The importance of industry experts in a time of health care reform

As the new presidential administration approaches 100 days in office, upcoming health care reform continues to develop.

“The House recently shared its preliminary plan to repeal and replace major components of the Affordable Care Act (ACA), but there will likely be many changes to the bill, titled the American Health Care Act, before it is passed,” says Erin C. Davidson, sales account executive II at HealthLink, Inc. “Once finalized, the new bill will likely have a direct impact on employers who recently transitioned to an ACA-compliant plan, or who were planning to do so in the near future.”

Smart Business spoke with Davidson about what to expect and what employers should know about the future health care reform.

What changes to health care reform can employers expect in the upcoming year?

One significant change is that employers who have ‘legacy plans’ that were supposed to transition to ACA-complaint plans by Jan. 1, 2018, may be able to keep their current plans through December 2018. The Centers for Medicare & Medicaid Services recently announced another one-year extension for transitional (grandmothered) policies. As details of the American Health Care Act are finalized, we should learn more about what changes, if any, may directly affect employers in the next year.

One thing is certain, self-funded plans are not regulated as heavily as fully insured plans, so they are not subject to certain reform regulations and mandates. In addition, employers who self-fund their health plans have been able to minimize the impact of the ACA and eliminate some premium taxes. Therefore, the current uncertainty surrounding future health care reform may have less of a direct impact on employers who self-fund their employee health plans.

With this uncertainty, where can employers get reliable information and advice?

No matter the state of the industry, it is very important that employers have a partner they can rely on for reliable, unbiased information. This could be their insurance broker, or their insurance carrier account manager or representative. For employers who self-fund their health plans, it might be their third party administrator (TPA) or network partner.

In times of change, an established relationship with an industry expert becomes even more valuable as employers have to decide the best option for offering health care benefits to employees. The wisest employers rely on multiple resources to gather information and make decisions. This means self-educating themselves about changes in the industry, gathering input from a variety of industry experts and examining options, such as self-funding, that safe guard their health plan from industry shifts.

However employers choose to make important policy decisions, they should have an industry expert they can rely on for information and advice.

Has the importance of relying on industry experts changed over the past five years?

Since self-funded arrangements come with the ability to customize nearly every aspect of the plan, it has always been important for employers to rely on industry experts to ensure they select the best network and programs for their employees.

In regards to fully insured health plans, health care reform has perhaps deepened the way employers rely on experts. Previously, employers depended on experts, such as insurance brokers, to shop around for them and ensure they were receiving the best coverage and the best rates. Once the ACA took effect, employers began relying on these experts more heavily to not only ensure they receive the best coverage and the best rates, but also to determine which mandates applied to their company and ensure they met requirements.

What else should employers know?

Many network providers and insurance carriers already have established relationships with industry experts that employers can take advantage of when searching for a partner to meet their needs.

Whether it is a broker, TPA or network provider, employers should talk to experts about the state of the industry, upcoming reforms and how their health plan may be affected by changes.

Insights Health Care is brought to you by HealthLink

More employers look to outsource leave management services

Managing employee leaves of absence is becoming more complex for employers of all sizes. Nearly every day, there are updated interpretations and applications of the Family and Medical Leave Act (FMLA) and Americans with Disabilities Act and Amendments (ADA/ADAAA). Plus, the increasing number of states and regions passing additional leave laws, paid and unpaid, make this complicated for all employers.

That’s why more employers, large and small, are looking to outsource leave management services.

Smart Business spoke with Linda Croushore, senior director of Disability Services for UPMC WorkPartners, about how to navigate the challenging proposition of managing absence.

How many companies are currently outsourcing leave management services?

The Disability Management Employer Coalition (DMEC) and Spring Consulting Group found in its 2016 Employer Leave Survey that 34 percent of all employers with 50 or more employees are now outsourcing FMLA management. Employer groups with more than 1,000 employees are outsourcing their programs at a rate of 45 percent, while also looking for help in managing the ADA leave accommodation process.

In general, what are the pitfalls that make employers seek help?

The DMEC study confirmed that one of the most difficult things that managers and supervisors face is accurately tracking intermittent leaves. Employees may also have difficulty accurately accounting for their time away from work. It is frequently a manual process and the timeliness of the reporting becomes an issue.

