Medical Child Support and HIPAA

[Guest Zephyr]

We have a self-insured health plan and recently received a QMCSO with regard to one of our employees. The employee has enrolled the children without protest, but we are running into problems with our TPA being unwilling to provide the necessary documents for the children (via the custodial parent) to make claims. The three pieces of information that we have requested the TPA to provide are the claims address for submission of claims, ID cards for the children, and EOB's on the children's claims to the custodial parent. The TPA is claiming that they cannot provide this information without the employee's consent due to HIPAA privacy concerns. Of the three items, the only one that I think may have the employee's PHI is the ID card (with his ID number). I believe that the exception to the HIPAA privacy rule permitting disclosures in order to comply with the law is applicable here. Not only does the order require us to provide information on how to submit claims, it is issued pursuant to Washington law, which has a specific provision requiring us to provide "enrollment membership cards". The TPA is still insisting on a release from the employee and I have a conference call with them tomorrow to try resolve the issue. We are not concerned as much with this particular employee (it seems likely that he would sign the release), but we are concerned about less-amicable situations where the employee would not be willing to sign anything. Have any of you experienced this before? How did you deal with it?

[Guest b2kates]

I am not sure to whom the documents need to be provided. IF you need the EOB to authorize payment, then it should be a condition of reimbursement of the plan and the TPA should be providiing it or any claims would properly be denied.

[Sandra Pearce]

There is a wealth of information regarding Qualified Medical Child Support Orders on the DOL web site at www.dol.gov/ebsa/publications/qmcso.html

If the order is qualified then one of the responsibilities of the health plan is to allow the custodial parent to file claims on behalf of the child and to have benefit payments made to the custodial parent or health care provider. This means you have to provide the custodial parent with the information necessary to file a claim and seek reimbursement for a claim. An ID card is only part of what you need to provide. Add to that a Summary Plan Description, any claim forms or claim filing information, etc.

[JDuns]

It could be that, because the EOB will show remaining family deductible, the EOB will tip-off to the custodial parent that the ex-spouse is incurring significant medical bills. That disclosure of the fact of treatment could be deemed a disclosure of PHI.

I would recommend that the employee sign an authorization for the disclosure and be greatful that your TPA is administering the HIPAA privacy rules so thoroughly.

I have long held the opinion that with coordinated deductibles it is not possible to sufficiently scrub the fact that services were rendered to avoid the disclosure.