Can Your Plan Recover Money It Wasn’t Responsible for Paying?

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That’s What Subrogation and Reimbursement Are All About

When a plan member requires medical treatment following an injury or accident, their health plan is almost always the first line of defense. In some instances, however, the responsibility for medical treatment should really lie with another insurance plan, such as the member’s auto policy or workers compensation coverage.

In most cases, the health plan pays the claim and has the option to use subrogation to recover the funds from another insurance company. In other instances where a third party may have been responsible for the injury or accident, it may be necessary for the health plan beneficiary to seek compensation from the third party’s insurance carrier. This process, known as reimbursement, will require that the responsible third party pay for the damage they caused, including the plan member’s medical treatment.

Serving the Plan’s Best Interests

Diversified Group helps self-funded clients use these tools to make sure their plan only pays health claims it is responsible for paying. While some employers are hesitant to use subrogation and reimbursement, plan sponsors have a fiduciary duty to ensure prudent management of plan assets. And while there are costs associated with these activities, the funds recovered will help cover future claim costs incurred by all plan beneficiaries. To learn more about subrogation, reimbursement and other matters related to fiduciary responsibility, talk to Diversified Group today.

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Isn’t Everyone Entitled to Know the Cost of Care?

doctor

The President’s Executive Order Demands Healthcare Cost Transparency

We have long chronicled the huge price swings that often exist among healthcare providers in the same locales. To combat this situation and help patients find low cost, high-quality care, the President recently signed an executive order directing HHS to develop rules requiring hospitals to publish clear and understandable pricing that reflects what people will actually pay for tests, surgeries and other procedures. HHS also wants the rules to ensure that providers and insurers give patients information about their potential out-of-pocket costs before receiving care.

While lobbyists argue that this requirement will only drive prices higher, the administration sees enabling patients to know how much hospitals charge as a relatively simple idea – one that will promote greater competition for health services and reduce costs for consumers.

When the Administration required hospitals to post prices online earlier this year, the step had little impact. Data included billing codes that few people could decipher and list prices which few people ever pay. While the rules for this order must be developed, it is intended to require that hospitals disclose what patients and insurers actually pay in a format that patients can understand.

We’re certain that the rules will not be written overnight and not without loads of input. But if an executive order can lead to an environment where patients can understand what costs lie ahead and how to find more affordable, high-quality options, then let’s give it a shot.

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Who says wellness isn’t worthwhile?

Business woman posing with exercise mat

Experience shows that worksite wellness is a big part of every high-quality health plan.

We take exception with a recent JAMA study that said wellness simply isn’t working. While we could point out many reasons why their assessment is short-sighted, our main objection is that their viewpoint was based on the assumption that all wellness programs are the same. Not true!

Corporate Fitness & Health, our worksite wellness subsidiary, has designed, implemented and maintained customized corporate wellness programs for businesses since 1985 – long before worksite wellness became a common part of the employee benefits landscape.

After serving as a consulting resource for clients around the country, CF&H knows that like health plans, there are no cookie-cutter solutions to worksite wellness. Our experience in both the fully-insured and self-funded markets helps CF&H design programs that work because they target the risks driving healthcare costs.

One thing we will concede is that short-term returns from wellness are tough to come by. Health is complex and you simply cannot influence behavior overnight. Yet, CF&H generates 80% participation in the corporate wellness programs it manages and 61% say their program has lowered healthcare costs.

Fostering a culture of wellness within an organization does take time. But when long-term health and well-being, employee attraction and retention and developing a sense of community within the work space are at stake, the investment is more than worthwhile.

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How Much Are “Ineligibles” Costing Your Health Plan?

Employees

If your plan isn’t managing eligibility at enrollment, you’re probably throwing money away!

Managing eligibility in a self-funded environment can place a big burden on HR Directors, not only at enrollment, but throughout the year. Employee benefit elections, dependents and beneficiaries must be monitored consistently and then there are new hires and terminations to deal with.

Not all TPAs are alike when it comes to managing enrollment and eligibility. While some accept existing data in an effort to save time, Diversified Group goes to extremes when onboarding a new self-funded group or helping an existing client with open enrollment. Some HR Directors find our detailed approach annoying but thank us later when their plans avoid the huge costs associated with an eligibility audit. Click on the following link to read about a local example.

http://www.courant.com/community/hartford/hc-news-hartford-internal-audit-commission-report-20190116-vdbxtfiganahnat3sa7szn3l2u-story.html

Diversified Group uses BenefitReady® technology to help employers and members facilitate many enrollment and eligibility functions. To ensure that benefits are available only to those employees and dependents who are eligible, we back this technology with knowledge and expertise.

