Contradictory Guidance? Prescription Drug & Healthcare Cost Reporting Confusion

This is getting into the weeds a bit but it goes to show that the details matter when it comes to reporting.  We learned this the hard way with our first compliance company in 2015 called  Remember how hard that first year of ACA reporting was?  The good news is that it got easier over time.

Now … on to this contradiction that is certainly going to cause some confusion.

The instructions ask that the reporting entity submit data on behalf of plan sponsors on a 12/15 type basis.  For those of us with stop-loss experience, we know this to be claims that were incurred in 12 month period and paid within 3 months after the end of the contract.

For Prescription Drug and Healthcare Cost reporting our reference year is always a calendar year so this means we are looking for claims to be reported that were incurred in a calendar year and paid by the end of March the year following this reference year.  Simple enough, right?  As you likely guessed, there are two problems …

First, in the paragraphs following they then ask for claims liability that have been incurred but not reported as of March 31st.  What?  If anyone has some insight into what this might mean shoot us a message.

Secondly, they ask that these claims be BEFORE any stop loss reimbursements.  With stop-loss contracts that don’t match up to calendar years this is going to also cause some confusion and interpretation as to what we should include or not include based upon the time of reimbursements.  Theoretically this might end up being simple, however that is going to depend entirely upon the TPAs system and how the claims are pulled out for this reporting.