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The Phia Group
The Phia Group, LLC

October 3, 2014
Quarterly Newsletter
Fourth Quarter 2014
In This Issue
The Book of Russo - From the Desk of the CEO

 

I'd like to start by thanking all of you that have chosen The Phia Group as your trusted partner.  I know very well that other options are available to you, and we are inspired and thankful everyday that you place your trust in us.  I have always, and will continue to promise, that our team of recovery specialists, plan drafters, paralegals, lawyers, and support staff will do everything in our power to maximize the benefits while lowering the cost of your health benefit programs!

 

We here at The Phia Group plan on being involved members of this industry for the long haul; and as such, with an eye toward the future, we are always looking for new ways to benefit you and your clients.  When you grow, we grow; when you flourish, so do we.  Our goal is to help you succeed.

 

We want to be your "one-stop-shop" for any and all issues relating to employee health plans and benefit programs.  We want to lower costs, tackle claims, recoup funds that belong to your customers, and redesign your benefit plans to ensure every contingency is considered.  The Phia Group's many products emerge from three general service types:

  • Consulting Services - Learn With Us... Confront the issues that impact our industry by coordinating relationships, providing guidance, and addressing conflicts that threaten plan operations and viability.
  • Plan Drafting Services - Plan With Us...Set the Industry Standard for Plan Language" by combining cutting edge technology, forward thinking creativity, and a client-centric customizable approach.
  • Subrogation & Recovery Services - Save With Us... Offer flexible service options driven by client needs , innovative methods to identify more opportunities and master applicable laws, yielding results unmatched by anyone else.

Regardless of the service, when it comes to The Phia Group and the competition, we dare you to compare!

 

I am confident that 2015 will be an exciting year, and I again want to thank you for supporting The Phia Group.  If you would like to discuss how we can better serve you, or you just want to talk about the latest issues impacting our industry, please let me know.  Happy reading!

 

 

To read all of this quarter's newsletter, click here.

 

Letter from the Editor
 

Much like everywhere else in the country, Boston has been dealing with sub-zero temperatures; lucky for us at The Phia Group, though, we don't have to wait long for things to heat up in the healthcare cost containment industry.


 
With each year that passes, healthcare reform brings about more rules, regulations, and of course, mandates!  In 2015, we will finally see the delayed employer mandate in action.  Almost a year removed from the individual mandate and insurance exchange roll outs, we'll finally see which projections regarding the impact of healthcare reform on health insurance premiums will come to light.  One thing is certain, if we start to see the exchanges failing, expect to see the anti-ERISA actions start to re-emerge. 

 

You see, attacks on ERISA, and specifically pre-emption, have been a part of the game for a long time.  We used to see it primarily in subrogation, but since healthcare reform we've seen the DOL make statements and take stances in opposition of pre-emption.  Whether in Vermont, for example, where the DOL joined an amicus brief in support of a law that would impose reporting requirements on self-funded plans in the state, or, Michigan where our friends over at SIAA are looking to the Supreme Court of the United States to overturn the 6th Circuit's decision supporting a tax levied on administrators; ERISA seems to be a target of many.  If this isn't enough to keep you interested, let's not forget how those state legislators have been trying to regulate self-funded plans by imposing laws regulating stop loss;  several states have already done so, how many more will follow suit?

 

If we sit back, those state regulators will certainly impose their will; so it's up to us to keep pushing back for the rights of our clients and benefit plans to do what they have shown time and again they can do more effectively than any government - that is - provide comprehensive, cost effective benefit plans to their employees. 

 

Thanks for joining us this month - we look forward to your feedback on the issues you're facing every single day - it helps us grow, it makes us stronger, it makes us better at what we do ... The Phia Group is listening, and we are here for you!!!

 

 

To read all of this quarter's newsletter, click here. 

Stop the Presses 

 

 

The Phia Group, LLC Announces The Release of its New Service - "Implant Cost Pro" Has Arrived!

