Experience rating from indemnity health plan PHI under HIPAA?

[Guest AJK0020]

We are an employer that offers four diffrent health plans (combined premium >$5 mil.). One is an indemnity, one PPO, and two HMO's. My main concern is the experience rating that we recieve once a month for the indemnity plan. Since it contains the employee's or dependent's name, type of service (general such as drug, med/surg, etc.), and amount paid for the service, would this document be considered PHI under HIPAA regs?

I have done much reading and feel like I'm riding a pendulum (one source leads me to believe yes another no). I would appreciate any input from a source outside my web of confusion.

Thank you for any help or comments.

(I apologize for any spelling errors, I'm lost w/o a spellchecker)

[GBurns]

I think that you do have a problem. HIPAA or no HIPAA this PHI is not something that is or should be given to any employer at any time for any reason. If you are fully insured then there are usually also state laws that also prohibit employers getting this PHI.

Summary data is okay PHI is not.

I suspect that you have been getting this in error and suggest that you get legal advice immediately if not before.

By the way, Why would you have wanted this PHI in the first place and of what benefit has it been to you?

[Guest AJK0020]

Thanks for your opinion.

In reply to your question, I believe long ago it was used when negotiating our premium rates before we joined a consortium(sp) and also, when we had few enough employees, to review for misplaced claims to our group. My thoughts are that we still get it because "thats the way it's always been".

[Steve72]

I agree with GBurns. HIPAA specifically states that Summary Health Information may be used for premium bidding. The release of PHI beyond SHI to the employer is something that will be prohibited by HIPAA.

I would advise contacting the insurer and informing them that they should change the report to make it SHI. They should be amenable, as this would be a HIPAA concern of theirs as well.