In today’s rapidly evolving healthcare landscape, self-insured employers face mounting pressure to reduce medical claims costs. As fiduciaries, you also have a legal and ethical responsibility to ensure that your company’s health plan expenses are reasonable and that your plan sponsorship responsibilities align with the financial interests of plan members. Achieving these goals can be challenging, especially when claims processors, such as Third-Party Administrators (TPAs) or Administrative Services Only (ASO) carriers, limit access to your health plan data.
This article clarifies plan sponsors' rights to access and utilize employer-owned health data held by claims processors and offers practical advice on leveraging data-driven technology to comply with relevant healthcare regulations.
Understanding the Gag Clause Prohibition
The Consolidated Appropriations Act of 2021 introduced several significant provisions aimed at enhancing transparency and accountability in healthcare. One key element in this legislation is the Gag Clause Prohibition, which forbids companies from entering into agreements that restrict employers' access to data held by their carrier or TPA. Such restrictions impede employers' ability to conduct an unbiased, independent financial review of their claims payments, a crucial aspect of fiduciary operational oversight.
The Centers for Medicare and Medicaid Services (CMS) issued an FAQ explaining the Gag Clause Prohibition and the risks associated with contracts that contain gag clauses, including potential legal action if employees file complaints with the U.S. Department of Labor. Plan sponsors should verify that their contracts do not include gag clauses before making the required compliance attestations due by the end of each calendar year.
The Fiduciary Duty of ERISA Plan Sponsors
As fiduciaries under the Employee Retirement Income Security Act (ERISA), plan sponsors must act in the interest of plan participants and beneficiaries. Under ERISA, you are obligated to adhere to health plan documents, pay only reasonable plan expenses, and exercise prudence in plan administration.
Accessing medical claims and other important health data is essential for good financial stewardship of your company’s healthcare program. Visibility into these assets empowers you to identify, recover, and prevent unreasonable plan expenses, protecting plan members’ interests and fulfilling your fiduciary duties.
Leveraging Technology for Enhanced Oversight
Many self-insured employers rely on third-party auditors to review medical claims as part of their ERISA compliance strategy. However, these vendors typically limit their reviews to the top 1% of high cost claims, and their findings are often subject to dispute by providers’ medical teams. Advancements in technology, particularly with GenAI and Large Language Models (LLMs), provide powerful new tools to help plan sponsors and their vendors dramatically augment auditing accuracy and scale.
Bluespine, a medical overbilling detection engine, leverages AI to parse and analyze a broad range of data assets, including claims, Summary Plan Documents (SPDs), individual plan contracts, and Machine-Readable Price Transparency Files (MRFs). Using these data sources, Bluespine creates highly-tailored, employer-specific audit rules that can pinpoint overbilling across 100% of claims, regardless of company size. The platform offers more control and visibility into your company’s healthcare expenditures, generating much greater savings than manual audits.
Bluespine: A Tool for Minimizing Fiduciary Risk
For self-insured employers, accessing and utilizing health plan data held by carriers/TPAs is a fiduciary necessity. By understanding and leveraging the provisions of the Consolidated Appropriations Act of 2021, you can ensure you’re fulfilling your company’s legal and ethical obligations. But gaining access to the data is only half of the equation. With the right technology, you can leverage this data to help your company enhance fiduciary operational oversight, reduce medical claims costs, and protect the interests of plan members.
At Bluespine, we are committed to helping self-insured employers navigate these challenges through an AI-powered platform that automates comprehensive financial reviews of medical claims to detect and rectify medical overbilling. While we are not an auditing service, our technology empowers employers to uphold their fiduciary responsibilities.
To learn more about how Bluespine can help your organization gain maximum value from its health plan data assets, contact us today. Let us assist you in harnessing the power of AI to enhance your operational oversight and reduce healthcare expenditures.
Visit our website for more information and resources on optimizing your health plan management.
Start Saving Money Now