 

Even the most diligent administrator feels powerless in the face of excessive implant costs, finding it nearly impossible to negotiate claims with providers, or apply reasonable and appropriate pricing.  Securing provider invoices and reliable, accurate cost data for surgical implants has not been possible . . . until now.

 

In keeping with its commitment to Empowering Plans™, The Phia Group is pleased to introduce Implant Cost Pro,a comprehensive program that combines targeted implant data, industry expertise, and negotiation by attorneys.  Implant Cost Pro clients secure the best savings on high-dollar implant claims. 

  • The Data: Many providers negotiate rates with implant suppliers, using comparative data when making their purchases.  The Phia Group taps into this data and uses it to define and agree upon equitable, market-based prices for implants. Using the most accurate data available,The Phia Group places payers on a level playing field with the providers, maximizing savings.
  • The Negotiators: A cost containment program is only as good as the people executing it.  The Phia Group's utilization of resourceful attorneys, familiar with the intricacies of this industry as well as the targeted data, creates unmatched results.  The Phia Group's legal expertise combines with objective cost data, yielding enforceable savings.     
  • The Phia Group Difference:
    • Industry Tested Plan Language and Contract Expertise
    • Accurate Claim Cost Assessments
    • Efficient Negotiations Performed By Industry Leading Attorneys
    • Signed Provider Agreements To Prevent Balance Billing

 

WITH COMPREHENSIVE DATA AND LEGAL ACUMEN, THE PHIA GROUP IS EMPOWERING PLANS™

 

To learn more about "Implant Cost Pro", contact The Phia Group's Ron E. Peck at 781-535-5617 or rpeck@phiagroup.com.

  


 

 

 

 

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SBCs - Revamped Services & Pricing Structure

 

On February 14, 2012, HHS, DOL and IRS (the "Departments") published the final rules regarding the summary of benefits and coverage ("SBC"). The regulations provided that all group health plans and health insurance issuers offering group health insurance coverage must provide applicants, enrollees, and policyholders or certificate holders with an accurate SBC. The SBC must be drafted in a manner consistent with the template and instructions provided by the Department of Labor.

 

Since issuance of the SBC regulations, there have been minimal changes to the SBC template format. The Departments intended to add additional coverage examples along with a minimum value statement and a minimum essential coverage statement to the SBC format for the 2014 plan years. However, the addition of the two statements only was approved.

 

Now after three years of minimal changes to the SBC format, the Departments are considering adding coverage examples beyond diabetes and maternity care.  If approved, this change can be anticipated for the 2016 plan years. Many payers struggle now with providing two coverage examples, so adding a third example (or more) would require additional calculations and quality assurance given the calculation complexities involved.

 

In addition, there is a possibility that the SBC format could change for the 2016 plan year. The Departments received feedback that the current eight-page template does not work very well with account-based plans, employer-assistance plans (EAPs) or prescription-only plans. Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs) need further explanation of their impact on participant cost-sharing. The Departments are considering how to accommodate these plans or perhaps provide sponsors with guidance on how to address these complexities.

 

The proposed rule should not come as a surprise. The Phia Group makes sure to notify our customers of any upcoming changes and accommodates our services to the new laws and regulations. Therefore, the Phia Group has extended the SBC services to include the following:

 

*      SBC Drafting

*      Existing SBC Review & Revision

*      SBC Template Modification

*      Coverage Example Calculation

*      Minimum Value Calculation

*      Format & Verbiage Compliance Analysis

*      Benefit Listing Compliance

*      Separate Document Detailing Issues & Suggestions for Improvement

 

With imminent change, payers should recognize that SBCs are a real business challenge and take a proactive approach to avoid the last-minute scramble. While safe harbors have protected payers and employers for three years, there is no guarantee how long they will last. Good faith efforts may no longer be good enough. The Phia Group will make sure the SBC is compliant with the new rules, when requested!


 


 

On the Road Again ... 2015 Upcoming Presentations in the 1st Quarter

  • February 17th - TABA - College of Knowledge   - Austin, TX
  • February 19th - Caprock HealthCare Forum - SIIA's Self-Insured Health Plan Executive Forum

To read all of this quarter's Newsletter, click here.


