AudxGuard can help your plan stay compliant.
By choosing Audxguard, health plan entities will prudently and proactively identify areas for improvement and make informed fiduciary decisions to provide the best posssible outcomes to their beneficiaries, while also ensuring a compliant and truthful annual attestiation.
Audxguard saves your plan money and risk by validating that you are truthfully attesting as required by law. We’ll give you transparency into your data by analyzing medical claims for abuse, errors, overpayments, and contractual incongruities.
Who Has To Attest?
Self-funded group plans have the greatest burden with this requirement.
Employers with such plans may attest themselves or may contract with their Pharmacy Benefits Managers (PBM), Third-Party Administrators (TPA), or Administrative Services Only (ASO) coordinators to facilitate the attestation.
For fully-insured group plans, compliance is a little easier.
Both the insurance issuer and the plan are considered to be in compliance when the insurance issuer makes its annual attestation. In other words, when the fully insured health insurance carriers inevitably make and file these attestations, both the plan and its sponsors will be in compliance. In general, employers with fully insured group health plans do not need to act unless otherwise notified by the carrier.
Entities Required To Attest | Entities Not Required To Attest |
|---|---|
ERISA Group Health Plans | Basic Health Program Plans |
Student Health Insurance Plans | State children's health insurance program plans |
Grandfathered and grandmothered plans | Medicare and Medicaid Plans |
Policies sold through an association | Issuers that offer only short-term, limited duration insurance |
Policies sold on or off exchanges | Accident-only, disability, and worker's compensation |
Dental, vision, and long-term care | |
Disease-specific insurance | |
Account-based plans, such as health reimbursement arrangements (HRAs) | |
Issuers and group health plans that offer only excepted benefits coverage | |
Hospital indemnity or other fixed indemnity insurance |
CASE STUDIES:
How Are These Gag Clauses Affecting Plans?
Recent lawsuits highlight how harmful these clauses can be.
One suit, filed by Kraft-Heinz, alleges that Aetna failed as a fiduciary by wrongfully retaining millions of dollars in undisclosed fees and overpaying millions of dollars in medical claims.
Another suit filed on behalf of union plans alleges that Anthem failed in its fiduciary role by withholding necessary claims data from union plan administrators. The unions claim Anthem was enriching itself at the expense of unions and their members.
What's Next?
How we can help you meet your requirement.
What should you do?
Audxguard saves your plan money and risk by validating that you are truthfully attesting as required by law.
We’ll give you transparency into your data by analyzing medical claims for abuse, errors, overpayments, and contractual incongruities.
Plans should ensure their contracts with TPAs and other health service providers comply with the CAA’s prohibition on gag clauses. Plans should also prepare to submit a truthful and positive compliance attestation by Dec. 31, 2023.
​
Reporting Entities can enter into agreements with their TPAs to provide the attestation, but legal responsibility remains with the plan fiduciary.
​
Plans can attest to gag clause compliance with the federal departments involved at the Department of Labor's website. It includes instructions, a system user manual, and a reporting template.