An employee questioned why he had received a check for $37,000 from the medical insurer. He did not understand why the insurance carrier was not, as he was used to happening, paying the bill.
The only recent medical services that he had was a trip to the Emergency Department for a severe hand laceration. There was concern that the injury would require surgery and a hand surgeon was called in to assess the situation. He determined that surgery was not needed and stitched the laceration in the ED.
When I called the insurer, I was told that the doctor was out-of-network, (a plastic surgeon, not a hand surgeon) so the payment was sent to the insured to then pay the provider. With respect to the amount of the payment, had the surgeon been in-network, the reimbursement would have been between $1,800 and $2,000. Since he was out-of-network, and because the plan paid emergency charges at the billed rate, his $37,000 bill would be paid.
- However, the employee still had an out-of-pocket maximum of $9,000 for which he would be personally responsible.
- The employee was shocked and outraged. He quickly got past his outrage when the doctor told him that he would accept the $37,000 as payment in full and mailed the check to the doctor.
So, a happy ending, correct?
- YES, FOR THE DOCTOR as he was paid, and YES FOR THE EMPLOYEE as he was not financially harmed.
- NO, NOT FOR THE EMPLOYER!
- The employer’s plan paid about $35,000 more than for an in-network provider.
- In turn, this impacted claim costs and therefore the employer’s cost and the employees’ share of the cost for medical coverage.
- MANY EMPLOYEES AND SOME EMPLOYERS DO NOT ASSOCIATE INCREASED CLAIM COSTS WITH INCREASED PREMIUMS.
What Can Employers Do?
- Continue communicating to employees that using network providers is important and not just because of cost.
- Health plans screen providers for quality and safety performance and credentialing standards. They also set ongoing quality standards and periodically re-evaluate their providers. Most plans have robust networks of physicians, hospitals, and other services patients will need.
- Not enough communication is done around the non-cost advantages of networks.
- Remind employees to check every time they are referred to a hospital, specialist, and laboratory to ensure that the provider is in-network.
- They need to check even if the specialist is associated with a network practice or hospital. It is their responsibility to make sure of the provider’s network status and no provider should be insulted to be asked.
Certificate (The Convention on International Trade in try this link cheap cialis Endangered Species of Wild Fauna and Flora).
- Make it easy for employees to find network providers.
- Most insurers have online provider lists so send them the link frequently and encourage them to use it.
- Consider communicating with your employees about how costs are calculated and the relationship between high claims and high premiums.
- As an employer you understand this relationship.
- However, many employees think the claims costs are the insurers’ problem and do not realize the direct effect on the total cost of coverage, including the portion by them.
- Work with your carrier on the issue of paying non-network physician specialists.
- It is difficult to find certain types of specialists in-network and employees should not be penalized.
- Know what your carrier will do if they do not have a particular specialty in-network or do not have robust network.
Author: Kathleen Sholinsky, Senior Consultant
For more information, including how Trinity’s team of consultants may be able to help you with BENEFITS MANAGEMENT RELATED MATTERS, such as cost containment and employee education and communication:
- Email me at KathleenSholinsky@TrinityHR.net or Trinity at info@TrinityHR.net
- Visit our website at www.TrinityHR.net
- Call us at 865.905.1762 or Toll Free at 877.228.6810
You have HR challenges…Trinity has solutions!