NU Online News Service, Sept. 5, 10:27 a.m. – Hewitt Associates, Lincolnshire, Ill., a global management consulting and outsourcing firm, has new research that indicates that more often than not, consumers are not at fault for disputes with their health plans.
According to the research, 71% of reported escalated problems, 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 of this year, Hewitt says.
Findings show that 54% of the problems originated with the plan administrator, and 17% with the provider of care, while only 29% originated with the employee or retiree.
The majority (86%) of reported problems were related to claims, while 12% were related to access to care issues and 2% were defined as “other”. Only 8% were critical, requiring resolution in 24 to 48 hours, while 92% were considered non-critical, which usually arises after care was received, according to Hewitt.
Most of the critical issues occurred because participants couldn’t receive access for treatment, according to Hewitt. Of the total issues, 90% were medical, 9% dental and 1% were for other types of coverage.
More than half of the overall claim-related issues required reprocessing, Hewitt says. The major causes included balance billing within network arrangements, all or part of the claim being missing, denial based on medical necessity or denial based on