Lawsuits from large companies and employers are increasingly being filed against third-party health plan administrators in an effort to access complete employee medical claims data.
Through lawsuits recently filed against TPAs, employers claim payers have breached their fiduciary duties by not allowing complete access to claims data and how claims are processed.
In a June 30 complaint, Kraft Heinz alleged Aetna has used its role as its TPA "to enrich itself to Kraft Heinz's detriment" through undisclosed fees and processing medical and dental claims without human review. Aetna told Becker's it has no comment on the lawsuit.
In December, bricklayer and metal worker unions filed a lawsuit against Elevance Health, alleging the payer does not allow self-insured plans to access their own claims data and charges the plans higher rates than it had negotiated with hospitals.
These lawsuits are largely being driven by the Consolidated Appropriations Act and the hospital price transparency rule that took effect in 2021, according to a July 6 Bloomberg Law report. As self-insured employers obtain greater access to medical costs, they are facing more pressure to uphold their fiduciary duty to employees.
"These are the first of many cases to be filed by employers and employer plan sponsors," Christin Deacon, founder of VerSan Consulting, told Bloomberg. "If these cases bear out and employers don't do something to correct this behavior, then the employer is at risk for being sued by their employees for breach of their fiduciary duty." Ms. Deacon was formerly an assistant director with New Jersey's employee benefits plan.
Bloomberg reported that at least one law firm is looking for employees of Target, State Farm and PetSmart on social media to determine if they would become plaintiffs in matters concerning their health plans.