“You have the legal right to demand access to claims, pricing, and performance data, even if the old contract says otherwise.”
By Kimberly Carleson
The Consolidated Appropriations Act (CAA) of 2021, along with ERISA, gives plan sponsors powerful tools to demand full transparency from , TPAs, and PBMs.
Under the CAA, you must ensure reasonable compensation for plan service providers.
You must obtain and review detailed claims and cost data and you are legally obligated to act as a fiduciary, making decisions in the best interest of plan participants.
A “gag clause” is any contractual term that prevents a plan sponsor from accessing or sharing cost, quality, or claims data.
-Under the CAA, health plans cannot enter into agreements that include gag clauses.
If a contract does include gag language, the plan should demand removal or amendment.
Plan sponsors are required to submit an annual Gag Clause Prohibition Compliance Attestation to confirm they are not bound by such terms.
You may need to renegotiate or amend existing contracts to remove gag language.
You have the legal right to demand access to claims, pricing, and performance data, even if the old contract says otherwise.
-Any clause to block access is effectively null and void under federal law.
Under ERISA, plan sponsors have the fiduciary duty to act in the best interest of plan participants, which includes the right to request and review claims data, contracts, and payment arrangements.
Ignorance is no longer an excuse. Whether you’re fully insured or self-funded, if you’re footing the bill, you have the right to know where every dollar is going. Federal and state law supersede wording in a contract. It’s
State transparency laws also support your right to obtain this data, even when TPAs resist.
If you’re not reviewing your claims, you are violating federal law without even knowing it.
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