From the Blogosphere  

 

Affordable Care Care Implementation FAQs  http://passionforsubro.com/faqs-about-affordable-care-act-implementation-part-xxi/

 

Source:  http://www.dol.gov/ebsa/faqs/faq-aca21.html

 

Court Comes Down on Children's Hospital of Central California  http://passionforsubro.com/supreme-court-of-california-case-notification-for-childrens-hospital-central-california-v-blue-cross-of-california/

 

Source: http://scholar.google.com/scholar_case?case=7674881407863557644&q=children%27s+hospital+central+california+v.+blue+cross+of+california&hl=en&as_sdt=40000006&as_vis=1

 

$37 Million Overbilling Settlement http://passionforsubro.com/dignity-health-to-pay-37-million-to-settle-overbilling-claims/



 

Benefits in 2015 - What Employers Needs to Know http://passionforsubro.com/health-care-benefits-in-2015-what-employers-need-to-know/


 
Source: http://ebn.benefitnews.com/insurance-industry-news/?utm_campaign=insurance%2520newscast%2520daily-dec%25208%25202014&utm_medium=email&utm_source=newsletter&ET=broadcasting%253Ae3461524%253Aa%253A&st=email

 


 
Vermont Giving Up On Single Payer Health System http://passionforsubro.com/vermonts-giving-up-on-single-payer-health-care-over-ballooning-costs/









SIAA Steps Up ... Again!!!  http://passionforsubro.com/association-positioned-to-protect-self-insurance-marketplace-once-again/

 

To read all of this quarter's newsletter, click here.

 

The Stacks  

 

Stay Ahead or Fall Behind

by Ron E. Peck, Esq.

Sr. Vice President & General Counsel

 

Status quo is no longer adequate for the self-funded health benefits industry.  The issue is that, while we all know "new" methods to achieve traditional goals (claim processing, payment, provider relations, claim recoupment, cost containment, etc.) is the endgame, no one is certain who is responsible to invent and implement said processes.  Our industry has for too long focused on costs and revenue.  While money is certainly one factor to consider, the other is risk and the value of removing risk from others.  Peace of mind is as valuable as gold and silver to some.  So, while self-funding often results in cost savings, it also comes with risk; and thus the "savings" we create may not be enough to sway some in our direction.  In other words, the benefits of self-funding need to outweigh the risk.  For some, that risk is unbearable, and thus these "risk averse" employers were willing to pay more over time via premium, to avoid risk; thereby securing fully insured policies.

 

The law has done some work for us.  With the advent of The Patient Protection and Affordable Care Act ("PPACA"), commonly called the Affordable Care Act ("ACA") or "ObamaCare," such fully funded insurance became more expensive; so much so that employers who had in the past been willing to pay a little extra (to avoid the risk that comes with self-funding) could no longer afford to fully insure. 

 

To read the rest of this entry click here.


 

Sick Employees:  A No Exchange Policy ... by Jon Jablon, Esq.

 

 

Since the advent of health insurance exchanges - in some states, created by the ACA, and in others, perpetuated by it - groups have been looking for ways to use the exchanges to their advantages, without actually utilizing the exchanges. Employer groups have been searching for ways to sponsor self-funded health plans, independent of the exchanges, but to still retain the option to move high-risk or high-cost individuals off of the health plan to ensure the plan's continued viability.

 

In the view of many employers, the exchanges are a perfect alternative to coverage under the employer's self-funded health plan; if the high-cost or high-risk employee can get superior coverage in an exchange program, many employers have been willing to foot the bill for the exchange premiums because that additional monthly cost is calculated to be far less than the cost to pay the individual's claims under the employer's health plan.

 

 

To read the rest of this entry click here.

 

4th Quarter Case Study

                           Implant Cost Pro

 

A self-funded benefit plan, which had historically secured a 10% discount with an ambulatory surgical center for services involving implants, advanced a $91,000 implant claim to The Phia Group.  Utilizing the Implant Cost Pro service, leveraging cost data and innovative arguments, The Phia Group ultimately secured a negotiated payment of only $22,000; a net 76% or $69,000 in savings.

