By Martine G. Brousse (still not AI)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
September 9, 2024
Watch the video:
If you are getting health insurance through your employer, are you aware of the two main types of plans available on the market? Do you know which one you carry? It is imperative to know, as this affects your benefits and remedies in case of issues.
Let's see the differences, pluses and minuses, and how to best take advantage of each.
A. What are they?
Self-Funded plans
These plans - also called "ERISA" plans, are plans whose expenses, such as claims for its members, are paid by the employer, usually a large company
The company - NOT the insurance company - assumes all the financial responsibilities and risks of covering their employees' claims.
Those plans do NOT rely on an insurance company to determine benefits, but instead let the employer set the parameters of coverage, extend of benefits and exclusions.
The insurance company whose name is on the card and EOBs, acts as a third party administrator, managing the plan, processing claims, issuing EOBs, handling appeals, providing a network of contracted ("In Network") providers but NOT actually paying the claims.
Although the insurance is involved in using the terms of policy to process claims, it has NO authority or power to change, extend or limit them. It acts on behalf of the employer, not on its own or its members' behalf. Hence the common complaint of lack of assistance or support by employees.
Plans are administered and supervised by the US Dept of Labor, which handles last-degree disputes and appeals
2. Fully-insured plans
These plans have been bought on the open market from an insurance company, either as a stand-alone plan, or within a "group" of employers, joining forces - and $ - to reduce costs and get more affordable premiums
In exchange for a monthly premium, the insurance company takes on the full financial responsibility and cost of the employees' medical claims
The insurance company determines the coverage and benefits, and sets exclusions based on its own standards or criteria.
The employer paying the premiums has NO authority or power over the terms of coverage or exclusions
Plans are administered and supervised by the State's Dept of Insurance, which handles last-degree disputes and appeals.
B. Pluses and Minuses
Self-funded plans Pluses
Members have 3 levels of appeals, in case of disagreement with the way a claim or request for an authorization was processed or denied. An appeal is the right to demand a review of an action which has turned detrimental to the member (i.e. denial of a treatment or Rx, rejection of a claim, incorrect processing of a charge..). The first 2 levels go to the insurance, the 3rd to the Dept of Labor's ERISA Review Board.
As the employer determines what is a benefit or not, HR or Upper Management can overrule the terms of coverage and easily authorize exceptions and extensions by ordering the insurance to cover a service. For example, they can approve your experimental cancer treatment or extend the number of ABA therapy visits for your autistic child beyond the 24 per year that the policy allows for.
What the policy will/should cover can be a bargaining tool at the time of negotiations. Should a policy cover more services, could mean less of a salary increase for employees, who would otherwise have to dig into their pockets to pay for non or under-covered health services.
It is easy for the company to address specific needs for the population of employees and their demographics. For example, a company employing younger healthy folks will appropriate less $ to cancer treatments or heart-supporting Rx and allow more toward preventive care or stress reduction.
2. Self-funded plans Minuses
The ERISA review Board usually only rules on whether the terms of policy were ignored or mishandled NOT on issues related to medical necessity, access to clinical care or billing issues. In those cases, the 2 levels of appeals with the insurance would be "it".
As the insurance itself holds no authority to change terms of coverage, it can offer limited support or options when special circumstances or needs occur, and all too often will reject appeals based on the parameters set by the employer
The plans are not always mandated to follow State or Federal guidelines, and can often opt-out. Only when the Law clearly includes such plans, must self-funded plans comply.
3. Fully-insured plans Pluses
There are 2 levels of appeals, the first with the insurance, the second with the State's Dept of Insurance where the plan is registered.
The insurance has more flexibility to issue special authorizations, exceptions, extensions of benefits or higher payments based on special circumstances: medical needs, lack of In Network provider, delayed access to care, new medical policy, treatment or Rx newly approved by the FDA, etc.
Policies can be "stretched" with documentation and evidence
4. Fully-insured plan Minuses
Only 2 levels of appeal, so don't waste them!
Depending on the State, that Dept can be more or less favorable toward patients. CA for example is very patient-friendly, Texas not so much
The State where the plan is registered as a business entity not necessarily your State of residence, supervises these plans. If your employer is registered as a business in more than your home state, and buys a policy in another state where it has headquarters (for example), that State would handle 2nd degree appeals
Premiums and coverage is not based on a specific population (working in the one company) and therefore can cost more to those not using many medical benefits
Choices of group coverage or plans can be limited in certain states, especially if the smaller company only does business from one State.
C. Some Tips
Self-funded plans
Don't turn to the ERISA review Board for clinical-related issues, as they will usually reject it. These are not doctors or medical specialists, but administrators whose job it is to enforce general terms of policy
Instead, turn to HR or Upper Management if an insurance's hands are tied. Once your employer sends the OK, the insurance will issue that payment or authorization.
If you and your colleagues have too many complaints against the insurance company administering the plan provision, file a complaint with HR. That insurance can be fired, as they are getting paid to provide supportive and helpful services to you.
2. Fully-funded plans
Know your policy or at least the headlines: check out the summary (blue pages) or the entire "evidence of coverage" document, especially if you need to use something in there against the insurance (happens more often that you think!)
Know the major laws: Federal No Balance Act, your State's main patient-protection laws such as Access to Care. Your insurance may not follow these mandates - by willful disregard or incompetence.
Take a look at your State's Dept of Insurance website. You can get info on legal mandates, file a complaint, file a 2nd degree appeal or learn more about the quality rating of your insurance
But first of all, KNOW YOUR PLAN!!
Ask HR or your insurance company as getting stuff covered and paid for (correctly!) will depend on that info. No point wasting your time and effort on the wrong regulatory agency or administrator!
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
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(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024
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