Compliance Stuff

Many employers are surprised to discover that sponsoring a company health plan can trigger full HIPAA compliance obligations. Even if you are not a hospital or insurance company, y our self-funded health plan may qualify as a “covered entity” under the Health Insurance Portability and Accountability Act . That can create potential legal exposure for both you, as the employer, and for your Third Party Administrator. What is a self-funded health plan? In a self-funded health plan, the employer takes on the financial risk of paying employee medical claims directly, rather than paying fixed premiums to an insurance carrier . Funds typically come from a dedicated trust or general company assets, with claims paid as they arise. Employers often choose this model for greater control over benefits design, potential cost savings (especially for larger groups), and better access to claims data for wellness initiatives. Key HIPAA trigger : Under federal rules , a group health plan, including self-...

A recent federal district court decision highlights a little known but significant risk faced by employers with welfare benefit plans that rely on medical provider and facility networks supplied by insurance carriers or third-party administrators (TPAs). In  Orrison v. Mayo Clinic , the US District Court for the District of Minnesota held that an employee adequately stated a claim against the employer plan administrator for maintaining an inaccurate database of medical providers. The September 19 decision means employer plan administrators may face possible liability in relying on the provider networks and related directories offered by insurance carriers and TPAs. What do you need to know about this decision, and what questions should you ask to monitor your plan’s network? The Facts In the  Mayo Clinic  case , an employee used an online search tool maintained by the TPA to find an available “in-network” mental health provider for her son. She alleged that the online too...

A federal appeals court just illustrated the importance of an employer’s duty to monitor service providers that assist with the administration of employee welfare benefit plans. In the May 21 decision of  Tiara Yachts v. Blue Cross Blue Shield of Michigan , the 6th Circuit Court of Appeals held that the employer adequately alleged that its third-party claims administrator (TPA) was a fiduciary and, as such, violated ERISA by causing the employer’s welfare plan to overpay medical claims . It also held that the employer is authorized under ERISA to seek equitable remedies from the TPA in the form of disgorgement of profits. What do you need to know about this decision, and what are the three big takeaways? How a Claims Payment Dispute Sparked an ERISA Showdown The employer, Tiara Yachts, alleged that its welfare plan’s TPA, Blue Cross Blue Shield of Michigan (BCBSM), systemically allowed out-of-network medical providers to overbill the employer’s welfare benefit plan for services tha...

  As employers look toward open enrollment for their group health plans, now is a good time to review action items needed for those plans by year-end, as well as upcoming deadlines in the near future. While fully-insured health plans generally have their compliance obligations satisfied by the insurer, self-insured health plans usually rely on the employer or the plan's third-party administrator (TPA) to meet the compliance requirements. Below is a brief summary of items that employers should be aware of for their health plans and, as appropriate, we have delineated when such compliance is limited only to self-insured health plans. Capitol Bridge Health Plan: Effective 03/01 - 02/28 TDB Communication, Inc. Health Plan: Effective 07/01 - 06/30 Capitol Bridge Health Services Health Plan: Effective 07/01 - 06/30 Capitol Bridge Puerto Rico: Effective (TO BE DETERMINED) 1. HIPAA Privacy Extends Special Protections to Reproductive Health Care: Employer Action Required by 12/23/24 Earlier...