The Phia Group Hosts Roundtable for TPAs and Stop Loss Carriers — New Language Drafted for the Carriers’ Policies Regarding IRO Decisions
MyHealthGuide Source: The Phia Group, Inc., 6/23/2011, www.phiagroup.com
The Phia Group, LLC held an industry event for certain third party administrators and stop loss carriers using a “roundtable” open forum format, appropriately dubbed “An Industry United.” This event was led by moderators Ernie Clevenger, Adam V. Russo, and Ron E. Peck. The true stars of the event, however, were the attendees.Mike Ferguson of SIIA discussed insights into the future of the self-funded industry from a legislative standpoint. Day 1 of discussions tackled the impact of PPACA on the self funded industry and marketing the benefits of self funding. Attendees expressed their concerns, focusing on external appeal and IRO requirements. The issue directly zoned in on whether stop loss carriers would be willing to reimburse claims overturned based on an IRO decision after the policy deadline expires. After hours of debate, The Phia Group was able to draft and propose new language for the carriers’ policies which directly addressed both sides of the argument.
| Draft New Language for the Carriers’ Policies Regarding IRO Decisions |
| It is the intent of the [Stop Loss] Company to:
Accept as eligible, claims paid in accordance with the Policy Holder’s Plan Document as revised to meet the requirements of PPACA; Not exclude any claims determined to be the responsibility of the Policy Holder by an IRO in accordance with PPACA; and Honor Policy Holder requests for an extension of the Company’s stop loss policy deadline for any claim and/or incidence of claims that exceeds the deductible, has not been paid, but is later the subject of an Independent Medical Review by an IRO in accordance with PPACA. |
Massachusetts Future Healthcare Reform?
When reform was discussed, we found that Massachusetts was mentioned as an example of what the nation might look like post-implementation of a health plan exchange. In the State of Massachusetts the “Mass Connector” or “Commonwealth Care,” allows employees to access privately funded coverage, via a government program, in lieu of traditional employer based benefits. To participate in the program, carriers must include certain mandated benefits in their policies. To keep these expensive policies affordable, ceilings were placed on how much the carriers can charge, subsidies are provided by the State, and taxes are levied against employers and individuals. Unfortunately, many health care service providers refuse to treat connector plan participants, as they dread dealing with the red-tape.
It was then agreed that the industry cannot treat Massachusetts as a crystal ball, and thereby gaze into a future where there exists a national exchange, for many reasons. The most obvious of such reasons is the difference in Massachusetts’ economy versus the national economy, sophistication and education of consumers, availability of health care service providers, and most importantly — the Massachusetts plan does not include a “public option.”
| Attendee Comments |
| “Terrific meeting and great event! It was reminiscent of the first several SPBA meetings that we had 30 something TPAs and no formal presentations and round table discussions like yours. I can’t tell you how much we all learned back then,” said Rick Raup, Business Administrators & Consultants. |
| “Thank you for the great hospitality and for an excellent, informative gathering. The Phia Group is an asset to our industry, ” said Laurie Burke, Verity National Group, Inc. |
| “Thanks for hosting the conference. It was a good event and we brought back a lot of good information. We need to figure out how to prevent providers from being able to appeal under the external appeals and that will reduce the appeals and the client’s exposure greatly, “ said Cheryl Williams Khoury, Affordable Benefit Administrators. |
| “I just wanted to take the time to thank The Phia Group for this past roundtable forum. I enjoyed the insight from The Phia Group team and am really excited that The Phia Group has taken such an interest in Self Funding and its issues. For too long we have downplayed what made TPAs a great alternative to insurance companies. I now know I have expertise in this industry that I can rely on (Phia) when I am facing the myriad of issues we have now, day to day. I know you have my back covered guiding me where I need to go in unchartered territory, ” said Gina Murphy, CWI Benefits |
Brokers’ and Legislators’ Knowledge of Self-Funding Urged
The Phia Group also discussed an effort to educate legislators and brokers alike regarding the benefits of self funding and the cost containment options available through self funding; working together to create an effective mechanism for marketing self funding in a way that is unique.
Attendees expressed overall dissatisfaction with the current broker/TPA relationship, but also acknowledged this is a broker-driven industry, and brokers need to be better educated on self funding. The need for transparent broker fees was discussed as well. Many, however, countered by advising that while fee transparency is important, it is also important that we explain self funding to brokers, work harder to market directly to employers, and prepare a simple, easy to understand “package” that brokers can use to educate themselves.
PPOs Causing Frustration
Many of the roundtable attendees came almost exclusively to discuss the industry’s aggravation over excessive charges, PPOs, and their desire to find something to replace them. Between suggestions that provider rights to appeal should be limited, assignment of benefits be revocable, and payable amounts be explicitly set forth in writing, many ideas regarding plan documents and provisions meant to deal with excessive charges and abusive network arrangements were shared. The Phia Group vowed to continue to develop legal arguments to counter abuses such as these, and draft plan language which will allow said arguments to be made, as well as notify service providers of the Plan’s stance preemptively.
Three Working Committees
The Phia Group has expressed a desire that roundtable members continue to communicate with one another, to share their strategies and create what we set out to accomplish, An Industry United.
To accomplish this, The Phia Group has developed 3 Phia Group Working Committees, dedicated to open discussion, sharing ideas and providing solutions for our industries most pressing issues. Currently, The Phia Group is hosting the following committee groups:
- “Self-funding Promotion” - It will be the task of this committee to discuss why self funding is a viable option and how to promote the differences and advantages of self funding, in a way that continuously grows our businesses and promotes greater client retention.
- “TPA & Stop-Loss United” - Resolving the conflicts that are part of age-old discussions between the TPAs, Plans, & Stop Loss is something that will be the task of this group.
- “PPO & Provider Conflicts” - This group will discuss the industry’s most pressing topic of provider overcharges, balance billing, as well as PPO networks and their potential replacements. These are turbulent times for networks with legal issues such as the State of California, ex rel Rockville Recovery Associates, Ltd. v. Multiplan, Inc., et al., in which Multiplan is facing accusations of fraud, due to its enforcement of relatively standard network contract language.
About The Phia Group
The Phia Groups CEO, Adam V. Russo, began working in the self-insured industry while in college. During this period, he obtained a part-time position working at a subrogation firm representing self insured employee benefit plans and TPAs. He continued his learning experience while in law school when he became Director of Sales at the same subrogation firm, meeting with TPAs from across the country. After graduating from law school and obtaining his masters degree in finance, Adam discussed the opportunity to create an innovative cost containment company representing the health insurance industry with his best friend from college, Mike Branco. Mike came from a financial sales background so the two of them figured they had what it took to make this opportunity last. What has developed over the past 10 years is beyond what either of them could have envisioned. Contact Andrew Milesky at 781-535-5636, amilesky@phiagroup.com and visit www.phiagroup.com.
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