I have a complicated matter I need your assistance with. Forgive me for
the length of my request but I feel the background information is
important.
Our District's self insured medical plan administrator has held the privacy
of our employee's medical records as his number one priority. To maintain
privacy, all medical records are offsite with our Third Party Administrator
(TPA). The TPA's contract specifies that our employees medical records and
their "Explanation of Benefits" are confidential and may not be released to
the District's administrator without written consent (CA Civil Code Section
56.05 et seq.). In addition, the TPA contract also provides for employee
confidentiality with regard to the list of claims that the TPA submits to
the District for payment (see exact language below).
The TPA submits the list of claims in the form of a check register to the
District's CFO. The check register lists the check number, the check date,
the payee, the check amount, the employees name and a code showing if the
claim is for the employee or a dependent. The check register is reviewed
by the CFO for clerical accuracy, to see the payees are reasonable, and to
see employees are eligible participants. The CFO authorizes the release of
funds to the TPA, marks the register confidential and then locks it up.
Monthly summary reports are provided by the TPA on types of services. The
summary reports are reconciled back to the check registers by the CFO to
validate the accuracy of the reporting. Reporting is also provided on stop
loss insurance claims. The stop loss reports do specify the insured's
name. Recoveries for stop loss insurance are made payable to the District.
Our employees feel their privacy has been violated by virtue of the
existence of the check registers, with their name and their service
provider's name listed, and the monitoring of stop loss claims. We are
trying to be sensitive to our employees without putting public funds at
risk.
How do the rest of you provide oversight of the TPA? What internal
controls do you have in place before releasing claim money? Do you receive
check registers and what information is on the check register? Do you have
any other ideas on how we can resolve this dilemma with our employees?
The District has contracted for periodic claims audits. The audits have
focused on the accuracy of claim calculations.
TPA Contract Language:
TPA shall provide the District a bi-weekly list of claims submitted by
District covered employees ready for payment. The list of claims shall be
in a form acceptable to District and shall not disclose information
pertaining to medical condition and treatment except when agreed to by the
covered employee or necessary in connection with a determination of
potential exceptions to Plan exclusions.
I would appreciate replies by March 1.
Rhonda McFarlane
Chief Financial Officer
South Tahoe Public Utility District
1275 Meadow Crest Drive
South Lake Tahoe, CA 96150
Phone: (530)544-6474 x211
Fax: (530)542-7073
E-mail: [EMAIL PROTECTED]
