Follow these tips for your next open enrollment

Open enrollment is a period each year when employees can sign up for their company-sponsored health plan, and as the insurance industry has changed, open enrollment has, too.

“The importance of open enrollment and the enrollment process have changed significantly over the years,” says Carla M. Flamm, sales and retention executive at HealthLink, Inc. “With all the new laws, extensions and even the increased use of electronic filing tools, open enrollment can be quite complicated for the average employer.”

For some employers, this complication is too much to add to their ever-growing list of to-dos, so they opt for the bare minimum open enrollment process. However, by not taking advantage of the unique educational opportunities open enrollment can offer, employers may be missing a chance to help save money for the plan and for their employees.

Smart Business spoke with Flamm about five tips to help employers with open enrollment.

1) Start early

The most prepared employers start planning for open enrollment four to five months before it starts. Employers should start by working with their broker, third party administrator (TPA) and network partner to examine the current plan and its performance. From there, employers can consider changes to make next year’s plan more effective.

Employers should also start planning for the actual enrollment process. They need to make some big decisions early on, such as whether or not they will require each employee to go through the enrollment process so they can collect updated information, or if only employees with changes need to re-enroll.

2) Collaborate with your partners

Employers should work collaboratively with their broker, TPA and network partner to plan for open enrollment early. Together, they should evaluate claim history and spending trends to determine if benefit changes are necessary. They should also compare the current plan offering to similar companies to determine how competitive the benefits are. These partners should be an employer’s trusted go-to resource for ensuring the health plan offering and open enrollment process meets all industry standards and regulations.

3) Educate employees

After making initial benefit decisions, employers should be diligent about educating their employees of their options, any changes that may affect them and how to make good purchasing decisions. Employers should consider giving employees educational materials that focus on selecting a plan that is right for them by encouraging them to evaluate components such as deductibles and out-of-pocket maximums, instead of focusing solely on premiums.

4) Be proactive with information

Employers should send benefit and educational materials to employees no later than two to three weeks prior to open enrollment. Employees need time to be familiar with this information so that they’re prepared to ask questions and make their selections during the open enrollment period. Don’t wait for employees to ask for these pieces, get them out as soon as possible. Proactive education means HR departments can spend more time enrolling employees in their plan and less time answering questions.

5) Consider a health fair

Hosting a health fair is the best way to optimize the open enrollment period and ensure success. Employees can get the information they need to make the best choice for them, and employers can take advantage of the face-to-face time to complete health and wellness screenings and enroll employees onsite, eliminating confusion and saving time. Employers that offer these fairs should be sure that every component of the health plan, including medical, dental, life and disability, etc., are present at the event so employees have a complete understanding. These events should be easy and convenient for employees to attend, with a potential incentive for attending.

Insights Health Care is brought to you by HealthLink

What employers need to know as opioid problems hit the workplace

The opioid epidemic has reached every corner of society, including the workplace. This epidemic involves the use of prescription opioid (pain) medications, illicit drugs like heroin or fentanyl, or mixing opioid drugs.

According to the American Society of Addiction Medicine, opioid problems cost employers around $10 billion annually from absenteeism. Unfortunately, only a small percentage of those with opioid problems ask for help or receive it.

In recognition of National Recovery Month, Smart Business spoke with Dennis C. Daley, Ph.D., senior clinical director at UPMC Health Plan, who has more than 30 years of experience in clinical care and addiction research, about what employers need to know about this growing issue.

How prevalent is opioid misuse or addiction in the workplace? What can employers do for someone struggling with addiction?

Opioid misuse and addiction has reached all levels of the workplace — it doesn’t distinguish between gender, race, geographic location or income bracket. About 5 percent or more of the population has misused opioids in the past month and over 2 million have an opioid use disorder. Opioid misuse can involve not taking medications as prescribed, taking too much, mixing opioids with other drugs such as sedatives, giving or selling opioid pills to family or friends, or using another person’s prescribed opioids. Many people with an opioid addiction have other substance and mental health problems, which makes recovery more challenging.

Employers can support employees who may have an opioid problem or are affected by a family member’s issue, but it isn’t a supervisor’s job to diagnose the problem. If managers witness increased absences, decreased work output or out-of-the-ordinary behavior, they should focus on tangible behaviors and let the employee know these issues are causing concern.

