Employer reviewing medical claims

[Guest jfsga]

An employer requires employees to submit medical claims to the employer who then submits them to the TPA for processing. Are there any regulations preventing this practice or would this fall under the privacy act. What good reasons can we give the employer for ceasing this practice. They don't see actual medical records but do see medical diagnosis, etc.

[jeanine]

There was a discussion on this same issue many months ago. This situation generally makes me very uncomfortable. Even before the HIPAA Privacy Rules were final I think you had issues of confidentiality and who exactly at the company was looking at this information. You don't need a diagnosis to know what it wrong with the employee--some claims speak for themselves. The employer needs to ask themselves: What legitimate need do I have to know about these claims; can I accomplish this need by having completely de-identified information; and is this need justified against even the appearance of impropriety. For example, you have an employee submitting multiple claims over a period of months that cost the plan a lot of money. You decide to terminate the employee for an entirely different reason, such as a need to reduce staff...how comfortable are you going to be if the employee makes a claim that he was fired because he cost the plan a lot of money, or that he had a medical condition such as AIDS. If you don't know how much he cost or what is wrong with him, you don't have to deal with the claim.

Beyond this, I believe that the HIPAA Privacy Rules will severely restrict the employer from reviewing claims before they are sent to the TPA. The Rule says that those employees performing the functions of the plan must be separated by a "firewall" from other employer departments. They should not be the same employees making hiring, promotions, firing decisions. It really is their liability and not yours but I can see why you are uncomfortable with this. Are they actually opening claims or can the employee submit them in a sealed envelope to be opened by the TPA? Tell them to carefully review the new Privacy Regs and comments and consult with an attorney if they still want to do this after reading the rules.

[Guest jfsga]

Do you know where in the regs I can find this? Thanks.

[Guest]

The Federal Register cite to the provisions on disclosures by health plans to plan sponsors (i.e., employers) is 65 Fed. Reg. 82809 (12/28/00). The cite to where it'll be in the regs is 45 CFR 164.504(f).