Your Right To Appeal

Health care and the processing of claim is not a perfected science. Claims get coded incorrectly by providers’ offices, sent with incorrect ID information, or processed incorrectly through benefit plans. For health care consumers, it can take some digging and effort in order to get these matters corrected. Sometimes, it even takes an appeal (or multiple appeals).

Based on a recent article by Money Magazine:

·         15% of health claims are denied

·         14% of denied claims are appealed

·         50% of appeals are successful

As patient advocates for our clients, the McGohan Brabender Customer Care Team acts as the patient advocate – mentioned in section 4 – to help identify errors, craft appeals, and escalate the battle when necessary.

Make sure to check out Money Magazine’s article for more information on your right to appeal!

Update: Express Scripts/Walgreens Negotiations

Express Scripts, the company that administers [Anthem/Empire/UniCare]’s prescription drug Plan has been notified by Walgreens of their intention to leave the network when the contract expires on December 31, 2011.  The parties are still in negotiations and Anthem hopes to have this signed by the end of the year.

We have heard that Walgreens is informing customers of their intention to terminate the relationship at the end of the year with letters.  

Below you will find a Q/A sheet that Anthem has distributed.  Please feel free to use this information as warranted.  As we have more information to share, we will continue to update this blog.

Thank you

Anthem FAQ

Controlling the Cost of Healthcare – for the Employer

The cost of healthcare seems to always be on the rise, both for employees and their employers. Various plans have been introduced throughout the years to help control these costs – from front end deductibles to high deductible/HSA plans. Recently, United Healthcare and McGohan Brabender partnered to launch a new, innovative program and product to help employers earn significant trend and rate adjustments for their renewals call Bend the Trend.

The easiest way to understand how the program works is to break the program down into Years 1 and 2.

Year 1 establishes the foundation for the Bend the Trend Program at the employer level. To "get on the field to play," employers agree to some basic strategic commitments in the following categories: wellness, optimal plan components, outcomes-based plan design, diabetes prevention/control. Don't worry, it sounds a lot more complicated than it actually is -- and chances are good that you're probably already doing some of it or all of it already. If you are an existing UHC customer, you can go ahead and start at year 2.

For meeting each employer strategic commitment, points are awarded Click Here to Download PDF Chart . The more commitments you meet, the more points you earn. Thus, the greater the premium discounts.

Beginning with your Year 1 start date, the Year 2 clock begins ticking. Now we need your employees to get involved. Do you remember those four strategic buckets we started with at the employer level? Well, we take those same four buckets and add some employee activities to them. Some are very simple, and others may require a little more effort – but that's ok. Our goal is to get your employees to own their health care plan…not rent it!

Just as with the employer commitment, employees earn points. Some of the points are awarded for participation while others are based on outcomes.

At the end of Year 1, your Year 2 rate adjustments are determined. This is done by adding up your earned Year 1 and Year 2 points. The greater your points, the greater your rate adjustment.

Want to know more about this program? Check out the Bend the Trend website for a potential financial impact calculator, wellVibe trailer, and a contact form!

Top 10 Reasons Your HSA Does Not Match Your Deductible #3

3. You put a deposit down for a procedure and are owed money back.

The growing trend of consumer driven health care has meant changes for the benefits offered to employees (higher deductibles, HSAs, FSAs, and HRAs). Those significant changes have also meant changes for providers. Higher deductibles mean that many providers will not receive any payment from insurance companies if deductibles have not yet been met, as the responsibility will be on the patient. With procedures that can easily go above and beyond a member’s high deductible, some providers are beginning to require deposits to be put down before they will perform surgeries or other costly procedures for members with high deductible plans to ensure that they will receive payment. Some members choose to use their HSA funds to pay for these deposits, and if their claim processes so the member’s responsibility it less than the deposit they made, the member’s HSA and deductible will be un-even until the provider gives the member the refund that they are due.

