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Self-funded health plan sponsors are fiduciaries, giving them special status and corresponding special responsibilities under the law. It is crucial for plan sponsors to understand their fiduciary duty and the related actions required for both ERISA compliance and successful administration of a self-funded health plan.

Self-funded health plans are HIPAA Covered Entities and must protect their participant’s health information. They must also take steps to ensure that their business partners protect the health information by requiring that they sign a Business Associate Agreement confirming the partners’ commitment to comply with HIPAA.

Data analytics firm Trilliant Health recently released a study regarding the wide variability of healthcare costs across the United States. It may contain shocking revelations for the common reader. However, the unreasonable and largely volatile prices – which the study notes have little to no correlation to the quality of care rendered – are nothing new for many insiders who routinely interact with the healthcare pricing and payment ecosystem.

This post from healthcare advocate and thought leader Chris Deacon raises important issues regarding self-funded health plans and the hurdles plan sponsors encounter while fulfilling their fiduciary duty.

Self-funded health plan fiduciaries should routinely review large health insurance claims (aka, bills) and ask questions. Their attempts to do so, however, are often thwarted by third party administrators (TPAs) or networks who assert that plan fiduciaries don’t have the right to “audit” claims. TPAs and networks will point-blank refuse to share the data necessary to review claims, either pre-payment or post-payment. The TPAs and networks are wrong.