Health Insurer Refusing To Provide Claims Information

[KJohnson]

A health insurer is raising its rates, but refuses to provide the employer with claims history. The insurer states that it only provides such information to employers with plans over 150 participants. Has anyone ever heard of this and is there an employer "right" to this information? I can't imagine the new proposed privacy regs would limit an employer's attempt at utilization review.

[KIP KRAUS]

It is very possible that an insurer will not provide claims experience on a medical plan that is not experienced rated and under 150 lives. Whether or not they have to provide experience would more than likely be a state insurance department issue, and how the insurer has its small groups filed with them. Contact the state and ask them.

You may also want to market the plan with other insurers to test the waters.

[Guest nac]

I have contracts with about 25 HMO's across the country, and most of them are small cases and do not provide any experience history. My largest HMO will provide claims experience, and their minimum is 500 lives. We have about 502, so we just make it!

But seriously, especially with community rated small-case plans, you're probably not going to be able to get anything.

[Guest nb]

The best employer "right" is to write a check to whomever they want. If the information is important to you, then I'd recommend that you explore alternatives.

[Guest ScottN]

In Colorado this practice is very common. If your plan is an HMO with capitated physicians or physiciam management groups, it is also possible the HMO has no claims data except Hospital or Prescription Drug claims for a specific small group.

[Guest Pat Cook]

Having worked with multi-state groups, this can be true anywhere, if it is not an experience rated group. However, the 150 is not a magic number, the insurance vendor usually sets their own minimum and it could be higher or lower. However, alternative funding arrangements, i.e., self-funded or partially self-funded plans would eliminate this problem. And if a partially self-funded plan is arranged corectly, it should not only save considerable dollars for the employer but also limit the employer liability in a worst-case scenario to no more than was the fully insured cost. And this does not reduce employees benefits. If you would like more information, please feel free to contact me.

[Guest mb]

Your problem in getting claim data from your HMO not unusual. It is the HMO's intent to obscure how they are financing your health care expenses so that they stregnthen the control that they have. Furthermore, if they do give you data,my experience is that it is not always reliable because of their convoluted methods of actual payments to providers. As a previous response indicated. Take control and responsibility for your own financing by "properly" self funding. You will own the data with this method and be practicing sound risk management.

[KIP KRAUS]

KJohnson:

Be careful taking self-insurence advise on a group less than 150. Depending on what underwriter you talk to even if you have three years of claims experienc on the group, the credability factor on the reliability of the claims data can be 75% on 150 lives to as low as 50% on 100 lives. This means predicting future claims liability is difficult. Without at least knowing what your prior experience is you're taking a 50/50 chance that self-insurance would be a better deal. However, you can purchase individual and aggregrate stop-loss insurance to limit your liability, but stop-loss coverage on a small group can be expensive, and typically whatever you spend on it is gone. You get no refunds even if the insurer pays no claims.