OPM Proposes Claims-Level Data Collection in FEHB Program

The Office of Personnel Management (OPM) has initiated a proposal to collect claims-level data from carriers under the Federal Employee Health Benefits (FEHB) program. This program, which covers over 8 million federal employees and their families, is the largest employer-sponsored health plan in the U.S. It involves 65 private insurance carriers, including Blue Cross Blue Shield, Aetna, and Kaiser Permanente.

Typically, private carriers process claims and maintain provider networks for the FEHB, while the government sponsors the plans. OPM's new proposal seeks detailed data from these insurers, including medical and pharmacy claims, provider information, and manufacturer rebate details, with monthly updates. This change represents a critical shift in how oversight is conducted within the FEHB program.

Enhancing Oversight and Cost Management

OPM aims to enhance oversight of health benefits, ensuring they remain competitive, quality-driven, and affordable. This initiative mirrors practices of large employers managing self-funded plans, who use detailed data insights to improve cost management and plan performance.

OPM's move from a federated data model to a centralized one aggregates data across carriers, raising privacy concerns due to the identifiable nature of the data requested. Unlike standard de-identified analytics, OPM plans to collect personal health information, including names, diagnoses, and treatments, prompting questions about privacy protection.

Regulatory and Privacy Concerns

This development comes amid recent changes, such as the establishment of the Postal Service Health Benefits Program. This program addresses FEHB's financial challenges by mandating Medicare enrollment for postal retirees, thereby reducing the risk pool burden on FEHB.

The implications of OPM's data request raise crucial concerns regarding data aggregation and privacy. While the objectives of negotiating premiums and improving oversight are essential, OPM must ensure robust privacy safeguards are in place. Balancing these regulatory concerns with oversight needs is an ongoing challenge, with details on protecting data privacy remaining unresolved.