How can employers address the issue?

The best-case scenario is an employee assistance program (EAP). Companies of all sizes can contract with an EAP, which is sometimes separate and sometimes a component of health insurance. EAPs often have clinicians and therapists on staff. They offer assistance in assessing problems, providing counseling, referrals, and training and education. If a manager suspects a problem, he or she can either contact the EAP directly or strongly suggest the employee seek help with an EAP.

It also can be difficult to maintain focus at work if you’re worried about a family member using drugs. Having a loved one suffer with an opioid or other substance problem affects millions of workers.

How else can an EAP help with opioid or other drug problems?

EAP experts will provide specific policies and procedures that can be shared at all levels of the organization. That way, employees know where to go for help if they are concerned about their own drug use or a family member’s substance use. EAPs are confidential. The EAP only divulges to the employer that the employee made contact and that there is a plan in place.

What do you tell employers without an EAP?

Work with your HR director and investigate an EAP. It is easy and inexpensive to partner with one and it takes a huge burden off of your managers and HR staff. There are also local treatment agencies, free or low-cost clinics, private therapists, websites such as, and community support groups like Narcotic Anonymous or Nar-Anon for families. At a minimum, employers should list these resources on the company website, bulletin boards or in the lunchroom.

What else should we know about opioid abuse and the workplace?

Although alcohol problems are more prevalent, opioid problems have substantially increased in the past several years. Prescription opioid use is declining, but more young people are transferring their addiction to illicit street drugs like heroin.

Employees struggling with opioid or other substance problems are not weak or morally corrupt, but they often need help accepting they have a problem or getting involved in treatment or recovery. Employers have an important role to play — they can help recognize the signs of a problem and then get treatment moving in the right direction.

Insights Health Care is brought to you by UPMC Health Plan

How to talk to your employees about their health

In today’s dynamic health care market, employers continue to look for new ways to curb spending and regain control of their health plan investment. For some employers, this means going directly to the source of the spending: their employees.

“Healthy employees are happier and more productive,” says Bridgette Bock, sales and retention executive at HealthLink, Inc. “Plus, without employee engagement, health and wellness and cost reduction programs are not effective. That’s why more employers are trying to make an impact by talking to their employees about their health.”

Smart Business spoke with Bock about strategies for talking to your employees about their health.

Why is it important to communicate with your employees about their health?

Communicating with your employee population about their health and different strategies for staying healthy is important because it helps keep the cost of care down. The typical consumer is not in the health care industry, so they may not be aware of the impact that their health has on their out-of-pocket health care spending or the impact it has on the cost of the health plan.

Employers that educate their employees about the available programs and services as well as best practices for staying healthy tend to have more success with their cost management strategies. Employers also have the unique opportunity to help their employees become more educated consumers by encouraging them to shop around and ask questions they may not have thought of on their own.

Do today’s employers have more of a responsibility to do this?

Absolutely. When an employer self-funds their health plan, it’s their money paying the claims, so they usually have more of a stake in keeping costs down. Self-funded employers are more likely to promote different incentive programs to engage employees and control costs.

However, with today’s rising cost of health care, even employers with fully-insured health plans should be taking an active role in talking to their employees about their health and educating them about the effect it has on costs.

What information is often misunderstood or not communicated when it comes to health and wellness plans?

Many employees don’t know that the majority of health plans cover standard wellness/preventive services at 100 percent, meaning there is no out-of-pocket cost to them. Employees also wrongly assume that if they never go to the doctor for a checkup, they’re saving money for the health plan. In reality, these employees may cost the health plan even more if they end up with health issues that could have been detected and treated through preventive visits.

Transparency is another topic that is getting more attention, but is still often misunderstood. Employees should be aware of the different transparency tools available to help them determine the costs of services so they can shop around and select the doctor or facility that is right for them.

What are the best methods and means to reach employees?

When deciding which methods may be most successful in reaching employees, it’s best to look directly at the employee population. Who are they? What do they do? Where are they located?

Employers should communicate with employees via the means that is best for the employees. For example, a large company with a diverse employee population may depend on the company intranet site or blog to distribute information. A smaller company may find that posting information in the break room is most effective. The method of communication should be unique to the workforce.

