I have United Healthcare in my area (Northeast Ohio) and I can tell you that we’ve had many frustrating things to deal with (NOT in the SPD – in fact, it’s not about what is or isn’t in the SPD/certificate of coverage, but how things change so often, you can’t keep up and there’s no logical rhyme or reason for changes). For example, we’ve had a high deductible health plan for 4 years now. When we renewed this year, they told us that now, even after you hit your $2000 or $4000 deductible, prescriptions will no longer be covered at 100%. Now, a co-pay will apply. That was a hard enough pill to swallow (pun intended) – now you can be extend WAY past your high deductible limit. Then, we find out that Tiers no longer bear a reflection of the type of drug. In other words, just because a drug is generic, doesn’t mean it will be on the lowest Tier/lowest cost. How can you explain to a person that their generic drug is on Tier 3 – and has potentially a $60 co-pay? Finally, and the worst of all, in this first year of having co-pays in post deductible situations, we’ve had two people whose Rx have gone up in price! Why? Well, we don’t know the complete and final answer right now, but do know that the price of the drugs themselves haven’t changed, but the “negotiated” rate they pay has a UHC member has been removed. Now these people are paying 50-100% more for the EXACT SAME drug they were taking before they hit their deductible. It’s sad, rediculous, and really scary. Whether or not our current issue is really just an error on UHC’s part, look at how much control the insurance company has. You are rendered helpless until they can “get back to you” – which is typically AT LEAST 30 days.

Now, we as administrators have to try to stay positive for our staff, who are in essence our clients. But, when you see these absolutely crazy and illogical things happening, it leaves you little to go on.

The long and the short of it is if you think that healthcare is doing excellent, you are not seeing the big picture. While you try to believe that the majority of your staff’s claims are being handled correctly, when you see the blatant errors in front of you (or worse, when you see the absolute irrational decision insurers make, and disguise it as the convenient excuse of “that’s what your certificate of coverage now says, so there’s nothing we can do”) your good intentions turn into anger and disgust. After you get over your feeling of either vomiting or crying, you try to go back to the employee and work things out as best as you can. Again, if you think, as a whole, healthcare is fine and dandy – it is not!!! There is a huge mess going on – and if you are one of the few who have a limited experience with the errors, frustrations, etc. then count yourself lucky. I hope you don’t have to experience the absolute insanity that can occur.

For those of you in the same boat as me, hang in there. There are groups out there surveying for a better future. You can make yourself heard – I asked just to take part in regular surveys, and now I get calls at least 2-3 times a year (hopefully my feedback goes somewhere, and not in the trash). All we can do is push forward, and keep in mind that we are here to help our staff – and make things better, in our own little way.

Then to find out anything you have to call 3 different places the Kaiser Customer service, the doctor network, and the third party administrator for processing the POS claims. Any one of which can not give you the full story and if the employee does not ask all the right questions they do not get all the information that they need. Employees are not supposed to know all the questions to ask that is why you have customer service to help them.

My employees get over charged constantly. I sent so much time handling claims issue that I now have a Kaiser rep come on site once a month to handle these issues. That has reduced the amount of my and my staff’s time on medical issues. But it is frustrating to have employees complain that a spouse who is in a comma is moved to a Kaiser hospital in the middle of the night without family consent. It takes 4 phone calls to find her and 3 days to get her back to her doctors. Or that emergency room co-pay is $200.00 when in clear writing it is only $100.00 both customer service and my sales support staff kept telling me it was $200.00 and I had to ask to see it in print before they said sorry our mistake. Yet the employee was being billed and threatened with collection before we got that straight.

I have volunteered to discuss my situation with my medical brokers other clients that are considering this 3 tier Kaiser, plus I belong to several networking and HR groups. I tell everyone about my experience that is the only way we can make life easier for each other in HR. Share the good and the bad information.

To give you an idea of what they do, they pay out-of-network claims based on the rates they have negotiated with in-network providers. Therefore, rather than basing the payment on a percentage of what is reasonable and customary for the area, they pay based on a percentage of the rate they have negotiated with network providers. So they discount the allowed amount to mirror their network rate and pay the reduced out-of-network percentage, leaving the employee stuck with paying the difference. And that overage…which would normally be written off by an in-network provider…comes out of the employee’s pocket and doesn’t count toward the deductible or the out-of-pocket maximum for the year.

They also take a very long time to pay claims. I have had furious, frustrated, distraught employees begging for my help with claims because they had been turned over for collection because the claim had been hanging for such a long time. They seem to have the business philosophy that claims are to be paid only when some very tenacious people keep after them…and even then, they still don’t pay some claims unless you go through the appeal process. The last man standing wins and that is usually them and they know this will be the outcome if they just dig in their heals hard enough!

Another thing they do is process CPT codes differently than most. One example I ran into has to do with a mental health benefit. Every other company I had ever worked with prior to BCBS paid claims for medication management by a psychiatrist as a doctor’s visit because no patient therapy was involved. Only when actual therapy was involved (and it’s a different CPT code) did the visit count toward the patient’s allowed number of visits for a calendar year. Not so BCBS! They count those 10 minute office visits where the patient has to check with with the psychiatrist regarding their medication as therapy. We were self-insured and couldn’t even get them to change the way they processed these types of claims. It was a nightmare!

I would love to see some kind of national survey and database where real administrators and HR professionals could weigh in on things like this to help others avoid some of the problems that have been encountered. I think it would go a long way to drive better customer service and force some companies to act with more integrity. As much as insurance costs, we shouldn’t have to fight a battle to get the insurance companies to pay claims and take care of our employees.

Whew! Now I feel better. Sorry for the rant!