Ownership of claims data

[Guest lg8355]

I work with employers that would like to obtain their claims data from their TPAs to use for various purposes like data analysis from external vendors, etc.

I have always believed that a self-funded employer "owns" their own paid claims data, however, there is a struggle right now with getting the TPA to actually hand it over.

I am wondering where the self-funded employer's ownership of their own data can be referenced in the law or other documents.

Does anyone know where this validation can be found?

[leevena]

A couple of things come to mind. The first is, you are correct in that the employer does own the data. If your client is self-funded, then the TPA does need to supply claim costs data to the client so that they can fund the account. I am guessing that this level of data is being made available. The second issue may be the ability of your client to obtain more detailed information beyond the usual date of service, service, cost, etc. If this is the case, then you may be running into a situation where the tpa is not able to develop such a level of detail in a report. So the question becomes, is the data/report available, or is the tpa unable to deliver such data/report.

If the data/report is available, and part of the reporting package that your client purchased, then by all means it should be made available to you/client.

[GBurns]

I think that it is the health plan that owns the data not the employer.

There is probably a struggle not because of ownership of the information but more likely because the TPA has reservations about turning over this detailed personally identifiable PHI to the employer who has no ability to use it and therefore no reason to get it. There probably will be no problem with the TPA if the information was being turned over to a service provider who enters in a Business Associate Agreement or is a health plan or otherwise eligible party. In fact, I have heard opinions that giving such information to most employers would be a HIPAA and state privacy violation, mainly because most employers are not set up in the manner required for privacy issues assuming that they have an acceptable reason to receive it.

As for the ability to actually create the data in a useable format, that is another story. Although it seems that most of the software packages have such reports as standard reports or easily created reports, surprisingly, there seem to be a number of TPAs who do not know how to use their software. Every time that I find one I then have to shudder at the incompetence of the claims adjudicatiion etc.

You should find it much easier if the request is made by and the format dictated by the "external vendor" who will be doing the analysis etc.

[Guest lg8355]

leevena You agree with regard to the "ownership" of the data, but do you know where in the law this can be referenced? With regard to the type of data, this is the "raw" claims data - beyond what is typically provided to fund the claims weekly. It is definitely available and is provided by the TPAs to vendors to do predictive modeling.

GBurns Who do you consider the "health plan" to be? This is a self-funded employer that has hired a TPA to administer their claims and "rents" provider networks. Our belief is that the employer's ownership of the data is absolute and the TPA has no right to withhold it from the employer - regardless of the employer's use of it. Granted, the employer is obligated to follow all applicable laws (HIPAA, etc.). In fact, there are employers that self-administer their claims, so in those circumstances ownership of the data is never disputed. What is being disputed here is "does possession equate to ownership"?

I certainly appreciate both of your responses and perhaps with this additional information, we can continue this dialogue.

I am especially interested, however, in where this topic is even discussed in the law.

[leevena]

I do not believe there is a law that covers the issue of data ownership...but I could be wrong. Rather, I would view it from the perspective of the buyer/seller relationship that existed when the group entered into an agreement with the tpa. Did the group not review what data was available? There are a variety of issues you should look at when selecting a tpa and one should be the types of reports available. Could it be that the employer entered into an agreement with the tpa and that agreement did not include this type of information? Not all tpa's are created equal.

[jeanine]

GBurns is correct. The health plan owns the data, not the employer. The employer is the plan sponsor but the plan is a separate legal entity. Chances are, employees of the employer work for the health plan. However, the health plan employees can't just give PHI to anyone. The health plan would have to be amended so that it is allowed to give PHI to the employer for certain settlor functions. As a TPA, we have every Self-funded plan declare to us who is the named Plan Administrator and any other person who they consider to be employees of the Plan. We give PHI only to the Plan Administrator or these designees. HIPAA was specifically written to protect employees from employers using PHI to make employment-related decisions.