Do Employers Own Their Claims Data? It's Complicated.

This video provides an in-depth exploration of the persistent challenge self-funded employers face in obtaining detailed healthcare claims data from their health insurance carriers. Dr. Eric Bricker begins by establishing the critical need for this data, explaining that employers require it to effectively understand their health plan's performance, implement targeted programs, and strategically structure their plans to improve healthcare access, enhance quality, and ultimately lower costs. He highlights the common resistance from major carriers like Blue Cross, United, Cigna, and Aetna, who often cite proprietary information as a reason to withhold detailed pricing data, likening it to a credit card bill showing only the total amount due without any itemized transactions.

The discussion then shifts to the significant impact of the Consolidated Appropriations Act of 2021 (CAA), which introduced new regulations aimed at increasing transparency in the health insurance industry. Key provisions of the CAA include mandatory disclosure of compensation for brokers and consultants, a requirement for employers to report medication and prescription costs to federal agencies (HHS, DOL, Treasury), and, most notably, the prohibition of "gag clauses." These clauses historically prevented employers and plan members from accessing crucial price and quality data. Despite the CAA's clear intent, carriers have continued to push back, leading to an ongoing dispute over the extent of price disclosure and a current lack of definitive federal clarification.

Dr. Bricker further illustrates the complexities through recent legal battles. He cites the case of Connecticut unions suing Elevance (the parent company of Anthem Blue Cross) for denying access to claims data, alleging a breach of fiduciary duty, though this lawsuit was ultimately dismissed. In contrast, he discusses a plan member on the Johnson & Johnson health plan who sued the company for failing to monitor medication costs, claiming a breach of fiduciary responsibility due to high prescription expenses that could have been significantly lower. This scenario places employers in a difficult position: being sued by their own plan members for high costs while simultaneously being denied the necessary data by carriers to manage those costs. Healthcare attorney Chris Condeluci's advice is presented as a strategic path forward, urging employers to leverage the gag clause prohibition by arguing that carriers' failure to share data forces plan sponsors to breach their ERISA fiduciary duties.

Finally, the video addresses the practical inconsistencies in data access, noting that it varies widely across employers of different sizes, different carriers, and even among different clients of the same carrier. As a practical middle ground for employers facing resistance, Dr. Bricker suggests prioritizing specific data points if full provider-identifying information (like tax IDs or NPIs) is withheld. He advises pushing for patient identifiers (PHI), allowed amounts (the actual negotiated price, not just billed charges), dates of service, and clinical codes (CPT, ICD-10, HCPCS). While carriers often resist sharing provider-specific data to obscure price discrepancies across their networks, obtaining this compromise set of data still enables significant analysis of plan performance, cost drivers, and opportunities for improvement.

Key Takeaways:

• Critical Need for Claims Data: Self-funded employers face a long-standing challenge in obtaining detailed healthcare claims data from health insurance carriers, which is essential for understanding plan performance, improving quality, and lowering costs.
• Consolidated Appropriations Act (CAA) 2021: The CAA introduced regulations requiring broker compensation disclosure, employer reporting of prescription costs to federal agencies, and prohibiting "gag clauses" that restrict access to price and quality data.
• Disputed Gag Clause Prohibition: Despite the CAA's ban on gag clauses, carriers continue to resist full disclosure of pricing data, claiming proprietary information, leading to ongoing disputes and a need for clearer federal guidance.
• ERISA Fiduciary Responsibilities: Employers, as fiduciaries of their health plans, are increasingly vulnerable to lawsuits from plan members alleging breaches of fiduciary duty due to unchecked healthcare costs, particularly for prescription drugs.
• Strategic Legal Argument: Healthcare attorney Chris Condeluci advises employers to argue that carriers' refusal to share claims data effectively forces plan sponsors to breach their ERISA fiduciary duties, providing a strong legal basis for data demands.
• Inconsistent Data Access: The availability of detailed claims data is highly inconsistent, varying significantly across different employers, health insurance carriers, and even among different clients served by the same carrier.
• Leveraging Negotiation Tactics: Employers can employ various strategies to secure data access, including direct conversations, threatening or issuing Requests for Proposals (RFPs) with data-sharing requirements, or pursuing legal action.
• Practical Data Compromise: If carriers refuse to provide provider-specific identifiers (like tax IDs or NPIs), employers should prioritize obtaining patient identifiers (PHI), allowed amounts (negotiated prices, not billed charges), dates of service, and comprehensive clinical codes (CPT, ICD-10, HCPCS).
• Value of Partial Data: Even without provider-specific details, access to patient, financial (allowed amounts), and clinical (codes) data allows employers to conduct substantial analysis of plan performance, identify cost drivers, and implement effective cost management strategies.
• Importance of Prescription Cost Monitoring: The Johnson & Johnson lawsuit highlights the critical importance for employers to actively monitor and manage prescription drug costs within their health plans to fulfill fiduciary obligations and ensure cost-effective care for members.
• Data for Operational Optimization: Detailed claims data is fundamental for employers to gain insights into healthcare utilization patterns, identify opportunities for cost savings, enhance the quality of care provided, and optimize overall health plan design.

Tools/Resources Mentioned:

• Consolidated Appropriations Act of 2021 (CAA): Federal legislation impacting health plan transparency and data access.
• ERISA (Employee Retirement Income Security Act): Federal law governing employee benefit plans, including fiduciary duties.
• Department of Health and Human Services (HHS), Department of Labor (DOL), Department of Treasury: Federal agencies to which employers must report medication and prescription costs.
• CPT codes, ICD-10 codes, HCPCS codes: Standardized medical coding systems used to describe medical procedures, diagnoses, and services.

Key Concepts:

• Self-funded employers: Companies that directly assume the financial risk for providing healthcare benefits to their employees, paying claims as they are incurred.
• Claims data: Comprehensive records of healthcare services received by plan members, including details on diagnoses, procedures, costs, and providers.
• Gag clauses: Contractual provisions used by health insurance networks to prevent the disclosure of healthcare price and quality information to employers and plan members.
• ERISA fiduciary duties: Legal obligations under ERISA that require individuals or entities managing employee benefit plans to act solely in the best interests of plan participants and beneficiaries.
• Allowed amounts vs. Billed charges: Allowed amounts refer to the negotiated payment for a healthcare service after network discounts, while billed charges are the initial, often higher, prices submitted by providers.
• Patient identifiers (PHI): Protected Health Information that can be used to identify an individual, crucial for detailed claims analysis while maintaining privacy.
• Provider identifiers (Tax ID, NPI): Unique numbers used to identify healthcare facilities (Tax ID) and individual healthcare practitioners (National Provider Identifier), often considered proprietary by carriers.

Examples/Case Studies:

• Connecticut Unions vs. Elevance (Anthem Blue Cross): A lawsuit filed by Connecticut unions against Elevance, the parent company of Anthem Blue Cross, for denying access to claims data, which was ultimately dismissed by the court.
• Johnson & Johnson Plan Member Lawsuit: A lawsuit brought by a plan member against the Johnson & Johnson health plan, alleging a breach of fiduciary duty due to the plan's failure to monitor and control high prescription medication costs.