This is interesting. The Phia Group is a law firm that works with Plan Sponsors in a number of ways. You may be a client of theirs but dont know it. The following deals with balance billing issues and how Phia defends the Plan Sponsor and how providers and their attorneys are using the Assignment of Benefits to their advantage (or at least they think they are).
by Ron E. Peck, Esq.
Multiple clients of The Phia Group have recently been receiving unusual letters from law firms claiming to represent the plan participant, appealing plan decisions to limit payable amounts or deny claims outright.
At first glance, our clients read the letter to mean that the plan participant retained counsel, and immediately begin devising means to educate the plan participant regarding why less than 100% of the charged amount was paid to the hospital or other healthcare provider. It is only after further examination, however, that they notice the provider has been carbon-copied (“cc’ed”) on the letter. Further consideration of the text itself reveals that the attorney is demanding not that the participant’s rights be protected, but rather, that the provider be paid additional funds.
This all leads to a revelation – the attorney represents the provider in fact, if not in name. How, our clients wonder, can an attorney claim to represent the participant, while championing the rights of the provider? The answer is easy to appreciate, once revealed by our team of experts. The providers view themselves, in these cases, as the plan participant themselves. Upon receiving an assignment of benefits from the original plan member, the provider thereby acts as if they have “stepped into the shoes” of the plan participant, and have thus become the plan beneficiary. They feel that, from that moment of assignment, they – the provider and the patient – speak with one voice.
Initially, this new strategy being utilized by providers to obtain additional funds may confuse and confound Phia Group clients; but fear not! The Phia Group has devised numerous methods to enforce plan decisions, even in the face of a patient/provider union.
We utilize all arguments – from enforcement of deadlines, to treating assignment as payment. In the end, once a plan administrator (with our help) responds in writing, enforcing the terms of the plan document, rationalizing the claims payment decision, arguing accord and satisfaction, and most importantly – strictly enforcing the appeal rules – the provider’s attorney recognizes the Phia Group client as difficult prey.
Indeed, while the provider and their attorney view assignment of benefits as a convenient method to appeal in the name of the participant, we show them that assignment is a double edged sword – and introduce them to the limitations that apply to both the participant, and their assignee. If this or similar issues are arriving in your inbox, please contact The Phia Group’s consulting team without delay.