What else should business owners know?

Effective cost management entails more than simply adding a product to your health plan. Engagement really is key to success.

Employees should also understand that just because a doctor or hospital takes your insurance, it doesn’t necessarily mean they are in-network for your plan. If nothing else, an employer should educate their employees about the tools available to them to find in-network doctors and alternatives to the emergency room.

Insights Health Care is brought to you by HealthLink

How population health management can save you big money

The Integrated Benefits Institute recently reported that poor health costs the U.S. economy nearly $600 billion per year, with a significant chunk of that cost coming from lost productivity.

But employers are fighting back. One way is by incorporating population health management (PHM) into a benefits package. PHM is an increasingly popular and powerful tool that helps employers to rein in employee health care costs.

Smart Business spoke with Marion McGowan, Ph.D., chief clinical officer and senior vice president of population health at UPMC Insurance Services Division, about how PHM can help lower health care costs and raise employee productivity.

What exactly is PHM?

Population health refers to the specific illnesses or health problems that exist within a targeted group, such as the employees of a particular company. Managing population health involves developing interventions, incentives and other strategies that lead to better individual health.

Interestingly, this trend represents a sea change among employers. In today’s workplace, making use of PHM extends the responsibility and interests of the employer beyond just providing salary and benefits.

Why is PHM important to employers?

Many employers see improving workforce health as a key to long-term cost management. Healthy employees translate into more productive employees. With the right PHM program, employers often see more engaged employees who enjoy increased levels of job satisfaction. The goal is to try to prevent those who are well from becoming ill, while improving the quality of life and enhancing health outcomes for those who have developed chronic conditions.

Should employers ask their health insurance company about PHM?

Employers absolutely should ask about PHM. They need to know the value they’re getting and that their employees are getting the right care. The chief cost drivers in any insurance plan are the sickest employees.

A good PHM strategy can help anticipate the needs of the employees who use health care the most. It can also tailor interventions to help curtail unplanned and costly care, and help employees with chronic conditions get the preventive care they need before it becomes more expensive for everyone.

What if your health insurer doesn’t provide this? Can employers still buy it?

There are two types of PHM. One is an integrated program and the other is a stand-alone. The integrated approach connects data, such as pharmacy, dental, vision and disability information to an employer’s population health platform. That platform may include clinical and disease-management programs. Analytics transform health data into real insights that give a more complete picture of employee health. It also helps identify potential gaps in care. This allows for earlier intervention for people who are at risk for health issues or who may have chronic conditions.

How does that approach compare with the stand-alone management?

A stand-alone PHM program is a vendor solution that provides data analytics, care coordination and employee engagement tools. This type of PHM identifies and stratifies the risk in the employer group with the goal of improving clinical outcomes and financial results. These stand-alone PHMs tend to be costly and aren’t always the most effective route.

In terms of overall employer costs, is it worth it to invest in a PHM program?

Growing evidence suggests the investment is worth it. The ROI for a PHM program ranges from $1.40 to as much as $13 in benefits per dollar spent on the program.

Does a PHM program make sense for smaller companies?

Because of the dollars large employers have at their disposal, they are most involved in PHM programs. But it’s arguably even more important for small companies. In a small company with only a few employees, one person with a chronic disease can skew the cost curve and risk pool dramatically.

Whether it’s a large corporation or small family-run business, every employer has the opportunity to positively affect the health of its employees.

Insights Health Care is brought to you by UPMC Health Plan

How self-funding can help correct health care purchasing mistakes

Business owners may feel helpless when it comes to health care because it can seem as if it’s beyond their control. However, self-funded health insurance can actually correct some of the biggest health care purchasing mistakes.

Smart Business spoke with Susan French, director of marketing at HealthLink Inc., about why self-funding may be the answer to your health care concerns.

Mistake 1: Not knowing how much you pay for health care.

Many senior leaders don’t know the itemized cost of health care services used by their employees, even though it’s one of their biggest expenses.

With a fully insured health plan, employers pay a predetermined premium amount to cover medical services for their employees, whether they receive them or not. This leaves most employers without real knowledge of where premiums are being spent. With a self-funded arrangement, employers only pay for the medical services — or claims — that their employees actually receive. Employers who choose to self-fund their employee health plan receive an itemized bill for all the claims incurred by their employees, so they know exactly how much they’re spending and where the money is being spent.

