“It is a common misconception that clients are entitled to receive any data, at any time, simply by virtue of being self-insured and having elected to receive Protected Health Information (PHI). This is not the case…….”
THE FOLLOWING LETTER WAS REFERRED BY DOUG ALDEEN – ERISA Healthcare Attorney and General Counsel – Austin, Texas
January 9, 2020
11595 N. Meridian, Suite 500
Carmel, IN 46032
Dear Mr. Horth:
We are in receipt of your request for itemized claim data on your current high cost claimants to enable Patterson Horth (PH) to market its stop loss. Cigna interfaces with numerous 3rd party stop loss carriers on behalf of our self-insured clients every day and has developed a set of standard reports used to assist clients in securing stop loss from 3rd party vendors. Our reports were developed to contain any and all of the information Cigna would need if it were quoting the stop loss coverage. In addition, our reports have also proven sufficient for the major stop loss carriers we provide them to, which provide us with added confidence that they contain all the data necessary to enable a stop loss carrier to produce a quote. These reports include:
– Claims in Excess with Diagnosis Report –. On a de-identified basis, this report includes age band, gender, medical product, relationship code, and lead ICD code with description. It can be requested at any threshold in excess of $10,000for paid medical claims only or paid medical and pharmacy claims.
– High Cost Claimant Report with Case Management Summary – Provides detail for individuals where claims have been paid at or in excess of a certain threshold amount for a defined period of time. This report also indicates whether or not a customer was referred and/or accepted into care management.
– Stop Loss with Case Management Including Transplants Report – Provides the same information as the High Cost Claimant Report with Case Management Summary (see above) with the addition of Transplant Zone, Transplant Type, and Transplant Status. In response to a request for a transplant waiting list, this report can be provided.
Cigna has a strict Policy not to provide information on Incurred, but not paid claims, projected claims, pre certifications of coverage, case management notes, course of treatment information or prognosis information. I understand that our refusal to provide certain information can be misconstrued as Cigna being difficult; however, we are following our standard Cigna Policies and contractual obligations for the protection of Cigna and the client. Non-paid claims data, such as prognosis or an onset date is speculative in nature and could be used as a basis for claim denials by the Stop Loss carrier, leaving the client and Cigna at risk. By providing this information, the Stop Loss carrier could try to hold Cigna and / or the client liable for the underwriting decisions they make based on the information we provide.
Finally, I’d like to address the issue of data ownership. It is a common misconception that clients are entitled to receive any data, at any time, simply by virtue of being self-insured and having elected to receive Protected Health Information (PHI). This is not the case; there are both contractual and legal limitations to what data can be provided to a client. At the onset, it is important to draw a clear distinction between “ownership” of information and access to information. While Cigna obtains some information from clients (eligibility) and performs services on behalf of clients (e.g., paying claims submitted by providers), the most critical information, claim information, is not provided by the employer/client. Rather, this information is submitted by providers, most often, Cigna participating providers. The claim record created by Cigna also reflects Cigna’s proprietary rate information and coding methodologies; as such, Cigna is the owner of these records.
That is not to say that PH does not have a need to access information in Cigna’s possession for plan administration purposes. For this reason, The Administrative Services Agreement between Cigna and PH contractually recognizes a client’s need to access information about transactions executed on their behalf by providing for reports, audits and the like. In other words, Cigna does contractually agree to provide access to information needed by a plan or the plan sponsor. However, contractual access to information is not the same as ownership of that information.
In addition, in order to comply with the HIPAA Privacy Rule and the terms and conditions of our Business Associate Agreements with our client, Cigna is required to limit the PHI disclosed to and on behalf of the client to the minimum amount necessary as it relates to a plan administration purpose. To meet this end, Cigna provides a set of standard paid claim reports that have been vetted by our Privacy Office and determined to be the minimum necessary amount of information to meet this purpose. As noted above, our reports were developed to contain any and all of the information Cigna would need if it were quoting the stop loss coverage. In addition, our reports have also proven sufficient for the major stop loss carriers we provide them to, which provides us with added confidence that they are the minimum necessary for the purpose for which they are provided. For these reasons, (in addition to the various business reasons also enumerated), we do not feel it is appropriate to provide additional reporting outside of the standard reporting package for 3rd party stop loss purposes.
Mary C. Clark, Esq.
Cigna Legal
