Compliance Deadline Coming for “Gag Clause”
No this has nothing to do with Santa! The “gag clause” is the attestation by plan sponsors (i.e., employers, generally) that they have complete, “unfettered” and unedited access to the results of their sponsored healthcare plans. For companies that are self-insured, this may be internal reporting or through a service; for companies that use an outside insurance company, this relates to the records of their plan with that company. The purpose is to provide a means to fully analyze their costs – and compare them to those of other potential providers. The “gag” referred to is any obstacle to access to those costs that might be imposed by the insurer. The specific prohibitions are restriction of any of the following activities on the part of the plan sponsor by any insuring party or affiliate of such party:
Share provider-specific cost or quality of care information with referring providers, enrollees in the coverage, or individuals eligible to become enrolled in the coverage.
Electronically access claims and encounter data on a per-claim basis, stripped of identifying details, including things like financial information, allowed amounts, financial obligations required by a provider contract, provider information, service codes, and “any other data element” included in the transaction.
Share any of the above information or data with the plan’s business associates.
It is not foolproof, however: as opposed to group health plans and carriers, service providers are not prohibited from have gag clauses in their contracts, so Congress has further work to do.
