Is AbleTo going to share my medical info with my health insurance?
May 9, 2019 12:24 PM   Subscribe

Got a call from a guy with AbleTo on behalf of Aetna, my health insurance provider. He asked me to confirm my DOB after he gave me my birth year. Then gave me their schpeel...

Basically, it sounds like they are trying to help Aetna customers manage and reduce depression / anxiety / stress and hopefully have less ER and hospital days. LSS, he said their 8 week program of calls with licensed therapists is completely covered by my health insurance. I said "Sounds great, do you share any medical information that I provide to the therapist with Aetna?" to which he of course swore up and down they wouldn't.

Should I take them at their word? Could my health care provider (or some future provider) legally use information I gave to this third party to negatively affect my coverage / benefits? State is CA if it matters. Employer is a small consulting firm and I already give back 10% of my salary in premiums and out-of-pocket, so I can't really afford for things to get worse on that front.
posted by allkindsoftime to Health & Fitness (4 answers total)
AbleTo Notice of Privacy Practices.


Payment: We will not disclose PHI (Protected Health Information) to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may use and disclose PHI to collect payment for services. We may also disclose PHI to insurance companies to coordinate the reimbursement of health insurance benefits. For example, if you provide us with health insurance information through an additional insurance company, we may disclose PHI to that other health insurance company in order to determine which company holds the responsibility for your claims.

Healthcare Operations: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may use and disclose PHI for purposes of performing our healthcare operations. Our healthcare operations include using PHI to determine fees to conduct quality assessment and improvement activities, to engage in care coordination or case management, to determine eligibility
for benefits.

To Plan Sponsors: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do
so by law. A plan sponsor is defined as the employer or employee organization that establishes and maintains the employee’s benefit plan. If you are enrolled in a group health plan, we may disclose PHI to the plan sponsor to permit the plan sponsor to perform plan administrative functions.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your PHI. The list will not include disclosures we made for the purpose of treatment, payment, healthcare operations, disclosures made with your authorization, or certain other disclosures. To request a disclosure accounting, you may contact us using the contact information at the end of this notice. You may request an
accounting of disclosures and the request may not exceed a six year time period. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your PHI, a description of the PHI we disclosed and the reason for the disclosure.

Restriction Requests: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. As permitted by law, we will not honor these requests, if it prohibits us from administering your benefits.

So - yeah, they will.
posted by Lunaloon at 1:06 PM on May 9, 2019

First, PHI includes things like you name, the date of session, the service provided and the diagnosis that would be needed by the insurance company if they are going to pay for your treatment. Also, the insurance company can audit your file at the provider to make sure the services being provided as billed. HIPAA has a much stronger wall in place between the insurance company and the provider. I think when they talk about sharing PHI with employer that would normally be information about who is enrolled in the plan, not diagnosis or use of their services. I don't know enough to know if there is a risk that your diagnosis might impact the company's rates in a way that could be disclosed.

If you already have a diagnosis of depression or anxiety, then I don't think this program will make things worse.
If does actually help you have less hospital or ER visits then I think it would be a win. (My logic - To the extant that there is any impact, it would be less if you are less sick.) If you don't have an existing diagnosis AND there is change in ACA and you have to buy insurance in a market that is allowed to discriminate or refuse to cover pre-existing conditions then there could be a risk. In general, I think it is worth it to get proper treatment for your problems and deal with the fall out, if any, later but I may be speaking from a place of privilege.
posted by metahawk at 1:19 PM on May 9, 2019

HIPAA already allows Personal Health Information, PHI, to be shared among healthcare providers, billers, and insurers. All are required to maintain patient privacy. If insurers were not able to share PHI, including diagnostic codes and diagnoses, they would not be able to pay providers accurately. Same arrangement applies to pharmacies, and physical therapy providers and others providers. Special protections above the typical HIPAA requirements exist for mental health diagnoses.

Your employer is not within this PHI "umbrella" and thus has no access to your PHI. They have a contract with Aetna, which has a contract with you. The employer is outside the PHI circle.

The third party entity AbleTo is required to obtain your permission to have the HIPAA umbrella extended to include them. It sounds like you don't want your Aetna-provided therapist to have any knowledge of what this organization might provide, which is your right. The last section you provided explains this. However, it may be to your benefit to allow communication between AbleTo and your therapist to enable coordination. You can always change the amount of communication later if you wish.
posted by citygirl at 2:15 PM on May 9, 2019

So high utilitization of ER services as defined by your insurance company is very very expensive. ER services are the most expensive way to get care, and ideally people would only use the ER in situations in which there is an actual emergency (but sometimes you can't know, and that's fine). It's a common initiative these days across insurances to have programs that try and address reoccurring themes that lead to high ER use. One ER visit can easily be 10 therapist sessions in cost, so if you drop your usage by one visit a year, it's a net gain for them.

So in terms of what your insurance already knows: you use the ER more than an average person (how it's defined can vary between insurers, but more than 3 visits in a year tends to be concidered concerning) your diagnosises, and your other health care utilization patterns (do you have a primary-care doctor, other specialists?).

Right now, pre-existing conditions are covered in the US period. It is the law. If this changes in the future, all the information is already recorded, they know or they wouldn't be offering you this program., and it's not going to change much honestly.

Generally therapists to get continuing care share the date you where seen. A diagnosis code, type of therapy, and usually something about target goals, like reduction in depressive symtopoms. You know the goals of this program already, though it could be something generic. Therapists don't give full notes of the session, and it's generally distilled down into pretty impersonal, measurable goals. Not all insurances require that part, but some do.

Basically the goal of a therapist is to give exactly enough info to get paid and no more.

If you want to do the program, i'd say go for it.
posted by AlexiaSky at 8:39 PM on May 9, 2019 [3 favorites]

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