Consumers Not at Fault for the Majority of Escalated Health Plan Issues; Hewitt Data Shows That Employees Are Generally Taking the Right Steps to Resolve Health Care Disputes.

Business Editors

LINCOLNSHIRE, Ill.--(BUSINESS WIRE)--Sept. 5, 2001

More often than not, consumers are not at fault for issues with their health plans. According to new research from Hewitt Associates, a global management consulting and outsourcing firm, 71 percent of reported escalated issues, such as access to care or billing, were originated because of errors made by the plan administrator or provider of care, and not by the participant.

Nearly 2,500 plan issues were tracked by Hewitt's participant advocacy services over an 18 month period, from January 2000 through June 2001. Findings show that 54 percent of the issues originated with the plan administrator, and 17 percent with the provider of care, while only 29 percent originated with the employee or retiree.

"The results are surprising because many people, including health care experts, would guess that the exact opposite would be true," said Marie Kobos, health management practice leader for Hewitt's advocacy services. "This shows that many employees are taking the correct steps to resolve benefit plan issues, but still need assistance with an escalated issue in navigating the health care system, which can sometimes be both frustrating and complex."

The majority (86 percent) of reported issues were related to claims, while 12 percent were access to care issues and 2 percent were defined as other. Only 8 percent were critical, requiring resolution in 24 to 48 hours, while 92 percent were considered non-critical, which usually arises after care was received. Most of the critical issues were because participants couldn't receive access for treatment. Of the total issues, 90 percent were medical, 9 percent dental and 1 percent were for other types of coverage.

More than half (51 percent) of the overall claim-related issues required reprocessing. The major causes included balance billing within network arrangements, all or part of the claim missing, denial based on medical necessity or denial based on plan provisions.

"These types of situations require a high level of teamwork for resolutions and administrators have been very responsive in working with us on these issues," added Kobos.

For 26 percent of the claim issues, Hewitt confirmed the action initially taken by the benefit plan and provided education to the employee or retiree. The most common reasons for denials included medical necessity determinations and plan provisions limitations across all plan administrators.

"An employer can expect that approximately 2 to 4 percent of their medically enrolled employees and retirees each year will experience an escalated issue which requires assistance," said Kobos. "The good news is that the percentage is relatively small compared to the number of benefit plans that a large employer typically offers. But, the bad news is that these types of issues are very time consuming, emotional and complicated for the employee, which can lead to decreased productivity, morale, as well as overall dissatisfaction with benefits."

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

Hewitt Associates LLC is a global management consulting and outsourcing firm specializing in human resource solutions. With 2000 revenues of nearly $1.3 billion, the firm ranked among the Top 200 of Forbes magazine's listing of the largest private companies and has the largest employee benefits consulting business in the United States.

                              Definitions

Access Issue
An employee or retiree (includes covered dependents) who is in need of
health care but is encountering a hurdle in obtaining care.

Administrator/Plan Administrator
The name of the health plan an employee is enrolled in.

Claim Issue
Any issue that stems from the filing, processing, or payment/denial of
charges for care rendered that the employee/retiree has been unable to
resolve. One attempt has been made by the employee to resolve the
issue before Participant Advocacy is contacted.

Critical Issue
A critical issue denotes: access issues with a potential delay of
health care; claims issues that, if not resolved, will cause action to
be taken against the employee/retiree; or other issues involving
controversial situations, expatriate access and claims issues or
service complaints. The advocate will work to resolve the issue within
24 to 48 hours.

Non-Critical Issue
A non-critical status is applied to access and claim issues that do
not have to be handled immediately.

Other
A quality of care issue, service complaint, or expatriate issue.

Participant
The employee or retiree who works for the advocacy client and who is
requesting assistance.

Provider
The licensed person who renders health care to an employee or retiree.