Employee Being Asked Health Questions

[kgmom219]

Need some help....

And I work in the under 50 group market, so don't throw anything.

I have a friend who recently (last September) got a job with an employer with 300+ employees. The friends son has a serious, ongoing medical condition. Its not life-threatening, but requires monthly transfusions, tests, prescriptions, etc. I would guess $1K in claims, monthly.

A "benefits analyst" from his employers broker called and wanted the diagnosis, treatment, etc. He stated that he was in need of the info as he was shopping the company benefits around before our renewal in April, and wanted to have more info.

Thoughts on why this is happening? Is it self-funded or going self-funded and they need to know? Wanting to know why they got a huge increase? I get HIPAA, but they are going to have access to the claims data anyway, so there's no point in citing privacy. Anybody have some insight? Thanks!

 

[cadylou]

You might be right about the self-funding, but does the "benefits analyst" really have a right to ask for such detailed personal health information? could they ultimately use this information to possibly end your friend's employment there if they deem that the insurance risk the son poses is too costly? You may want to check with your Dept of insurance to determine if this is something they should be doing at all . . .

 

[leevena]

I agree with cadylou, to a point. I would not go to the dept of insuance so quickly. With all due respect to the various players, many times the first story is not always the accurate one.

First thing I would do is have the employee get an explanation from the employer. When an employer is engaged in collecting this type of data, they usually announce it ahead of time with some kind of explanation. The "benefit analyst" could very easily be an underwriter who in fact can call and ask.

 

[kgmom219]

I agree with cadylou, to a point. I would not go to the dept of insuance so quickly. With all due respect to the various players, many times the first story is not always the accurate one.

First thing I would do is have the employee get an explanation from the employer. When an employer is engaged in collecting this type of data, they usually announce it ahead of time with some kind of explanation. The "benefit analyst" could very easily be an underwriter who in fact can call and ask.

The employer confirmed that it was a "legit" call. But why would an underwriter/benefits analyst want it? Self-funded and trying to figure out claims for the upcoming year?

And I'm with you...I don't believe ANYTHING anyone tells me anymore. Except the folks at healthcare.gov. Their information is always accurate.

 

[cadylou]

One more thing on this - you said they "called" and wanted the information. Typically this information would be collected on paper, especially if this is being done for everyone employed there . . . .if it's "legit", it is usually in writing. I'd have the employee ask why they need it, are they collecting it for all employees and can the employee have something in writing that discusses the policy of collecting the information. They should be able to provide that if it's "legit" . . . .just my two cents. . . . . .

 

[leevena]

The employer confirmed that it was a "legit" call. But why would an underwriter/benefits analyst want it? Self-funded and trying to figure out claims for the upcoming year?

And I'm with you...I don't believe ANYTHING anyone tells me anymore. Except the folks at healthcare.gov. Their information is always accurate.

(By the way, I have been doing self-funding for over 30 years.) In small group self-funding, say from 5 lives to 200, the employee usually completes some type of medical questionaire. This questionaire is designed to create a risk profile of the employer risk, and allow the underwriter to develop a rate/cost. As you can imagine, there are many times when an employee will not answer the question with complete clarity. For these situations, and others, some underwrites utilize a phone call to the employee to learn more.

If it is a legit call, more than likely there is a document that explained this to the employee, usually it's on the form itself.

 

[kgmom219]

Thanks everyone for your help!

He has not seen any forms, since the original enrollment doc in Sept. The group is currently self-funded and they are getting killed on stop-loss quotes. So the agent is asking for claims info, because the stop loss carriers claims estimates are about 5x what it actually costs. He's getting everything in writing and is going to go ahead and provide the last 12 months of EOB's. Since in reality, they can get them anyway.

 

[junkman]

The broker is just trying to find out what's going on so he can disclose as necessary. Basically what was necessary when health conditions affect underwriting.

I've never been a fan of self funding. Have seen too many groups get bitten. We had a spouse file a claim with Medicare. The group was primary but was never notified of the claim. Medicare paid and came back to the employer years later and wanted reimbursement.

Federal law says the employer is responsible for the claim. They were fully insured and the carrier paid. They would have been outside the contract filing limits had they been self funded and the employer would have eaten the bill.