For instance, let’s say that you have a $1000 deductible and start the year with $1000 in your HSA. You go to the hospital because you are having stomach pains. After a day of observation, you doctors have decided that you need surgery. The surgery is expensive, though, and to ensure that they receive payment, the surgeon requires that you pay a $500 deposit. You pay this out of your HSA, leaving you with $500 in your HSA and $1000 deductible to be met since no claims have been submitted yet.

Your claims from the hospital are submitted to the insurance first and total $1500. Your insurance processes this, applies $1000 to your deductible, and pays the remaining $500. Then, your surgeon submits her bill to your insurance for $10,000. Since you have already met your deductible and do not have any co-insurance due, this claim is paid in full by your insurance and you do not owe anything. However, you now receive a bill from the hospital for $1000 and only have $500 in your HSA. Everything has been done correctly by insurance, but now that your surgeon has received payment in full for your claim, you are owed $500 back from the deposit you put down. Once those funds have been returned to your HSA, you will have $1000 in your HSA and can pay in full your responsibility to the hospital for $1000.

Want to know to rest of the top 10 reasons your HSA does not match your deductible? Check out the McGohan Brabender checklist and look for upcoming and previous articles explaining the other reasons!

Pregnant? Check out United Healthcare's Healthy Pregnancy Program!

Pregnancy can be one of the most exciting time of a woman’s – and couple’s – life. At the same time, it can also be a time full of questions, concerns and confusion regarding medical care, the options available, and what steps should be taken to ensure a healthy baby and mother.

In order to make this process easier, United Healthcare has created a site healthy-pregnancy.com that can be accessed by anyone as well as a program for expectant mothers on their plan.

At healthy-pregnancy.com, you can utilize tools such as a due date calculator, week by week baby growth explanations, fitness and nutritional tips, descriptions of the types of delivery available to women, and resources such as an appointment tracker and links to sites that can help you know more about the care your planned hospital offers. Make sure to check out the birth plan checklist (which is printable) so that you can easily communicate your birth plan to your entire labor and delivery team.

The program that United Healthcare has created also provides additional resources to their members. By enrolling for the Healthy Pregnancy Program during the first 33 weeks of their pregnancy, expectant mothers are given access to 24-hour toll-free access to experienced pregnancy and childbirth nurses, educational materials and resources, as well as one-on-one support. Currently, over 41,500 high-risk pregnancies has been identified and supported by the nurses of this program, helping expectant mothers to be more informed throughout their pregnancy.

Tour Your United Healthcare eServices site!

Utilizing employer eServices sites can be a wonderful tool for HR Administrators. With just a few clicks of your mouse, you can have the ability to enroll new hires, order ID cards, and ensure that your employees' benefits are processed in real time!

Although this option can be a blessing for many administrators, sometimes the systems can be difficult or confusing to navigate at first. Thankfully, United Healthcare is one of the carriers that has been proactive in ensuring that groups feel comfortable using their eServices websites.

If you would like to take a guided tour or use an interactive site demo, United Healthcare has created these options to ensure that your can confidently utilize the eService site. We have even added a link to the guided tour on our video tutorial page for you to go back to should you ever need a refresher!

Change Forms

Have employees needing to make changes to their benefit elections throughout the year due to qualifying events? It is important to supply them with the correct form so that the carrier can process the change request.

To simplify this process for you, you can now access change forms for many of our carriers here on our blog!

Resources for Staying Up-to-date on Reform

Staying up-to-date with the latest health care reform is not only important for groups, but it is also important for individuals. Knowing what is in the Afforadable Care Act and how it applies to you or your groups policy can make a large impact on how you utilize your benefits.

One of my favorite sites for group is the McGohan Brabender Health Care Reform site. Not only does is provide clarifications of many changes to health care, but it does so in an easy to understand format. If you are your group's plan adminstrator, I strongly suggest that you take a moment to peruse this site.

Additionally, I have found that Health Care and You is a nice site for both employers and employees. Here you can find state and age specific changes to laws as well as a handy timeline as changes have become effective.

It may seem as though there is a lot to know when it comes to keeping up-to-date on health care reform, but utilizing helpful resources such as these sites can ensure that your group - and employees - stay informed.