Employers Rights and Obligations to Access Healthcare Plan Data
As many employers know, plan sponsors not only have a legal right to access their plan data, including medical and pharmacy claim data, but, via the Employee Retirement Income Security Act (ERISA), they also have a legal obligation to access that data so they can administer the plan.
For employers, the challenge is and always has been – how do you access the claims data that you have a legal right to so you can satisfy your legal obligations as a plan sponsor?
To be clear, via ERISA, health plans must provide participants with plan information, including information about plan features and funding; enforce fiduciary responsibilities on those who manage and control plan assets; require plans to establish a grievance and appeals process for participants to get benefits from their plans; and give participants the right to sue for benefits and breaches of fiduciary duty.
The problem is, insurance carriers and TPAs often do not provide plan sponsors with their data, claiming that the healthcare claims data contains confidential and proprietary information. Those assertions are a false front and do not trump the plan sponsor’s fiduciary responsibilities to access data and use it in ways that benefit plan members. They do not trump the health plan’s fiduciary responsibilities to those who manage and control plan assets.
How are plan sponsors able to fulfill their legal responsibilities if insurance carriers and TPAs do not provide access to all the data elements necessary to make decisions about their employee health plans? Obtaining this data should be a priority for all employers. It’s your data, let’s get you access to it.
We've built a solution to solve for this data challenge
As a practical matter, obtaining this data isn’t easy. There are daunting privacy and information-security concerns. The potential liabilities are substantial.
The Lockbox helps plan sponsors solve these problems.
The Lockbox platform integrates plan data across all vendors in the entire benefits ecosystem into a single data logistics solution. It gives plan sponsors complete and transparent access to their benefits data. Its uniform data model easily feeds into any business intelligence tool for real-time analysis, visualization, and reporting. As a result, plan sponsors can motivate, measure, and improve member engagement, increase value on investment, hold vendors accountable, and deliver on their benefits plan strategy. The Lockbox enables transparency, competition, and accountability and does so in a HIPAA and SOC II compliant manner. There is no other solution like the Lockbox in the market.
A Recent Lawsuit Illustrates the Issue
In December 2022, Trustees of International Union of Bricklayers and Allied Craftworkers Local 1 Connecticut Health Fund and Trustees of Sheet Metal Workers’ Local No. 40 Health Fund, filed a class-action lawsuit against Elevance Inc. (formerly Anthem). The suit claimed violations of Elevance’s fiduciary responsibilities under ERISA, particularly regarding access to participant claims and reimbursement data. This suit further alleges that Anthem breaches several federal rules enacted to further transparency around healthcare plan costs, including:
- The Transparency in Coverage Rule, which requires plans to publish machine-readable files listing provider rates for covered items and services,
- The Hospital Price Transparency Rule, which requires hospitals to publish payer-specific negotiated rates, and
- The Consolidated Appropriations Act of 2021 (CAA), which prohibits plans from entering into agreements with service providers that offer access to a network of providers if the agreement directly or indirectly restricts the plan from obtaining electronic access to claim and encounter data for all plan participants, sometimes referred to as “gag clauses.”
Let's Improve Vendor Transparency & Accountability
Lawsuits occur when the market fails. Nobody really wins a in a lawsuit except the lawyers.
Abett envisions a world in which plan sponsors have access to the data they have a legal right to, via a product like the Lockbox. Plan sponsors fulfill their obligations and responsibilities in a secure and efficient manner. By partnering with employers and their vendors, we not only aspire to improve how plans operate, but to also enhance the health and experiences of their members. It’s your data, let’s get you access to it.