Mistake 2: Believing that health care spending is out of your hands or is just the cost of doing business.

The flexibility that comes with self-funded arrangements makes them ideal for effectively using cost management strategies to save money for the health plan and employees. Employers that self-fund have access to detailed claim and utilization data that they can use to determine where they are incurring the most costs. Employers can sit down with their broker, third party administrator (TPA) or network partner to examine if there is an issue or lack of benefits at the root of high costs.

After there is a solid understanding of where health care dollars are being spent, there is an opportunity to better predict these costs and implement cost containment programs to control health care spending like never before.

While fully insured health plans also feature cost containment strategies, these programs and services remain under the control of the insurance carrier. For some employers, this is ideal. They prefer to take a more hands-off approach by simply paying a monthly premium and letting the carrier take care of the rest.

A self-funded arrangement is more hands-on. Cost containment strategies can be customized specifically to meet the unique needs of the employee group. In the end, the decision of which programs and services to implement, and how to structure the health plan, is up to the employer, not the carrier.

Mistake 3: Being in breach of your fiduciary duty to protect a health plan’s assets.

In a self-funded arrangement, transparency starts with the availability of clinical and financial data that employers can use to uncover utilization trends, high-risk members, inappropriate and/or costly treatments and plan waste. With a self-funded health plan, this data belongs to the employer. They have full access to it and the conclusions that come from it.

In addition, many network providers have developed transparency initiatives designed to help employers and their employees become more educated health care consumers. Tools that help employees look at the costs associated with different procedures and/or facilities, and tools to help employees decide which level of care is appropriate are examples of transparency tools that may be available through different network providers.

Mistake 4: Undervaluing human resources.

An HR department can be an invaluable resource when it comes to selecting and implementing an employee health plan. Often the HR department may have additional insights into the needs of the employee group, which can be useful when determining which benefits should be included in the health plan. The HR department should also be the go-to resource for educating employees and answering questions during open enrollment. Engaging the HR department during the decision-making process and having their buy-in can have a positive impact on the health plan.

Insights Health Care is brought to you by HealthLink

Sitting is the new smoking: How to fit activity into your workday

The prevalence of sitting jobs has risen 83 percent in the U.S. since 1950, according to the American Heart Association. The result? Employees are spending a lot more time being sedentary each day.

You may think that all of those hours you spend sitting at your desk are unhealthy. And they are — sitting for more than three to four hours a day may take valuable years off of your life.

Research is clear that sitting for long periods of time each day over many years can increase a person’s risk of cardiovascular disease, diabetes, depression, higher levels of stress, as well as neck and lower-back pain.

Smart Business spoke with Dr. William Shrank, chief medical officer at UPMC Health Plan, to learn more about what many experts are calling, “sitting is the new smoking.”

What are the benefits of standing?

Simply standing more each day provides overall health benefits and increases work productivity among employees. For example, research shows that you burn 30 percent more calories when you’re standing than when you’re sitting.

Standing more each day can also help improve posture, increase blood flow, rev your metabolism, and increase your energy and alertness.

How can employers encourage some small moves for big benefits?

Here are some quick and easy changes employees can make at work to improve their health and productivity — starting today:

  • Go vertical: Take the stairs instead of the elevator as you enter and exit the office each day and get in the habit of walking up the escalator instead of standing.
  • Take frequent detours: Take an extra lap or two around the office on your way to the restroom, coffee pot or printer.
  • Communicate like it’s 1989: Instead of sending emails to your co-workers, walk to their desks on a regular basis.
  • Make it automatic: Find an app for your phone or computer that prompts you to get up from your chair every 30 minutes and move around.
  • Track your steps: Fitness trackers or basic pedometers measure the amount of steps you take each day. Keep a log of your steps and push yourself to get a few extra steps each day.
  • Take breaks: Get in the habit of taking micro-breaks, such as standing while talking on the phone. Better yet, make it a point to walk for at least 10 minutes every day at lunch time.
  • Sit up straight: Proper posture while sitting is important for your overall musculature. Check your posture and remember to roll back your shoulders, squeeze your shoulder blades together, engage your core and straighten your back.
  • Toss it farther away: Move your trash or recycling bin away from your desk so you have to take a few extra steps.
  • Have mobile meetings: Instead of sitting in a conference room for a 30-minute meeting with colleagues, turn it into a walking meeting.
  • Give up your seat: Choose to stand on public transportation rather than sit.

