The Most Common Benefit Issues Employees Experience

by Sarah Kline, 44North

Congratulations! You just completed your annual employee benefits renewal. Whether you made benefit changes or renewed as is, a new benefit year always comes with questions and issues. You prepared employees with an awesome open enrollment presentation, beautifully designed brochure, and a convenient online portal/app. Now your employee and their dependents are all alone at the doctor’s office, pharmacy counter, or opening that bill at home and something isn’t right.

Don’t panic. Let’s walk through the most common issues employees experience, and how to resolve them.

You’re not covered. When a provider or pharmacist tells you you’re not covered, this could be for a variety of reasons. Within the healthcare and insurance industry, there is an immense amount of data flowing between your enrollment process, your insurer and the provider/pharmacy, and there is no such thing as a perfect system.

If your provider isn’t finding your coverage, the first thing to ask is if they are using your current insurance information. When you give your provider your insurance information, they store it in their system. That’s why you don’t have to show your card at every visit. If you receive a new card from your insurer, be sure to show your new card at your very next visit.

Did you know that at some pharmacies, your insurance information could be tied all the way down to the individual prescriptions you’re filling? This means even if your information is updated for your overall account, the old insurance information could still mistakenly be used to bill your individual prescriptions.

Coordination of Benefits. Employees and their dependents may have access to a variety of insurance coverage sources. The benefits you provide as their employer, their spouse’s employer plan, Medicaid, Medicare, and Tricare are some of their options depending on their specific situation. They all need to know about each other and know their place in the order of who pays. Even if your employee has no other coverage to coordinate with, your insurer needs to know. Just as with #1 above, there is a lot of data flowing between all these parties, and if there is any breakdown in communication it can cause issues.

“A member received a bill for over $46,000. Understandably he called in a panic. When I contacted their insurer, I discovered the claim had originally been paid, but the payment was pulled back, because the member hadn’t updated their coordination of benefits information with them indicating they no longer had other coverage. I helped the member through the process to update the Coordination of Benefits information with the carrier. The claim was then processed correctly, and the member only owed $540,” shared Niki, a 44North Patient Advocate.

Preventive v Diagnostic Benefit. When the Affordable Care Act required plans to start covering preventive services with no charge to members, it created another layer in the health insurance claims process. Everything in the claims process is based on codes, and there are over 100,000 codes to choose from. What you thought was a simple office visit equated to 10 different codes in the billing process. As with #1 and #2 above, there is a lot of data flowing between the provider and your insurer. Not only do those 10 codes need to be billed, but the order they are billed in could impact how the claim is paid. We all know preventive services should be at no cost to the member, but sometimes the preventive code that tells the insurer to eliminate member cost share gets lost in the mix.

Billing Errors. Between 30% and 80% of medical bills contain errors, and an audit by Equifax found that for hospital bills totaling $10,000 or more, there was an average error of $1,300. How does that happen? At the risk of sounding like a broken record, there is so much data flowing through the healthcare and insurance industries that it’s more of a surprise when things go right. What’s the average lay person supposed to do? As the proverb goes, “The best defense is a good offense.”

When employee benefits is one of the largest items on your balance sheet and is a critical component to recruiting and retaining top talent, it’s key to maintain the integrity of what you’re providing. A breakdown in any part of the system could leave employee’s feeling their benefits aren’t really a benefit. In addition to being an informed healthcare consumer, ideally you also have access to a benefits professional 24/7 to navigate and resolve benefit issues on your behalf.

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