Managing enrollment and eligibility may sound like a little thing. But little things add up, especially when they lead to costly claims your health plan should have avoided. Get the help you need to take control. Talk to Diversified Group today.

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What Good Is Information If People Can’t Use It?

medical expenses

CMS Administrator Seema Verma calls the new rule a small step. We couldn’t agree more!

According to recent reports, what was touted as a giant step for healthcare cost transparency has turned out to be little more than a puzzle few can solve. The rule, which took effect on January 1, 2019, requires that hospitals post their prices online in a machine-readable format for consumers to download. The problem is that the price lists, which payers refer to as chargemasters, break common procedures into retail-priced, coded components that are meaningless to the general consumer.

A law professor describes chargemasters as huge spreadsheets containing complex codes that only a billing expert could interpret. Determining the cost of a visit to the ER, for example, would require knowing the codes and locating the costs for all parts involved in the visit. Really? If the goal is to help people understand what medical services really cost, shouldn’t hospitals display prices they accept from health plans, or at least a typical range from low to high?

The Goal Is to Help Who?
HHS is currently seeking public comment on whether or not patients should have the right to see discounted or negotiated prices before choosing a provider. While most providers and payers and their respective associations cite antitrust violations and other concerns, it seems that providing healthcare consumers with price information in an easy-to-understand format could be a BIG step towards lowering costs for health plans and plan members. Isn’t that what healthcare cost transparency is supposed to do?

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Are You Encouraging Members to Shop for the Best Care and the Best Price?

It can be as easy as handing them a check for a percentage of savings.

In last month’s HCU, we discussed the flexibility that self-funding provides – emphasizing that within regulatory parameters, self-funding gives the employer significant power over plan design, selection of providers, ways to incentivize plan members and much more.

These days, more and more employers are choosing to reward employees who do their homework and find high quality care at more affordable prices. We’ve all heard about joint replacements in major markets ranging in price from $11,000 to $120,000 or hospital charges for baby deliveries varying from $8,000 to $35,000. Or how about the $300 nebulizer that can be found on Amazon for $118 – need we continue?

While naysayers are quick to complain about employees who seem oblivious to the healthcare cost crisis, smart employers are encouraging their members to become part of the solution.

Many incentivize employees to help lower prescription drug costs by waiving copays on generics. Encouraging the use of Telemedicine and Minute Clinics goes a long way to help reduce Emergency Room utilization.

Still other plans are giving a significant percentage of their savings back to every employee who chooses a recommended hospital for a costly procedure. This can amount to hundreds or even thousands of dollars – real money!

These measures are not rocket science. Rather they are good old-fashioned common sense – no different than choosing one credit card over another because it gives you cash back on your purchase. We respond to incentives all the time and so do your employees.

To learn how Diversified Group helps self-funded employer groups turn members into responsible healthcare consumers, just give us a call.

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Who says your health plan has to cost 5% more every year?

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Done right, self-funding provides the flexibility needed to control costs.

A 2018 Kaiser Employer Survey showed that the cost of employer-based, family coverage rose to $19,616, an increase of 5 percent from the prior year. While this increase may be considered moderate or acceptable by many employers, we work hard to help our self-funded clients raise the bar (or in this case lower the bar).

In contrast to fully-insured plans, partial self-funding gives employers the freedom to write their own plan document. This enables our clients to adopt a totally different mindset – a “take charge” attitude that not only allows a plan to meet employees’ needs but encourages members to do what they can to keep costs in check.

After focusing on plan design and cost management, we turn our attention to claims data. While others may be quick to pay claims, we help clients look closely at claim costs each month. We use the data to identify trends, treatment patterns or chronic conditions that have the potential to result in a high dollar claim. When we see something that raises a red flag, we go to work on it immediately, looking for ways to minimize costs while striving to achieve the best possible outcome.

The bottom line is that sitting back and hoping that healthcare costs won’t increase next year will not accomplish a thing. Managing the rising cost of healthcare takes know-how, expert administration and the ability to act when cost saving opportunities surface. These are the things we do for our clients each and every day. To raise the bar for your health plan, give us a call at your convenience.

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