What are other ways to encourage less sitting and more activity, long term?

Corporate wellness programs help employees to start fitting more activity into their workday. And it’s important to keep that momentum going over weeks, months and years.

One key is for employees to tap into their essential motivation for wanting to get more active. It’s often not enough to simply say that you should exercise more, or should burn more calories or should get a standing desk. Many employees need more tangible and basic reasons, such as wanting more energy or focus during their workday. Or perhaps they want to lose five pounds in the next month or want to be able to keep up with their kids or grandkids at the park.

For extra motivation to help employees to get more active each day, check with your health care plan to see if they offer health coaches that will help to guide your staff and stay on track with their activity goals. These health coaches can provide extra motivation for you to get up and go.

Insights Health Care is brought to you by UPMC Health Plan

Add maternity management to help cut costs and raise productivity

Integrating a maternity management program into a health plan is a win-win for moms-to-be and employers. Employees and employee spouses who are pregnant or planning to become pregnant can join the program to get the support they need to help them have healthier pregnancies and healthier babies.

“Every pregnancy is unique, that is why maternity management programs offer personalized support from the start of the pregnancy until after the birth of the baby,” says Judy Dawson, HealthLink sales and retention executive. “This support can help keep pregnant employees healthy, reduce their need for unscheduled or emergent care and keep their medical costs down.”

Smart Business spoke with Dawson about the benefits of maternity management.

What are the overall goals of a maternity management program?

The No. 1 goal of a maternity management program is to reduce risks associated with preterm delivery and low birth weight, and encourage employees to be more active in health-related decisions during pregnancy. To achieve this, the program focuses on educating and supporting pregnant employees from prenatal to newborn care.

Employees who enroll are sent educational materials and can receive customized help from nurse care managers so they can understand what is best for them and their babies. They also get access to a 24-hour, toll-free nurse line so they can connect with someone who can answer their questions or direct them to their best option for care.

How does a maternity management program impact employees?

A maternity management program can have a great impact on an employee’s pregnancy and her newborn. Once they join the program, they are assigned a nurse care manager who can provide a number of services, including giving moms-to-be information on healthy eating and exercise, providing education and information on labor options, helping smokers quit, checking for health risks, screening for depression during and after pregnancy, and more.

Every service is focused on healthier moms and healthier babies and can be customized to fit the unique needs of the mom-to-be. The educational materials alone can really impact the decisions a pregnant employee makes during the course of her pregnancy and delivery — and the added support can make a big difference in helping parents-to-be feel prepared and confident as they approach parenthood. For employees who may not have all the support they need at home, a maternity management program can make a huge impact.

What are the benefits to the employer?

Like many supplementary cost-management programs, a maternity management program can help employees achieve optimal health outcomes in a cost-effective and timely manner. This can lower costs for the plan and for the employee. A variety of studies show that maternity management can lower inpatient costs, reduce the number of low-birth-weight babies that require additional care and lower neonatal intensive care unit (NICU) costs by reducing NICU admissions.

In addition to the cost-reduction benefits, offering a maternity management program is a great way to provide additional support to employees as they go through a series of life-changing events. When employees feel supported, it can boost morale and even productivity, and in the case of moms-to-be, it can positively impact their overall health and their transition back into the workforce.

What else should employers know?

Maternity management programs may not be a good fit for all companies. Employers should consider the potential impact offering the program will have on employees before implementing a maternity management program. For example, if a company has a largely older or all-male population, it may not make sense to add the program. Many maternity management programs are purchased on a per employee per month, or PEPM, basis, so it’s important for employers to determine if the outcome is worth the investment.

Employers should talk to their broker or network partner to explore all of their health and wellness and cost management options.


Insights Health Care is brought to you by HealthLink, Inc.

