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Employment Resources


By March 1, 2008No Comments

Is your benefit department routinely tied up responding to complaints about medical claims for your company’s health plan members?

Medical claims problems are frequently the result of poor information and/or poor communication. Try some of the following methods to reduce the confusion, relieve the burden on your staff and improve the satisfaction of your plan members.

Remember, any time your staff works with personal health information, special care must be taken to assure that the information is treated confidentially and in compliance with all applicable HIPAA privacy rules.

Hold orientation sessions about health care benefits for members
It’s human nature to pay less attention to information that is not immediately useful. Consequently, many people who receive new benefit information do not absorb important changes if those changes do not appear to affect them at that time. Consequently, when the need unexpectedly arises, your plan member may not remember, for example, that she must place a call to her primary care physician within 24 hours of an emergency department visit.

One way to work around the “relevance/absorption” issue is to make effective use of scenarios during orientation sessions. The group leader should provide fictional examples of situations that illustrate new benefit rules. These examples will cause most people to apply the information to potential situations in their own lives and imprint the correct procedures or generate questions that will clarify information.

Hold orientation sessions about health care benefits for health care providers
This technique will not be practical in large city settings but can be very useful in smaller communities. If your company is introducing a new health plan into the community, everyone will need to incorporate new rules into their work. Invite the office staff of a local physician, hospital admitting and billing staff and others as appropriate to an orientation session with the insurer.

These staff members juggle many sets of health plan rules each day and, expectedly, cannot always keep information straight. They will be much more likely to integrate your new plan rules into their office practice if you have provided an opportunity for them to receive a full briefing and ask questions.

Select health plans that offer interactive Web sites
Medical claim problems often occur because the physician office or hospital admitting department has no way to verify eligibility or ascertain the specific rules related to your company’s plan. Health plans with interactive websites allow providers to go online and check eligibility, determine special rules, note any changes to the policy benefits, etc. This connectivity solves many of the potential medical claim problems.

Establish a regular meeting with the insurer to review medical claim issues
HR staff should keep a log of all medical claim complaints and status. Persistent problems should be turned over to the insurer with direction to resolve. In general, this technique keeps your HR staff as an intermediary so they are aware of problems but provides for the appropriate transfer of those problems to the insurer in a forum that requires follow up and reporting back results.

Data collected during this process, e.g., number of complaints, time to resolution, etc, can be useful evaluative tools. If your communication with the insurer is facilitated by a third party insurance broker, be sure that you have an agreement with the broker that all health information will be handled in compliance with HIPAA privacy rules.

HR as Advocate
Your staff will always play a middleman role for plan members because they are your members’ advocates to the health insurer. However, using these techniques should reduce the referee burden on your benefits group.