The Train is Leaving the Station: The First Big Suit Addressing the Consolidated Appropriations Act.
We all use products made by Kraft and Heinz—cheese, ketchup, mustard. It is one of the biggest food companies in the country. They are suing Aetna, one of the biggest health insurance companies in the country over Aetna’s failure to provide full access to all of Kraft and Heinz claims data. This is the first in many fights over data and control between self-insured employers and the “insurance companies” that administer their claims.
These employers have always had a fiduciary duty to act responsibly about health care for their employees just as they have had for 401K funds. They have an obligation to be certain they are providing the best medical benefits for the best price but the Consolidated Appropriations Act of 2021 insures better access for employers to their data about the details of health care spending by their claims administrator. Aetna is fighting to keep Kraft and Heinz from seeing the details of their own health care spending. That alone speaks volumes.
Attorney Chris Deacon is one of the foremost authorities on the topic. This quote is lifted from the link above: “What the law says is that employers cannot enter into an agreement with a third-party service provider or network carrier that would limit [the employer’s] access to their [own] de-identified claims data,” said Chris Deacon, founder of VerSan Consulting, in an interview. “What it does is it inherently recognizes that the claims data is the employer’s, and it says you can’t contract with a party that limits your access to that data. The onus is really on the employer to make sure that they’re not party to such agreements. The implication there is very direct that the employer has an obligation and responsibility to be looking at that data … to make sure that they’re spending their plan assets prudently.”
The lawsuit is about Aetna’s failure to comply with the provisions of this new law. Kraft Heinz made a formal request of Aetna for its medical claims data. It took over a year for Aetna to supply selected and edited medical claims data. It was far from complete. “Accurate information regarding payments to providers, dates of coverage and other essential information was excluded. The lawsuit claims, “Without this data Kraft Heinz is unable to assess Aetna’s handling of the Plan’s funds and associated payment integrity….Kraft Heinz owns this data and has an absolute right to it.” Deacon said the reason Aetna isn’t providing full access to the data is because it knows that Kraft will find errors Aetna made.
There is much more to this lawsuit. Based on the limited data that is does have from Aetna, Kraft Heinz is also claiming that Aetna “paid millions of dollars in provider claims that never should have been paid, wrongfully retained millions of dollars in undisclosed fees, and engaged in claims-processing related misconduct to the detriment of Kraft Heinz.” No wonder they want the rest of the data.
And that is not the only suit that has already been filed. Two unions have begun similar lawsuits. If Aetna has played fast and loose with a powerhouse like Kraft Heinz, what is your insurance company doing to you. The revolution is just beginning, and it is going to be rough. As Cheryl Larson, president and CEO of Midwest Business Group on Health said: “I can’t imagine that other healthcare stakeholders are ready for what is about to happen. … I think this is the tip of the iceberg.”
I am working with several other stakeholders to provide an alternative to these big insurance companies that won’t provide the data. Most “medical insurance companies” are not insurance companies at all. Your employer pays the bills, the “insurance companies” just process the claims. They are known as third-party administrators or TPAs. The new law forces TPAs to give your employer access to detailed information about where their money is going. The other stakeholders and I are already working with self-insured companies to get their claims data from TPAs through Congruity Health where I work, and we are learning where the problems are. That is just the first step. Then we collaborate with other stakeholders at Health Direct Partners to provide best-in-class answers to those problems. We have recently digested the data from a client that runs a worksite clinic for the Coushatta Resort Casino. Patient seen in the clinic cost half as much in part because there is an 80% reduction in hospitalizations and a 64% reduction in ER visits. Health Direct Partners works with TPAs that are aligned with our mission to improve health and lower costs. We can provide self-insured rates for companies with as few as five employees. Make the right way the easy way. Let us help you meet the requirements of the Consolidated Appropriations Act with one contract.
We have our supplement insurance with Aetna this past year (Medicare Advantage) thru my husband’s retired teachers “union”. It is sooooo inexpensive but we have not given it a real test. I hope we don’t have to actually. BCBS normal supplement handled my hip replacement well last summer (2022). This is something to watch. Thanks.
Thank you again for discussing this important topic. So concerning that we lack affordable common sense care. Everyone wants a profit it seems.