Gag Clauses Are ProhibitedYour TPA can no longer contractually block you from accessing the claims data your plan pays for. An official compliance attestation is required annually.
Total Fee DisclosureBrokers, TPAs, and consultants are legally required to disclose exactly what they are paid—including all indirect compensation.
Personal Liability Under ERISAPlan fiduciaries are personally and corporately liable for the prudent management of plan assets. Claims spending is plan assets.
“prohibit group health plans and health insurance issuers offering group or individual health insurance coverage from entering into an agreement with a health care provider, network or association of providers, TPA, or other service provider offering access to a network of providers that would directly or indirectly restrict the plan or issuer from:
1. making provider-specific cost or quality of care information or data available to active or eligible participants, beneficiaries, and enrollees of the plan or coverage, plan sponsors, or referring providers;
2. electronically accessing de-identified claims and encounter information or data for each participant, beneficiary, or enrollee in the plan or coverage consistent with applicable privacy regulations, upon request; or
3. sharing such information or data described in (1) and (2), or directing such data be shared, with a business associate, consistent with applicable privacy regulations.”
“These prohibitions, collectively referred to as the ‘Gag Clause Prohibition,’ became effective on December 27, 2020.”
“Plans and issuers must annually submit an attestation of compliance with these requirements (a Gag Clause Prohibition compliance attestation (GCPCA)) to the Departments.”
“The first GCPCA is due no later than December 31, 2023, and subsequent attestations are due by December 31 of each year thereafter.”
“The first file will show negotiated rates for all covered items and services between the plan or issuer and in-network providers.”
“The second file will show both the historical payments to, and billed charges from, out-of-network providers.”
“An initial list of 500 shoppable services as determined by the Departments will be required to be available via the internet based self-service tool for plan years that begin on or after January 1, 2023.”
“To address these unlikely provider-rate combinations, the proposed rules include proposals to: 1) require group health plans and health insurance issuers to exclude from their In-network Rate Files provider-rate combinations for items and services for providers that would be unlikely to be reimbursed for the item or service given that provider’s area of specialty.”
“First, the Departments propose to require a plain text file (.txt file) located in the root folder of a payer’s website with information on the specific location of the machine-readable files as well as contact information including a name and email address for those that are responsible for the machine-readable files.”
“In addition, the Departments propose to require group health plans and health insurance issuers to add a link in the footer of the home page of the plan’s or issuer’s website titled ‘Price Transparency’ or ‘Transparency in Coverage’ that routes directly to the publicly available web page that hosts the machine-readable files.”
“The Departments also propose to require plans and issuers to update and post the In-network Rate and Allowed Amount Files quarterly rather than monthly.”
Your ASO or TPA is required by law to provide the data. The letter can be sent unchanged.
Once uploaded, Ruth cleans the data. Ruth maps exactly what you were charged against what the identical care costs at named independent facilities nearby.
Ruth generates a time-stamped, dated corporate report. This document is your dated record showing you checked your rates, documented what you found, and acted to protect plan assets.
No record shows whether your ASO or TPA’s negotiated rates are reasonable, in an employee lawsuit or a Department of Labor audit.
You hold an active, dated ledger showing exactly what you paid, what the market alternative cost, and the structural plan protections you instituted as a result.