Energizing employees about their health benefits

Surveys show that health benefits selection is confusing and stressful for employees. Getting your employees more involved in open enrollment and other benefits administration activities can pay big dividends in reducing this negative experience, says Jo Hartoyo, CTO at eBenefits Solutions, an affiliate company of the UPMC Insurance Services Division. This division includes UPMC Health Plan, UPMC WorkPartners, LifeSolutions, UPMC for Life, UPMC for You, UPMC for Kids and Community Care Behavioral Health.

Smart Business spoke with Hartoyo about ways to engage employees through their benefits selections.

What are the benefits of increased employee engagement?

According to a recent survey, when employees are actively engaged in choosing their benefit options, they are three times more likely to be satisfied with their jobs than employees who are not actively engaged.

Those who are actively engaged in choosing their benefits are twice as likely to value those benefits their employer is offering.

The key takeaway is that a more engaged employee is going to make better-informed benefit choices. This helps both the employee and the employer. The employee can potentially save thousands of dollars by choosing the right plan and the employer is more likely to save on overall health care costs.

How can employers encourage more engagement?

1) Offer integrated tools. It’s best to integrate decision-making tools, cost calculators and other helpful information directly into the benefits enrollment process. These tools enhance the benefits enrollment experience and provide a more interactive, engaging experience. This makes it easier for employees to evaluate options and to make the right decisions. This enhanced level of self-service has the beneficial side effect of freeing up your HR business partners so they can tend to higher-level strategic programs aimed at achieving an organization’s goals.

2) Provide user-friendly, web-based technology. Better-designed technology with simpler, more intuitive interfaces is vital for increasing employee engagement. Employees are consumers and, as such, expect retail-like websites that are easy to use. It’s also vital to allow employees the ability to enroll in and manage all of their benefits seamlessly through a secure single-sign-on technology platform.

In addition, single-page applications allow employees to access their benefits, claims information and human resource updates all on the same screen, as opposed to skipping around from screen to screen where each page has a different look and feel. The one-screen approach makes navigation far simpler, more intuitive and more responsive for a better overall user experience.

3) Communicate with a multi-channeled approach. A recent workplace survey found that when employees received benefits communications through their preferred channels — via print, email, onsite meetings or a combination — 70 percent were very confident in their selections. When employees didn’t receive benefits communications through their preferred channels, less than 40 percent were very confident in their selections. Overall, the study showed that when employees both receive communications and enroll through their preferred channels, they are more likely to make better enrollment decisions. They are more informed about health benefit details such as deductibles, out of pocket maximums, and employer contributions.

At the end of the day, in order to energize and engage your employees with their benefits, you want to make things easy for them.

A basic example of this is to allow employees to enroll online. This means employees can sign up 24/7 from their home or office and can check their selections and benefits any time. It’s also much easier for employees to compare plan options and benefit details when everything is online.

These simple strategies will yield a huge payoff in terms of getting employees more engaged in the process and happier with their benefit selections. This translates to more satisfied employees and higher employee retention.

Insights Health Care is brought to you by UPMC Health Plan

How to help employees reduce the risk of health care fraud and identity theft

The health care system in the United States is complex and unwieldy, which unfortunately makes it susceptible to fraud. While only a small fraction of health insurance claims are fraudulent, they carry a hefty price tag. Some estimates put the total cost of health care fraud at more than $200 billion each year.

“Health care fraud costs everyone money — providers, health insurers, employers and consumers,” says Veronica Hawkins, Medical Mutual vice president of Statewide Accounts. “Additionally, it can result in a loss of benefits, higher out-of-pocket costs and inaccurate medical records.”

Smart Business spoke with Hawkins about health care fraud and identity theft, and the role employers can play in helping to decrease the risk.

What does health care fraud involve?

Health care fraud involves using the health care system for financial gain. It can be committed by dishonest providers, pharmacies, medical equipment companies and other related entities. There are even organized crime groups that run complicated scams. The most common types of fraud are misrepresentation of services, billing for services not performed, altering claim forms for higher payments and providing unnecessary medical services to patients.

Fraud can also be committed by regular people who steal medical identities so they can see a doctor, get prescription drugs, receive medical equipment or file false claims with insurance carriers. This can affect treatment, insurance and payment records, and credit reports. A 2015 study found that more than 2 million people are victims of health care fraud each year. These victims have to pay an average cost of $13,500 to fix their stolen or compromised identity.

