Most Health Plan Problems Begin With Plan Administrator: Report

September 6, 2001 (PLANSPONSOR.com) - More often than not, consumers are not at fault for issues with their health plans, according to new data from Hewitt Associates.

Nearly three-fourths (71%) of reported escalated issues during an 18-month period originated with errors made by the plan administrator or care provider, according to the study. Those issues included disputes with access to care or billing.

More than half (54%) originated with the plan administrator, 17% with the care provider and the remaining 29% were attributable to the covered individual.

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The study was based on tracking of nearly 2,500 plan issues by Hewitt’s advocacy participant services from January 2000 to June 2001.

Claim Counts

The vast majority of issues reported (86%) were related to claims, while 12% involved access to care, and 2% fell in the “other” category. More than half (51%) of the overall claim-related issues required reprocessing.

Just 8% were classified as “critical,” that is, requiring resolution in 24 to 48 hours. The remaining cases involved issues that generally arose after care was received.

The major causes of reprocessing included:

  • balance billing within network arrangements
  • all or part of the claim missing
  • denial based on medical necessity
  • denial based on plan provisions.

The most common reasons for denials were medical necessity determinations and plan provisions limitations across all plan administrators.

Hewitt currently provides advocacy services for 16 benefits outsourcing clients, representing more than 2 million employees, retirees and their dependents.

Workers At Risk, Feeling Trapped

September 5, 2001 (PLANSPONSOR.com) - Only a fourth (24%) of American workers are committed to their employers and plan to stay on for at least two years, while over a third are at risk, according to a new survey by Walker Information.

The survey found that 34% of employees are “at risk” neither committed nor planning to stay. An even larger group (37%) was identified as “trapped”  not committed to their employer, but planning to stay on at least two years.

The results of the 2001 National Employee Benchmark Study are bad news for employers, with the replacement costs estimated to represent 18 months of those workers salaries, according to a study by consultant Hay Group cited by the survey’s authors.

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Above and Beyond

Just as critically, the survey notes that committed employees report a willingness to do things above and beyond the normal job requirements and would recommend their firm to other employees.

Just over half of all employees said they believe their firm treats employees fairly, with 50% acknowledging that their pay is fair, while a somewhat smaller 45% said workplace policies were carried out fairly. In addition,

  • 44% say they experienced genuine care and concern from their employers
  • 45% believe their firm cares about developing people for long-term careers
  • 41% believe their employers trust them.

Less than half feel encouraged to try new ways of doing things at work.

Unionized workers were more likely to fall in the “trapped” category (53% versus 34%), while just 25% of union members thought their employer showed genuine care and concern, versus nearly half of nonunion workers.

The survey consisted of 2,795 self-administered questionnaires collected during the second quarter of 2001 and represents employees across the United States.

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