--- title: "Your Employer may be Paying UHC, Anthem, or CVS to Deny Your Care" slug: "250929-employer-paying-uhc-anthem-cvs-deny-care" date: "2025-09-29" author: "Holden Karau" description: "How self-insured employer health plans and third party administrators create opportunities for additional appeals" tags: ["ERISA", "self-insured", "employer-health-plans", "UHC", "Anthem", "CVS", "third-party-administrator", "TPA", "PBM", "appeals", "utilization-management"] readTime: "6 min read" --- Approximately [60% of Americans under 65 have health plans through their employers](https://www.kff.org/health-costs/health-policy-101-employer-sponsored-health-insurance/?entry=table-of-contents-introduction), with [35 million on "self-insured" plans](https://www.dol.gov/sites/dolgov/files/EBSA/researchers/statistics/retirement-bulletins/annual-report-on-self-insured-group-health-plans-2024.pdf). If you work at a large company there is a good chance at least some of the health plans offered to you may be self-insured. Self-insured plans are set up following the [Employee Retirement Income Security Act (ERISA)](https://www.dol.gov/general/topic/health-plans/erisa) and subject to Department of Labor oversight so you can take a look for those keywords in your summary plan description. These self-insured plans have been increasing in popularity, but most companies' core business is not running a health plan. ![ERISA PSA](/static/images/erisa-psa2.png) ## The Role of Third Party Administrators In most cases, your employer will contract with one of the big names you've heard of to act as a "third party administrator" ([TPA](https://www.healthcare.gov/glossary/)). For employees, the TPA is usually the face of the plan: they issue the ID cards, process claims, and often deliver the dreaded "denied" letters. In addition to your health plan's administrator, there may also be a separate organization called a [pharmacy benefit manager (PBM)](https://www.cms.gov/newsroom/fact-sheets/pharmacy-benefit-manager-transparency-measures-fact-sheet) who is responsible for approving (or denying) medication. To be fair, there can be benefits to TPAs and PBMs, most employers normally do not have the expertise to run a health plan nor do they have the staff required to negotiate contracts with all of the providers you might need. ## The Cost-Savings Focus Often, TPAs pitch themselves to employers on reduced costs which have to come from somewhere. While these savings could come from better contract negotiations, we believe that so-called "[utilization management](https://www.cms.gov/medicare/utilization-and-quality/utilization-management)" (or how aggressively they say no) is a large part of the savings that these TPAs are able to offer. As with TPAs, PBMs focus on cost savings but where those come from can be much more complicated. PBMs often receive [rebates](https://www.ftc.gov/news-events/news/press-releases/2024/07/ftc-finds-top-pharmacy-benefit-managers-inflated-drug-costs-over-1000) (or less charitably kick-backs) on certain drugs which can influence their selection of which drugs they will pay for (and how much). If you've ever had an interaction with your health plan where they couldn't tell you what medication would be covered it could be because the PBM and the TPA are not talking to each other. ## Why This Matters to You Now you might be saying to yourself "cool, why should I care?" – and that's because the complicated dance between your TPA and your employer can create additional informal opportunities for appeals. Another important reason to care here is if you're thinking about switching jobs – two plans from two different employers can be very different. With self-insured plans, often your employer's HR department can direct the third party administrator to reconsider coverage decisions and can be an additional, albeit informal, source of appeal. The biggest downside to this is it involves disclosing personal health information to one's employer, which for many sensitive issues may not be something you wish to do. ## Here's What To Do Even if your employer is unable to help (or you don't want to share your medical information with them), you can generally request [external review](https://www.healthcare.gov/appeal-insurance-company-decision/external-review/), reach out to the [department of labor](https://www.dol.gov/agencies/ebsa) (although they're pretty overworked in our experience), request claim file, ask for your plan documents & contracts (not just the summary plan description), and even proceed to court (although ERISA does cap damages for misbehaving administrators). Proceeding to court should be done carefully as while there are some protections against retaliation we've all known some companies with perhaps a limited sense of humour. At the end of the day, we think it's important for employers to ensure that their third party administrators act in good faith and represent their company values. Paying other people to be mean to you is a choice, and certainly not one we judge as an SF based company, but we'd love to see more transparency here from employers and insurers. So next time you're looking at a health plan or a denial, take a look and see if it mentions ERISA or who the regulator is. Also if you do have an ERISA plan, we'd encourage you to ask for the full plan documents at the start of every year – employers generally have 30 days to provide them to you and it's better to have them on hand and not need them than otherwise. ## P.S. If you're in HR, maybe take the time to let your employees know that you're there for if the insurance company is not being true to your values, you might be surprised just how often they're doing something you don't want. ### References - [KFF: Employer-Sponsored Health Insurance](https://www.kff.org/health-costs/health-policy-101-employer-sponsored-health-insurance/?entry=table-of-contents-introduction) - [DOL: Annual Report on Self-Insured Group Health Plans 2024](https://www.dol.gov/sites/dolgov/files/EBSA/researchers/statistics/retirement-bulletins/annual-report-on-self-insured-group-health-plans-2024.pdf) - [DOL: Employee Retirement Income Security Act (ERISA)](https://www.dol.gov/general/topic/health-plans/erisa) - [Healthcare.gov: Glossary](https://www.healthcare.gov/glossary/) - [CMS: Pharmacy Benefit Manager Transparency Measures](https://www.cms.gov/newsroom/fact-sheets/pharmacy-benefit-manager-transparency-measures-fact-sheet) - [CMS: Utilization Management](https://www.cms.gov/medicare/utilization-and-quality/utilization-management) - [FTC: PBM Report - Drug Costs Inflation](https://www.ftc.gov/news-events/news/press-releases/2024/07/ftc-finds-top-pharmacy-benefit-managers-inflated-drug-costs-over-1000) - [Healthcare.gov: External Review](https://www.healthcare.gov/appeal-insurance-company-decision/external-review/) - [DOL: Employee Benefits Security Administration](https://www.dol.gov/agencies/ebsa) - URL: https://www.fighthealthinsurance.com/blog/250929-employer-paying-uhc-anthem-cvs-deny-care/ - Site index for agents: https://www.fighthealthinsurance.com/llms.txt