Failure to accurately account for missed time leads to missed opportunities for the employer to evaluate the validity of the time being requested against the FMLA. Accurate and timely completion of the medical certification needed to support the intermittent leave can also be a stumbling block.

What did the study find to be the major leave management challenges for most organizations?

According to the DMEC study, the top challenges facing organizations are:

  • Managing intermittent leave.
  • Training and education about roles and responsibilities of managers.
  • Integrating with ADA/ADAAA.
  • Managing workers’ compensation leaves in conjunction with the FMLA.
  • Managing short-term disability with the FMLA.
  • Coordinating leaves with attendance policies.
  • Relying on managers for leave enforcement.
  • Keeping up with new federal, state and/or municipal/county laws.
  • Controlling employee abuse.

How can employers streamline the process?

An area of increasing litigation is the end of leave process used by employers in relation to ADAAA. In many cases, employers do not offer an extension of the federally mandated FMLA time as an ADAAA accommodation. In addition to time away from work, other situations may arise where an employee asks for accommodation for a protected disability.

While some requests are straightforward and require little interaction, many of the disabilities for which an employee may request accommodation are not clearly recognized and could easily be ignored. These situations require discussion with the employee and the health care provider to determine functional abilities and possible accommodations. The employer is obligated to provide a reasonable accommodation that allows the employee to function in the workplace. However, the requested accommodation may or may not align with that definition.

What should employers that are considering outsourcing look for?

In seeking a third party administrator, look for one that can provide a streamlined process that centralizes intake, and integrates management of leave and short-term disability claims. Look for one that can act as a single point of contact for employees, their health care providers and front line managers.

Insights Health Care is brought to you by UPMC Health Plan

Decrease workplace stress with a more relaxing, healthier environment

Stress is a critical health issue most employees face at work. It has been called the “health epidemic of the 21st century” by the World Health Organization.

According to the American Institute of Stress, it costs American businesses up to $300 billion a year.

“Stress in the workplace has become a significant issue for many businesses,” says Amber Hulme, Medical Mutual regional vice president for Central Ohio. “Beyond the health care costs involved, employers see a loss of productivity, absenteeism, turnover and disengagement. That’s why it’s important to educate employees about how to manage their stress.”

Smart Business spoke with Hulme about how a stressed workforce can affect your bottom line and what organizations can do to help employees reduce, or at least manage, their stress to make themselves healthier, happier and more productive at work.

Why is stress such a problem in the workplace?

Clinical research suggests that stress is an underlying factor in at least 70 percent of all visits to family doctors, and 30 percent of employer disability claims are behavioral in nature.

Most employers advocate a healthy work/life balance, but in today’s work culture it can be challenging to really put the philosophy into practice. If it’s a priority for supervisors and upper management, however, it can really make a difference.

What activities have been shown to help?

For most people, stress management starts with a healthy lifestyle. Exercise, in particular, can be very effective when it comes to reducing stress levels at work. Employee wellness activities, such as paying for a portion of employees’ gym memberships or running group-wide healthy eating challenges, are good ways to help employees unwind and feel better.

Programs don’t need to be overly complicated or regimented. The process can be as simple as organizing a regular walking group or exercise program. Then it can grow from there.

Medical Mutual, for example, will help organizations develop and implement stress reduction programs that offer employees access to personal health coaches and online options for virtual coaching.

How important is flexibility?

When possible, enabling employees to work remotely or have a flexible schedule has proven to be good for morale. This sort of approach demonstrates trust and allows employees to manage their own time.

It also helps to remove extra stressors that working parents, for example, might face — worrying about child care, sick days or doctor’s appointments.

Of course, it’s important to set clear parameters for employees and make sure they understand exactly what is permitted. It can be challenging for some organizations, but it can have a very positive effect.

What about environmental factors?

That can make a big difference, too. For many employees, their surroundings can have a significant effect on their productivity and overall job satisfaction — both of which factor into stress levels.

Organizations might consider brightening the color scheme, adding a few plants or hanging some artwork. It’s also sometimes helpful to have a space where employees can get away for a few minutes. When employees have the ability to break away, even for a short time, it can help boost their productivity for the rest of the workday.

What else should employers know?

Communication is critical. Managers should be encouraged to be as open and transparent with their employees as possible. When you keep employees informed, it can dramatically decrease their levels of stress and anxiety.

