HIPAA - Requesting High Claimant Information from a fully insured HMO

[Guest akwallace]

We have requested high claimant information from one of our fully insured HMOs, for stop loss underwriting purposes for another plan.

The HMO has indicated that they cannot share this information with us, as it is a violation of HIPAA.

Is this the case? We do not have a Business Associate Agreement with them, as they a fully insured plan.

[Jbentz]

I went to the regs and under 164.504 (4)(f)(1)(i):

(f)(1) Standard: Requirements for group health plans.

(i) Except as provided under paragraph(f)(1)(ii) or (iii) of this section or as otherwise authorized under § 164.508, a group

health plan, in order to disclose protected health information to the plan sponsor or to provide for or permit the disclosure of protected health information to the plan sponsor by a health insurance issuer or HMO with respect to the group health plan, must ensure that the plan documents restrict uses and disclosures of such information by the plan sponsor consistent with the requirements of this subpart.

(ii) The group health plan, or a health insurance issuer or HMO with respect to the group health plan, may disclose summary health information to the plan sponsor, if the plan sponsor requests the summary health information for the purpose of :

(A) Obtaining premium bids from health plans for providing health insurance coverage under the group health plan; or

(B) Modifying, amending, or terminating the group health plan. or in connection with any other benefit or employee benefit plan of the plan sponsor;

So, what does your plan document say about restrictions? You might also try asking for summary health information, rather than the high claimant information.

Hope this helps.

Judith

[GBurns]

In addition to what was suggested by jbentz, Ask if they would provide "Shock Claims" information above the minimum value that you need. This is a term that they will be more familiar with.

[Guest llerner]

I notice that health carriers are using HIPAA for everything they can to avoid possible liability & minimize work load. When an employer tries to help an employee obtain their prescription because the employee less skilled person or not versed in insurance, they are blocked by HIPAA, even though the employee came solicited help.

When I tried to find out Individual Conversion for HMO for a particular carrier who had only one plan, they told me that only the subscriber could do so. When asked about the HIPAA plans available, they stated that only the member could get the info due to HIPAA. I was trying to help a client's family member that was paralyzed in car accident in Florida obtain their options since this person owned the company that had the health benefits through United Healthcare Small Group. He was going to dissolve the company so he would not be eligible for COBRA. This was a general question not involving a specific person. The Florida Dept of Financial Services who handles group insurance agreed with the carrier.

HIPAA is being used to block information under the guise of privacy.

Try a supervisor. It worked for me one time when a client needed a form for a terminally ill employee. I told them I don't even want to see the form or the employee's name. Here is the member number. Just send it to the address on file for this number and she relented.

Sorry I didn't answer your question. It just upsets me when carriers twist things either out of laziness or to block access to very sick people who don't have the energy to obtain the information themselves. They can always get a Power of Attoney or some type of affadavit naming someone to have access in the cases I mentioned but that is one more hurdle in a life mired by stress.

Claims data should be available though as long as the employee's data is blocked. They can state 2 claims for $10,000 etc as long as they don't identify the the employee in any way which is logical and reasonable.

[mroberts]

HMO's should be allowed to supply large claims information. As long as you're not asking for any employee's identity, it shouldn't be an issue. And if the group is so small that it could be obvious who the high claims utilizers are, you could always ask for the amount of claims without prognosis and diagnosis. I agree that some lazy employees at insurance carriers are going to use the HIPAA excuse to try and cut down extra work, which is really sad.

[KJohnson]

The following link to a thread is pre-HIPAA, but privacy issues aside, some insurers/HMOs simply will not provide you with this data. http://www.benefitslink.com/boards/index.p...st=0entry4376