With the trend towards more consumer-directed healthcare, employees need to be more aware of ways to save money and get better quality care from their benefit plans. Employees should make sure they know the Benefit Summary for each plan, what the plan will pay for vs. how much they will share in the cost. Employees are encouraged to follow a general continuing education to make the most of their benefits:
- Understand what you have (get and read all plan information);
- Ask, before you need it (talk to plan sponsors and providers of service);
- Be proactive, take responsibility for your own care and costs. With the trend towards automation, there are usually a number of on-line or phone-based tools available to get and track details of the plans;
- You may want to get a 2nd opinion, to determine the best course of action; And when deductibles are involved, employees have an incentive to obtain costs estimates to compare the costs of different providers, and then trading off the costs vs. quality of the providers of care;
- Be aware of your needs, as your life circumstances change;
- Know what to do if a claim is denied and/or you’re unhappy with your plan;
- Stay informed as changes occur, subscribe to websites and/or newsletters;
- Know what will happen if you lose coverage.
Here are some tips about working with providers:
- In-network and out-of-network providers usually will result in significantly different out-of-pocket costs which come in the forms of: annual deductibles, coinsurance and co-pays;
- Out-of-network providers (if covered) may also result in balance-billing, so you need to check your providers carefully;
- Depending on your policy, you may or may not need to get a referral from your primary care provider to specialists, and that may be a good idea even if the plan does not require it, since it is some evidence of medical necessity;
- For complicated or expensive procedures, prescriptions, dosages, etc., providers of care may be responsible to get pre-authorization from the plan prior to providing care – it’s a good idea for you to check with your insurance carrier for each procedure!
- Preventive, Routine or Diagnostic (be attentive to other similar sounding jargon, such as Screening, Maintenance, Follow-Up, etc. and ask for clarification) claims may be processed differently, so it’s a good idea to know what type you are getting, in case you need to follow-up with the insurance claim and/or provider billing department;
- A claim may involve multiple procedures, examinations, immunizations, labs, radiology, pathology, anasthesia, etc. so you should work with your providers to find out what might be or will be performed;
- If there has been a lapse in your coverage for a specific amount of time, your insurance company may deny payment for pre-existing medical conditions;
- When there’s only a small gap in coverage, or no gap between policies, providing your current insurance carrier with “proof of prior coverage” (also known as a HIPAA Certificate, or “certificate of creditable coverage”) can be a simple way to avoid unpaid claims;
- In addition to the above, insurance carriers will generally only cover medically necessary procedures!
Some denied claims are simply the result of administrative errors, such as:
- Incorrect coding;
- Misunderstanding the application of deductible and/or coinsurance;
- Wrong service dates, billing address or patient information.
Some employers provide a Health Advocate, as part of the benefits plans or separate from the benefits plans, to help employees with their benefits:
- Find the right doctors, dentists, specialist and other providers;
- Schedule appointments, arrange for special treatments and tests;
- Locate the right treatment facilities, clinical trials;
- Answer questions about test results, treatments and medications;
- Research and locate newest treatments, secure second opinions;
- Help cut through insurance red tape!
A Health Advocate can help explain employee benefits coverage and financial responsibility, whether a claim is approved or denied. Typically provided by a registered nurse (supported by medical directors, benefits and claim specialists), this service is less expensive than even my favorite group vision plan. Wellness programs such as these save money on direct healthcare costs, and also indirect costs that are born by the employer due to absenteeism and presenteeism.
For benefits proposal, contact firstname.lastname@example.org
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