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Two House Democrats want all employers with self-funded health plans to file Form 5500 annual plan reports, and they want the reports to include coverage denial statistics.
Rep. Bobby Scott, D-Va., and Rep. Mark DeSaulnier, D-Calif., put that proposal in a letter they sent last week to Julie Su, the acting secretary of the U.S. Labor Department, and Lisa Gomez, the assistant secretary in charge of the department's Employee Benefits Security Administration.
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Today, only employers with 100 or more plan participants must file Form 5500s.
Scott and De Saulnier asked the department officials to eliminate the exemption for small plans and to require plans to send in more data.
The extra information should include "the number of approved and denied claims, appeals, unpaid claims, and the annual dollar value of paid claims," the lawmakers said.
If possible, the department should also "ensure claims denial information is disaggregated by type of services (such as treatment for mental health and substance abuse disorder) and is provided with details regarding the utilization of artificial intelligence and automated processes in making adverse benefit determinations," the lawmakers said.
Scott is the highest ranking Democrat on the House Education and the Workforce Committee.
DeSaulnier is the highest ranking Democrat on the House Education and the Workforce Committee's Health, Employment, Labor and Pensions Subcommittee.
Scott and DeSaulnier wrote in response to physicians' longstanding frustration with health plan utilization management programs and with news reports of plans using artificial intelligence systems and harsh algorithms to deny many requests for coverage and claims without looking at the applications for more than a few seconds.
State insurance departments can set claim review standards for insurance companies.
But Scott and DeSaulnier noted that, because of the way the Employee Retirement Income Security Act works, only the federal government can regulate self-funded employer plans' utilization management strategies and prior authorization program vendors.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
