up!!!
Jason Kemp advanced to a CRS IV (specializing in WC)
Amanda Grogan transitioned from CE to CI
Leiana Turner transitioned from CI to a CRS Assistant
Naviana to CS Auditor & Trainer
Kathy Gatanti to Team Leader
Shannon Burns - Info Tier to Case Tier
Derriek Mish - Info Tier to Case Tier
Lyneka Hubbert - CSR to Info Tier
Jessica Goscik - Promoted to Customer Services Department
Additions to the Phamily ...
Mattie Sesin, a Case Manager with The Phia Group, welcomed a new addition to her family ... Say Hello to ...
Kaitlyn Francis Sesin
To read the entire 3rd Quarter Newsletter, click here.
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