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Employment Resources


By April 1, 2011No Comments

If your benefit department is frequently tied down responding to medical claim complaints from your company’s health plan members, it can be a huge burden for the department to handle and create widespread dissatisfaction. Many medical claim issues tying up the system are the result of poor communication and poor information. There are a few simple methods that can be put into place to simultaneously relieve the burden on your benefit department and decrease confusion and increase satisfaction among plan members and providers.

Benefit Orientation for Members. Some people may retain information from just reading it, but many of us retain information better if more than one sense is used during the learning process. This means not only reading a pamphlet, but seeing and hearing the information too. Another problem with retaining information is that people tend to pay less attention to that which isn’t immediately relevant or useful to them. The result is that members don’t absorb what they view as irrelevant and often don’t remember the new rules when an unexpected benefit issue arises in the future. One way that you can get around these two problems is by presenting scenarios during your orientation sessions. For example, new benefit rules could be presented by the group leader using fictional examples of applicable situations. This element of presentation can make participants more at ease to ask questions, better help them relate the information to their own lives, and retain the information for future use.

Benefit Orientation for Providers. Although orientation sessions for health care providers aren’t very feasible in highly urban areas, it can be workable in smaller communities. You might invite local hospital billing and admitting personnel and a local doctor or clinic’s office personnel to an insurer orientation session. Affording provider personnel this opportunity to hear new plan rules and ask questions can help them smoothly integrate the new plan rules into their office procedures and distinguish your particular health plan rules from the countless others they see.

Choose a Health Plan with an Interactive Website. Many medical claim problems are the direct result of a hospital admission office or doctor office not being able to check the specific rules of a company’s health plan or verify a member’s eligibility. The connectivity of a health plan with an interactive website can solve many medical claim problems by allowing providers to determine rules, note policy benefit changes, and determine eligibility with a simple click.

Review Medical Claim Problems and Issues with the Insurer. Direct your HR personnel to keep a running log of all medical claim complaints and their status. Problems that are persistent should be sent to the insurer with a request for resolution. This makes your HR personnel the intermediary contact for medical claim problems and the insurer responsible for follow up and apprising you of any resolution results. The time it takes to resolve the issue, number of complaints, types of complaints, and other data collected during the process can be excellent evaluative tools. Do keep in mind that HIPPA privacy rules must be complied with any time your personnel works with health information. So, if you use a third party insurance broker to communicate with the insurer, then you must have an agreement with the broker that confidential health information will be handled in a HIPAA compliant manner.

Playing the Advocate. Your HR personnel will always be the member advocate with the health insurer and play a middleman or referee role between the two. That said, the clarity and increased satisfaction brought from initiating the above techniques should cut down on the frequency with which this role must be played.