Within the last two years I was working with a client with approximately 400 employees on their medical plan who was contemplating transitioning from a fully-insured plan to a self-funded plan.  Approximately 6 months prior to their potential go live date of the new plan, it was revealed to them through a meeting with their current carrier that there was a member on the plan with an extremely expensive medication, one that was projected to cost over $750,000 in one year. To the carriers credit, they did share the name of the drug however very little else would be released, such as prognosis, who the claimant was, etc, “due to HIPAA restrictions”.  

Now why would an employer need to know who it was? I am in no way suggesting that this employer, or any employer, would make decisions surrounding how to manage their plan that would target any particular individual. This is illegal. What if, however, by knowing who the claimant was, additional information may be brought to light that could inform decision making.  For example, what if it were known that the particular individual in question was scheduled to retire in a few months, or was relocating to FL and taking a new job. Knowing this sort of information may lead an employer to make drastically different decisions about how best to manage their plan if it was available to them. The exact same thing could be said about having prognosis information.

In this particular case, armed with the name of the drug I was able to conduct extensive research into what it treats, projected future costs, and develop strategies to ensure the patient continued to receive the medication while mitigating the exposure to the plan. In the end, I was able to identify a strategy that mitigated the risk (i.e. cost) to the plan for all claims of this nature while not putting any individual with a similar claim at any additional financial risk. The impact was a $700,000 savings to the plan.