In addition to relieving stress caused by the unknown, having an open dialogue makes employees more likely to share their own concerns, ideas and thoughts. And that will often create a healthier — and less stressed — culture throughout the organization.

Insights Health Care is brought to you by Medical Mutual

Selecting the best specialty coverage for your health plan

When evaluating which specialty coverage — vision, dental, life or disability — to include in their employee health plan, employers may benefit from going back to the basics.

“Employers should remind themselves that while the marketplace always evolves, some aspects may remain the same. They should continually evaluate the latest, greatest differentiators between specialty line carriers to ensure they are getting the best coverage,” says Judy Dawson, Account manager III at HealthLink, Inc.

Smart Business spoke with Dawson about what employers need to weigh when adding specialty coverage to their health plan.

What should employers pay attention to in regards to network access?

When selecting a specialty carrier, employers should look for a strong local and national dental and vision network. They should also look for a vision carrier that has a blended network of independent practitioners — opticians, optometrists and ophthalmologists, the leading retail providers in the marketplace, such as Sears or Lenscrafters, and more regional vendors like Crown Vision Centers and Clarkson EyeCare Centers. A strong mix is important as employees may choose to see an independent practitioner for their eye exams, but prefer the convenience and access that a retail provider offers.

How do contracts need to be set up?

When it comes to contracts for specialty coverage, there is more than meets the eye. For example, many employers tend to focus only on the copayments associated with exams and materials (lenses or eyeglasses), but they may be overlooking additional services that are not covered, but are often preferred, such as polycarbonate lenses or scratch coating. Contracts for dental coverage are evolving, too.

Many carriers are changing the way they cover certain services. For example, crowns and bridges may be covered only every seven to 10 years instead of every five years as it has been in the past. These sorts of changes may seem slight, but they could have a significant impact on employees’ out-of-pocket costs. That’s why it is important for employers to assess the contract associated with their current specialty coverage and then shop and compare other available contracts.

What’s important to know about integrating benefits?

Many leading insurance experts believe there is real value in integrating benefits to provide extra diagnostic and preventive care. For example, regular dental cleanings may detect symptoms that trigger or require further intervention on behalf of that member. By having an integrated benefit solution, a more proactive approach may help get the employee the resources and assistance he or she needs to get on the right treatment track, rather than being passive and waiting for the medical condition to deteriorate. The result is better health for the employee as well as the group, which can lower the costs of the overall health plan.

How do voluntary plans fit into specialty coverage trends?

As medical and other personnel costs continue to increase, many employers are moving away from an employer-sponsored dental, vision, life or disability plan. As an alternative, employers may offer an ancillary program where the employee pays for the benefit. This sort of voluntary plan allows employees to elect the additional coverage that suits their personal needs.

When deciding which carrier is best for their specialty coverage needs, employers should still pay close attention to network strength, contractual provisions and competitive rates. However, it is also important that the selected carrier has enrollment procedures, communication materials and other support they can provide for employees. Whether it is via hard copy informational kits, electronic communications or even phone-based webinars, the carrier should have a process in place to get the plan set up and encourage employees to participate in the voluntary coverage options.

When selecting a carrier to provide employee benefits, employers should feel confident that there is a solid plan in place to ensure the best possible outcomes for employees.

HealthLink is a fully owned subsidiary of Anthem, Inc., one of the nation’s leading health benefits companies.

Insights Health Care is brought to you by HealthLink

Seven reasons why online benefits administration makes a lot of cents

Not long ago, the main reason employers weren’t converting to online-based benefits enrollment was the cost. Now, because of more competition among vendors and other factors, the opposite is true.

“Nearly three-quarters of U.S. companies have moved their benefits administration online because of the cost savings. But to get there, it’s important to look for a vendor with high-touch service to help show you the way,” says Ryan Smith, a sales executive with eBenefits Solutions, a part of UPMC Health Plan.

Still not convinced this high-tech benefits admin approach is the way to go?

Smart Business spoke with Smith about seven great reasons to switch over now — and every single one leads to cost savings.

Reason No. 1: Online self-service benefits administration costs less.

According to a recent CFO.com survey, the average cost for an HR staff to manually enroll an employee in benefits is around $110. The average cost for an employee to self-enroll online is just under $22.

