The Huge Responsibility of the Self Insurance Admin….

As people learn more about self insurance,  one surprise to them is the lack of transparency that many companies give employees,  along with this, the power of the plan administrator. 

In our case the SVP of HR is the plan administrator. (This is discoverable, according to our plan, which you can ask for from your HR Department. Photo below.) 

Let’s break down the conversations my husband had with the SVP of HR last October. 

Interaction #1 as relayed to me by my husband: 

“John, IP is self insured and I’m the final decision maker. I’m running a $500MM business, and others have more expensive treatments, let me look into this.”

Interaction #2 at a later date, as relayed to me by my husband: 

“John, MaryEllen’s treatment is not FDA approved, I’m not going to approve it, and I’m not doing a favor for you.”

Concerning both of these statements my husband shared with me, I have a few takeaways. 

I find it interesting that, again, according to my husband, (and a very interesting response by outsourced “IP” lawyers, who wrote to John and me, on behalf IP) the SVP of HR denied all of these statements during the IP Helpline investigation. 

It’s interesting because everything he told John was essentially true to their approval process. It’s stated in their Consumer Driven Health Plan, which I still refer to as I try to understand and comprehend all of what happened to our sweet ME.  

(We’ll unpack the whole Helpline process later in the year. You will likely find it as concerning as I did.) 

Let’s dissect each pertinent quote now, from above: 

“I’m the final decision maker.” 

It’s true. At IP, the SVP of HR is the final decision maker. As I studied this, and those who understand the fiduciary role of the final decision maker, state/federal officials say this is the most dangerous organizational design for a self insured company. A lot of companies have committees that make the final decision so that one person with an agenda, or lack of skills,  doesn’t put the company at risk. 

Read below directly from EBSA document

Here’s another area we’ve not touched upon much yet. 

People are also shocked to find out the SVP of HR has full access to all of your health information, and this is the same person who leads key leadership selection decisions. 

The day I learned this, after hours upon hours on the phone with “Cigna” I was heartbroken. All these years as I begged for help with “Cigna”, and it was essentially a waste of time. 

(My recent post shared where night time calls finally helped us, if I truly got a Cigna employee.) 

However, the shock that many others share with us, is palpable.  What they thought was a private matter and was known only by Cigna, not by their employer, was/is concerning to them. 

This was was not as much a concern in the same way for me, 

(other than the phone call that shook me up, which was my very first realization that our daughter and my phone calls were at the very least known by my husband’s company. But also, perhaps, used to oversee my response to our daughter dying.) 

…because I was hoping anyone would listen to us and help us. 

But that is not the case for everyone. 

Many families spoke to “Cigna” concerning what are deep family matters, that they preferred their employer did not know about concerning their family member’s health. 

Privacy issue? Not sure, but I hope to dig into that more. Again, conflict of interest? Very possible. Which we will break down more at another time. 

Simply informing employees who is truly behind the health care benefit plan would alleviate this concern, and create more transparency. 

John reported his concern about privacy issues to the helpline team. He shared with me that the Director of Ethics and Litigation said, “We’re not worried about this. He doesn’t have time to look at everyone’s health care.” 

This doesn’t mean that other employees don’t know. They are, after all, working for the administrator of the plan. 

Shockingly, the concern expressed by employees wasn’t a concern of the Helpline process team. 

Now let’s break down more of the statements my husband reported he heard. 

“I’m running a $500MM business.”

As we learned more,  this one was very telling. 

Technically, it is illegal to “intend” to make money on self insurance. (I’ve a team digging for me for more on this.) The purpose of the plan is to first and foremost, give the consumer who purchases the plan, what is promised in the plan. In good faith. If after doing this, you make a profit, all’s well. But that’s not the primary purpose of the health benefit plan. 

Businesses are designed to make money. 

I have questioned this with others, who have told me,  he may wish  he said he’s running a $500MM self insurance program instead of what he said. 

Is it possible this is why he denied saying this? 

If you run an insurance business there are three ways I know of to improve profits. 

Aquire more customers, raise price, or lower cost. 

Our guess is MaryEllen got caught up in lower cost initiatives? 

Was she caught in bureaucratic red tape?  

Until EBSA taught us, (after we filed with ERISA), we didn’t understand this could be a part of what she was caught in the middle of. Slowly, it was becoming more apparent. More on this another day. 

Let’s break down more of the above quotes from above: 

“It’s not FDA approved.”

Either they didn’t know about the off label process (which is appalling since 40-60% of prescription drugs are administered through this),  or they used this as an excuse to deny it. 

My husband believed the persons who said this to him, until I taught him about the Off Label process, as taught to me by our Katie Beckett case worker, and a BlueCare TN specialty pharmacist. 

If a prescription is not FDA approved for a specific purpose,  it is always denied the first time. This is to be expected. 

However, when the 120 page document was sent through for the off label process, the state of TN then approved immediately…. 

Meanwhile, “Cigna” put ME’s doctor through the wringer, in spite of the fact that he did the exact same off label process for “Cigna” that he did for the state of TN. 

More wasted dollars for those on the medical team. The hours this took for Dr Hoy and his employees, is truly shameful, and a waste of hard earned money. There is a reason for the the off label process, and it should be properly followed.

Thankfully, her doctor, and his employees, did all they could do to correct this wrong. 

Now let’s breakdown the final statement from above:  

We addressed this in a previous post, but it’s important to address again. 

“I’m not doing a favor for you”.

This one hit John hard. 

He never asked for a favor. He asked for the review process to be done correctly. Fairly. And efficiently. 

I’ve said it before, I’ll say it again, those who know John, know that a favor is something he wouldn’t ask for. Following rules and processes that are designed to make the company a better place for employees, consumers, and anyone who works with a company, is what John stands for. 

It felt like a final gut punch. He believed MaryEllen’s treatment could never be done. He believed the HR employees. It took me, and many on ME’s health care team, hours to teach him otherwise. 

The document being withheld was all he needed to understand that incompetence was possible, when he believed “there was no way his company would ever do this.”

It’s also important to remember, that John has reported five similar cases that he’s aware of. He shared his desire to report these to the  highest levels of the organization. 

He has not been contacted by anyone to investigate. 

This  leads us to believe they have chosen not to investigate. 

Again, it begs the question… why?

We will continue to use our experience to educate you so you can protect your family from any mistakes or mishandlings by your self insured company. 

This entry was posted on Monday, November 6, 2023. You can follow any responses to this entry through the RSS 2.0. You can leave a response.

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