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Adding an On-Site Clinic / Disease Mgt / Welness Program to Existing Plan

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I would appreciate others' thoughts on this scenario. Company has an existing self-insured group health plan. It now wishes to contract with a group that will establish an on-site nurse practioner clinic at the company in order to provide general medical services for minor illnesses and injuries for employees. The clinic will also serve to operate a wellness program conducting detailed health risk assessments and interventions, counseling, and education and other management of participants with various risk factors in an effort to reduce or better manage claims under the plan.

Question is how best to integrate and incorporate this new benefit into the plan? (Or maybe the bigger question is should this really be done as part of the existing plan versus being done as a separate plan.) The group which is contracting to set up and staff the clinic appears to intend (and has drafted their contract) so that the clinic (and all related activities) appear to be conducted as an additional benefit under the existing group health plan.

I assume one key reason for this is that they prefer to piggyback off of the existing plan's ERISA and HIPAA compliance efforts rather than viewing the clinic as a separate plan or program which might raise its own compliance issues. (I know there are exceptions from HIPAA and ERISA for certain on-site clinics but given the nature of activities to be performed here, I'm not sure this clinic would qualify for those exemptions even if set up as a plan or arrangement separate and apart from the group health plan. If it is part of the existing plan though, I assume all activities under it are generally subject to everything the group plan is subject to so full blown ERISA and HIPAA.)

Would appreciate any thoughts or words of wisdom from others that have set up similar clincs or programs. In particular, I would welcome thoughts on what sorts of changes to the plan's existing HIPAA Privacy procedures are likely required to ensure HIPAA Privacy compliance if the clinic is viewed as part of the existing group plan and the information flow is all arguably within the "plan" even though the clinic / nurse practioner is getting claims information from the insurance company providing administrative services to the plan.)

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I like the piggybacking idea better than the separate plan one for the reasons stated in your post.

With a Wellness Program, make sure that HIPAA nondiscrimination is not violated with respect to other aspects of the ER's plan.

For HIPAA privacy, I'd suggest that the on-site clinic take the compliance steps required of both a health care provider and a plan functionary.

By the way, if the nurse practitioner commits malpractice, is the ER possibly liable too for having selected the company to staff the on-site clinic?

John Simmons


Note to Readers: For you, I'm a stranger posting on a bulletin board. Posts here should not be given the same weight as personalized advice from a professional who knows or can learn all the facts of your situation.

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I have learned, over many years, to be very sceptical regarding what people advise when they have a vested interest or gain in the outcome.

What this group proposes to do might be being done in the manner that expedites or facilitates their sale, and not in the best interests of the client. I suggest using competent legal advice to evaluate all aspects of their proposal.

I also suggest that you make contact with a few of the companies (not their clients) who have implemented such programs and solicit their advice etc.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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