How can fraud impact patient care?

Patients who are victims of fraud may not get the treatment they actually need. If a doctor falsifies or exaggerates a diagnosis, a condition that someone doesn’t have could be added to his or her medical record. Fraudulent providers may order inappropriate medical services or expensive and unnecessary diagnostic tests.

In cases of medical identity theft, patient medical records can be compromised or legitimate insurance information can be used to submit falsified claims. This could make a big difference in your future treatment if your medical records are inaccurate.

How does it affect health insurance?

Health care fraud can have a big effect on insurance by leading to higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage. For employers, health care fraud increases the cost of providing insurance benefits to employees and the overall cost of doing business.

What role can employers play in helping to lower the risk?

Employers can help educate their employees about how to better protect themselves. First, encourage them to pay attention to their explanations of benefits and billing statements to make sure the listed services are accurate. Too often, people don’t read these documents thoroughly.

Member ID cards, explanations of benefits and other health plan correspondence should be secured just like credit cards. These documents need to be kept in a safe place so that no unauthorized people can gain access to them. It’s also a good idea for employees to monitor their credit reports to identify any medical debts.

In addition, employees should only share their ID numbers and personal health information with trusted doctors and other providers. Check the network of providers available and make sure to view their ratings. Beware of ‘free’ medical services or treatments, as these offers are sometimes used as way to get information for filing false claims.

Insights Health Care is brought to you by Medical Mutual

How to combine programs to create a superior self-funded benefit solution

One of the biggest advantages of a self-funded arrangement is the ability to customize the health plan to fit the needs of a specific group of individuals. For example, if an employer group has a large number of women who may be at the age to start a family, a maternity management program could be a great tool for them. Or if an employer group is mainly located in a rural area, or is more tech-savvy in how they want to receive medical services, a telemedicine program might be a good fit.

Whichever programs and services meet the unique needs of a group, employers may have the opportunity to bundle those core programs together, lowering costs and reducing plan waste.

“By bundling core programs, employers can be confident that they are not paying for unnecessary extras and their employees will receive the care they deserve at a price the employer can afford,” says Erin Davidson, sales account executive at HealthLink.

Smart Business spoke with Davidson about putting together a custom health plan in a self-funded arrangement.

How does an employer know which programs are best for employees?

Employers can look at past years’ claim data and the demographics and common characteristics of their employee population as a basis for deciding which programs to implement. Employers should also rely on their network account manager to help them review data and draw conclusions.

After employers have a better understanding of which programs and services will be the most beneficial for the group, they can work with their network partner to bundle the selected programs together at a discounted rate, rather than paying for them on an a la carte basis. Plus, when certain programs are bundled and working together, they can help employers control the cost of their health plan and optimize outcomes for employees.

For example, when you bundle network access with a medical management program, you can have a collaborative team of health care professionals working together to better identify employees at risk and offer guidance toward appropriate care management. This integration of the provider network with cost containment services achieves the best possible outcomes for the employee and the benefit administrator.

Many networks already have ‘bundled’ options for some of their most popular programs that they offer at a discounted rate.

Once they have decided which programs they want to offer, what is the next step?

Many employers don’t realize that their network provider offers these supplementary programs and services and when they bundle them with their network access, it may be less expensive. Also, when programs are bundled with network access, employers can ensure that the doctors who are overseeing precertification or case management are in-network.

Employers should work with their network partner to bundle and implement a plan that is unique to their company and their employee group.

Are there programs that work well bundled together? What about any that don’t?

When building a comprehensive plan, employers should aim to have all bases covered. This means medical coverage, as well as some specialty (vision, dental, life and disability) and health and wellness programs. Selecting coverage from each of these components can make bundling the programs easier and more effective.

What else do employers need to know?

Just because your network partner offers a bundled solution, doesn’t mean it’s right for your company. It’s important to do the legwork to decide which programs and services make the most sense for your company, rather than simply assuming packages that have worked for other companies will work for you. Employers should rely heavily on their network partners to help them make these decisions.

Employers should also remember that health and wellness and cost containment programs need engagement to be successful. It’s not enough that employers work to develop a comprehensive benefit plan; they need to be prepared to promote the plan to facilitate engagement.

Insights Health Care is brought to you by HealthLink