Understanding IRS Rules: The Importance of Substantiating Health FSA and DCAP Claims

Understanding IRS Rules: The Importance of Substantiating Health FSA and DCAP Claims

Introduction

In the realm of cafeteria plans, health Flexible Spending Accounts (FSAs) and Dependent Care Assistance Programs (DCAPs) play a crucial role. However, the process of claim substantiation often raises questions among administrators. This blog post aims to shed light on the IRS rules regarding claim substantiation for health FSAs and DCAPs.

The Necessity of Claim Substantiation

According to IRS rules, all health FSA and DCAP claims must be substantiated. This substantiation requires information from an independent third party describing the service or product, the date of the service or sale, and the amount of the expense. These requirements are designed to ensure that health FSAs and DCAPs reimburse only legitimate claims.

The Role of Debit Card Programs

IRS rules regarding debit card programs also require that claims be substantiated and reviewed. However, certain categories of expenses are treated as automatically substantiated without any receipts or review beyond the swipe.

The Risk of Substantiation Shortcuts

Administrators might be tempted to engage in substantiation shortcuts such as reviewing only a percentage of claims (i.e., sampling) or automatically reimbursing claims that are below a “de minimis” dollar threshold or that appear to be from medical or dependent care providers. However, these actions could jeopardize the income exclusion that would otherwise apply to reimbursements from these arrangements under the Code. This could result in all reimbursements becoming taxable, not just those approved using the impermissible techniques.

The Consequences of Non-Compliance

If a health FSA or DCAP fails to comply with applicable substantiation requirements, all employees’ elections between taxable and nontaxable benefits under the entire cafeteria plan will result in gross income. A March 2023 IRS Chief Counsel’s office memorandum reconfirms the substantiation requirements for medical and dependent care expenses, as well as the prohibition and consequences of sampling and other substantiation shortcuts.

While the process of claim substantiation might seem daunting, it is a necessary step to ensure the legitimacy of claims under health FSAs and DCAPs. Administrators must adhere to IRS rules and avoid substantiation shortcuts to maintain the tax benefits of these programs.

Source: Thomson Reuters

HHS Proposes HIPAA Standards for Electronic Health Care Claims Attachments 

HHS Proposes HIPAA Standards for Electronic Health Care Claims Attachments 

HHS has proposed regulations that would adopt a set of standards for the electronic exchange of clinical and administrative data to support prior authorizations and health care claims adjudication. As background, HIPAA requires that covered entities (and their business associates) comply with rules designed to standardize the format and content of specified electronic transactions. Specifically, the proposed regulations would adopt standards for “health care attachments” transactions that would support both health care claims and prior authorization transactions, along with a standard for electronic signatures. Regulations proposed in September 2005 would have adopted certain standards for health care attachments but were never finalized. 

Explaining that the prior regulations were not finalized due to comments about the standards’ “lack of technical maturity and stakeholders’ lack of readiness to implement electronic capture of clinical data,” the preamble to the new proposed regulations notes that despite the subsequent widespread deployment of electronic health records and greater industry experience with the HIPAA standards, transmitting health care attachments is still primarily a manual process. The preamble provides detailed information about the organizations responsible for developing and maintaining the transactions standards and advises that the timing for implementation is right because the industry consensus-based standards are now mature, and covered entities are ready to implement them. The regulations do not propose to adopt attachments standards for all health care transaction business needs. Instead, the approach is for covered entities to gain experience with several standard electronic attachment types so that technical and business issues can be identified to inform potential future rulemaking for other electronic attachments standards. 

Source: Thomson Reuters

HHS Proposes HIPAA Standards for Electronic Health Care Claims Attachments 

3 ways to access HRA funds

As many know, a Health Reimbursement Arrangement (HRA) is an employer-funded account that helps pay for a medical plan’s deductible and co-insurance expenses. There are three ways to access an HRA. Here they are as follows.

  1. Filing an electronic claim: this can be submitted by signing into your NueSynergy account.
  2. Filing a paper claim: a paper claim along with a copy of Explanation of Benefits (EOB) can be emailed to NueSnergy. A paper claim can be obtained by signing into your NueSynergy account or by calling NueSynergy’s customer service team (855-890-7239).
  3. Providing documentation: A copy of your EOB from your insurance company is required to approve any claim for reimbursement.

For more information on accessing HRA funds and about this account in general, check out this handout.

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