Hand Over The Data! Why Employers Are Fed Up With Payers Hiding Costs

Employers are seeking claims data, but payers are refusing.

Employers are at odds with payers over their cost and claims data.

Claiming that insurers consistently block access to this data, employers are saying it is increasingly difficult or even impossible to understand what they are being charged in their health plans. Despite a federal mandate that restricts health plans from limiting access to this valuable data, employers are still struggling to obtain it from insurers, turning to lawsuits as a last resort.

In 2021 The Consolidated Appropriations Act (H.R. 133) required employer sponsored health plans and health insurance companies to affirm by the end of 2023 that their contracts don’t contain “gag clauses” that would restrict the handover of information about the cost or quality of medical services.

But it hasn’t been that simple.

What’s happening?

As employers begin to use hospital and health plan data to compare prices and create well-structured plans, some questions are rising, and payers aren’t answering. Much of the time, employers and plan sponsors say that insurers are refusing to hand over their claims data, leading to federal investigations.

This dynamic has led to a push from Congress and some states to stiffen the legal requirements to ensure health plans have access to their cost and claims data.

The argument employers, and specifically member benefits directors, are making is that their plans need to access their claims data to check that payments made to medical providers are accurate, which can sometimes far exceed the actual billed amounts.

Some insurers are arguing that they do provide information about their plans, but only when specifically authorized by the state.

According to an article by Bloomberg, Health Care Service Corporation (HCSC) discussed the possibility of allowing a data warehouse to provide the information to employers, but that would be accompanied by a whopping $20,000 price tag. That’s not the answer employers are looking for.

In June of last year Kraft Heinz filed a complaint that Aetna “breached its fiduciary duties and engaged in prohibited transactions” through permitting undisclosed fees and processing medical and dental claims without human review. Aetna never commented on the complaint, and the matter was moved to arbitration.

Do unresolved complaints turn into lawsuits?

In December, labor unions that were contracted with Elevance Health sued the insurer, claiming the giant did not allow employers access to their own claims data and then charged the plans higher rates than what it negotiated with hospitals.

Employers are fed up with paying the higher fees. Studies show that when employers do have access to this data, they are able to significantly reduce their costs.

What does this mean for hospital and health system leaders?

And as we know in healthcare, reducing those benefit costs are important to hospital and health system leaders. As labor costs in general are weighing heavy on CFOs, they are now playing a bigger role in healthcare benefit decisions.

The breadth of information they consider in making health plan design and purchasing decisions has expanded well beyond monthly premiums and cost sharing, and claims data access could play an important part in that decision making.

In fact, a study by NIH that examined employers' access to claims data stated: “Employee health claims data offer a unique opportunity for employers to yield additional savings in the long run through implementation of wellness and other targeted programs and have a lasting, positive impact on their employees.”

As the struggle continues, the payer landscape could see more lawsuits like the Kraft/Aetna case in the future; and maybe even with a hospital or health system. Will the action and complaints from employers be enough to get insurers to loosen their grip on their data?