 

 

To read all of this newsletter and other industry news, please visit our blog.

 

Get to Know... The Employee of the Quarter!

Jamie Calder began working with The Phia Group in 2007 shortly after graduating from Bridgewater State College in 2007.  She started at the bottom tier of Claim Recovery Specialists and spent years learning about claims recovery, applicable law and negotiation.  Now, Jamie is much closer to the top of totem pole as  a Senior Claims Recovery Specialist who is routinely among the best recovery professionals at the organization with a track record for being at the top of rankings in amounts recovered.  As if that wasn't enough, in 2012 she received a paralegal certificate. 
 
Jamie enjoys spending her free time with family, friends & her dog, Bentley, that is, when is she is not busy planning her upcoming wedding in April 2015!

To read all of our quarterly newsletter, click here.

Get to Know... The Employee of the Year!

Katie Dever 
received a Bachelor's Degree in Psychology from Framingham State University in 2006.  After college, she worked for a stock transfer company handling transfers and sales of high dollar shares.  Katie was with that company for about a year when, one of her childhood friends and an employee at The Phia Group suggested she put her name into the fold for a new position.  The rest is history!  
 
Katie joined the team in 2007 as a Claim Recovery Specialist and spent several years handling recovery cases, learning the industry and the business, all leading her to where Katie sits in her current role as the recovery department's Claim Recovery Liaison.  In 2012, she received a paralegal certificate and in addition to aside to monitoring several of the most complicated cases with matters involving stop loss, Katie monitors compliance of departmental procedures and ensures all new and existing employees within the recovery department are appropriately trained.
 
Katie loves animals, the beach and road trips but above all, she enjoys doing whatever she can to make her friends and family laugh!

 

To read all of our quarterly newsletter, click here.

Phia News

 

New Faces at Phia

  • Joseph Huddleston - Claims Support
  • Alex Theberge - Office Management Assistant
 

Movers & Shakers!!!!

  • Christopher M. Aguiar  - Now licensed to practice law
  • Sean N. Donnelly - Now licensed to practice law
  • Jen Marsh - Customer Service Manager
  • Christine Sands - Team Leader, Claims & Case Support
  • Ashley Schramm - Advanced to CRS IV and now handles worker's compensation cases
  • Jason Kemp - Transition to CRS IV handling Bodily Injury Cases
  • Danielle Bates - Transitioned from Assistant to Case Investigator
  • Amanda Grogan - Advanced to Claims Recovery Specialist II
  • Nick Murphy - Advanced to Manager, Claim Analysis
  • Mike Mears - Advanced to Senior Claims Analyst
  • Jason Thibodeaux - Advanced to Senior Claims Analyst
  • Todd Geiger - Joined Claims Analysis as a Senior Claim Auditor
  • Lisa Tamulynas - Moved from Recovery Department to Phia Group Consulting
  • Tumi Gugushe - Transition to Legal Assistant

 

Phia Gives Back in 2014


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    

 

Well ... Christmas came early for the great kids of JFS ...


 

 

Salvation Army Angel tree


 


 

 

The 2015 Charity is ...Susan J. Komen of Massachusettes - The Komen Promise

 

The Komen Promise- To save lives and end breast cancer forever by empowering people, ensuring quality care, and energizing science to find the cures.

 

For more information visit  www.komenmass.org/site/c.6oIEJTPxGcISF/b.7453505/k.BDD2/Home.htm

 

Passion Personified - Phia Celebrates the Holidays .... 

 

 


 

 

 

Additions to the Phamily ...

 

Danasha Welcomes Dariyah 

 

Elizabeth Wecomes Ryliegh

 

 

 To read the entire 4th Quarter Newsletter, click here.

The Phia Group, LLC | 781-535-5600 | www.phiagroup.com
163 Bay State Drive
Braintree, MA 02184

Copyright 2014. All Rights Reserved.