August 8, 2023
By Nomi Health on September 25, 2023
We all feel it. Healthcare costs are getting out of control and getting many people into debt. In fact, healthcare costs have been escalating for decades, employers are looking at a median 7% rise in rates for 2024, and there’s no end in sight. As employees look to employers for some type of relief from increasing premiums, employers must find ways to get the most value out of their health plans while also understanding where to cut costs.
Utilizing accurate and complete healthcare data is the best way for employers to make better decisions. But this insight rich data is hard to access when Third Party Administrators (TPAs) and insurers gatekeep information. In what is the tip of the iceberg when it comes to data misrepresentation, this was the recent cause for Kraft Heinz suing their insurer, Aetna, claiming that Aetna was withholding medical claims data.
In June of 2023, Kraft Heinz slapped Aetna with a lawsuit claiming that Aetna was knowingly withholding medical claims data. Among the cited complaints are Aetna paying false, fraudulent, and improper claims upwards of millions of dollars, as well as failing to provide complete claims data upon request. A few callouts from the lawsuit:
“Aetna intentionally and artificially limited this file to be a ‘tab-delimited, fixed-length, text without a header record’ with 178 Aetna-cherry-picked data fields limited to fit within a 1480-character data-string.”
“Kraft Heinz pays Aetna to prevent payment of duplicate claims. Yet, Aetna has taken millions from Kraft Heinz to pay thousands of duplicate claims since 2016.”
It is clear Aetna knowingly withheld information for their own benefit, leaving Kraft Heinz in the dark, unable to gain a clear picture of their data. Through this lawsuit, Kraft Heinz is setting the tone for employers taking back their rights as fiduciaries and demanding greater control.
Employers can no longer fly blindly if they want to control expenses and drive satisfaction for employees, which has become increasingly important. As the Kraft Heinz lawsuit revealed, many self-funded employers are likely getting short-shifted by their plan administrators and hidden costs will cause the rates to continue to go up. By not taking a more active role, employers are losing money and control, with no end in sight.
By proactively managing their healthcare plans and data, employers can:
Improve cost control and transparency
Enhance employee health and wellness programs
Better make decisions for meaningful benefit design
Enhance privacy and security measures
Big insurers are not the only choice when it comes to healthcare plans. There are independent TPAs that may offer more insight and control for plans. By ensuring your TPA is offering you transparent information, understanding where money is being spent, and finding ways to ensure more flexibility in your plans, employers can unlock each of the benefits mentioned above.
To take full control of healthcare plans and data access, employers will need to understand the current state of their control, invest in the right tools, and review current contracts.
Understand current access. Employers will need to dive deep into what data they are currently being given by their consultants, brokers, TPAs, and PBMs (Pharmacy Benefit Managers). It might even take some hard conversations to understand the full picture and if important data is being gatekept.
Review spending and contracts. It is important to understand what the current contracts are, how much is being spent on them, and whether they are aligned with the company’s best interests. If it is revealed that information is being withheld, then swift action must be taken.
Invest in the right tools. Having a benefits analytics and insights tool will help you dig into where money is being spent and what can be cut to help save costs and reinvest in areas that will make a higher impact.
By taking these three steps you’ll have a much better picture of where your money is going and how to manage spending in the future.
The future of healthcare data management promises a transformative shift towards greater accessibility, interoperability, and empowerment. Buyers of healthcare don’t have to accept anything less than transparent. It’s your money, your data, and your healthcare – you deserve to know where it is going.
The Kraft Heinz v. Aetna case is just the beginning when it comes to large TPAs gatekeeping information. More companies are realizing the impact of the withheld data and are taking back control, through self-funded plans and independent TPAs.
At Nomi Health, we’ve built our model exactly on that, putting buyers, employers, and providers back in the driver’s seat. Our Open Network reduces medical spend by up to 30% while offering transparent pricing and streamlining a better patient experience for your employees. We actively work with employers and providers to build a partnership that changes healthcare. The providers we work with offer reasonable rates in exchange for full settlement upon submission of a clean claim and Nomi Health passes on these competitive rates to employers who are able to move away from high deductible plans and capture savings. With fully transparent data, we show you exactly how much money you are saving and how you can build health benefits plans that are meaningful to your business and employees.
If you’re interested, check out our Open Network and how we are slashing healthcare costs by giving control back to employers, providers, and members.