Reason No. 2: Online self-service takes less time for HR staff.

An industry survey found that when employees do their own benefits administration online, it results in a 15 percent time savings by HR staff.

Reason No. 3: Online benefits administration can cut in half the time needed for open enrollment.

Among other things, a self-service site frees up HR staff to focus on more strategic tasks and initiatives, such as wellness or employee engagement programs. These help to create a healthier workforce and reduce overall health care costs.

Reason No. 4: Online benefits administration saves on paper, printing and postage.

Printing and mailing benefits packets can be costly and time consuming. When you convert to online, costs for these ‘three Ps’ can be eliminated altogether.

Reason No. 5: Online benefits administration cuts down on premium payment mistakes.

One recent study found that manual benefits administration could significantly increase the likelihood of monthly premium billing errors — leading to higher employer admin costs.

Reason No. 6: Online benefits administration can lower the number of ineligible employees who are enrolled in coverage.

A recent study conducted by a large benefits consulting firm shows that the cost of ineligible employees and dependents (age 26 and older) who receive benefits is between 2 to 8 percent of the total medical premium cost. When electronic data feeds and system eligibility rules are used, this unnecessary cost is virtually eliminated.

Reason No. 7: Online benefits administration is just plain easier.

Online enrollment means employees can sign up 24/7 from 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. Clearly employers benefit from this ease of access as well.

If an employer does decide to switch, what’s important to look for when picking a vendor?

To ensure your online benefits administration runs smoothly, it’s more important than ever to look for a vendor with deep HR experience and a high level of technical expertise. This vendor must be able to offer high-touch customer service to your HR staff as well as individual employees.

And by the way, employees will applaud the switch to online the loudest. It turns their benefits selection process into an easy, retail-like experience akin to an Amazon.com visit. Many online benefits admin platforms even include decision-support tools that help employees determine in real time which products and services are the best fit.

Insights Health Care is brought to you by UPMC Health Plan

How to help your employees better manage their care and costs

As the cost of health care continues to rise, studies have shown that almost half of those costs are unnecessary or avoidable. To reduce those expenses, many organizations want to help their employees make better health care choices on their own.

“When employees understand their health insurance, they can make good decisions that benefit themselves and their employer,” says Veronica Hawkins, Medical Mutual vice president of Statewide Accounts. “That’s why it’s important for organizations to make sure their employees have all the information they need.”

Smart Business spoke with Hawkins about what organizations can do to help their employees take a more active role in their health care decisions.

What resources are most important to help employees understand what’s covered?

Probably the most important resource is their benefits book or certificate of coverage. This is the document that explains what services are covered — and not covered — under the plan. Organizations should make sure their employees receive a copy, or have access to it online. This can help them understand the terms of their plan so there are no surprises when they need a service or supply.

How much does the network of providers factor into costs?

It can be significant. The doctors and hospitals employees choose to utilize factors into how much they pay for services. By choosing doctors and facilities in the insurance carrier’s network, employees may only have to pay their copay and any deductible or coinsurance that applies. Employees receiving services outside the network often have to pay any balance beyond what the insurance carrier has agreed to pay.

Before choosing a doctor for any type of treatment, or a facility for any test or procedure, it’s important to check the network. Even if a doctor or facility was listed in the network previously, that status can change. Employees should make sure their doctor is in network by calling their carrier’s customer hotline or going online and searching the provider directory.

What are some other easy ways to save money?

Many people aren’t aware that doctors and health care facilities charge different amounts for the same services. Often, patients can be charged more for seeing a doctor at a facility he or she doesn’t own, like a hospital-owned clinic. It may cost less to see that same doctor and have the same treatment at a different facility. This can also apply to lab costs, as price differences can be significant. To maximize benefits and minimize out-of-pocket costs, it’s important to shop around within the plan’s network.

Some insurance carriers offer online tools for comparing costs. Price estimates are often available for everything from office visits to X-rays to surgical procedures, and may factor in facility fees and other associated costs. These estimates should be pretty close to what the member will have to pay.

What is the best way to keep employees informed?

Good communication is critical. Organizations can partner with their insurance carriers to create a customized approach for building awareness of all these tools. This could include interactive presentations that use visuals and easy-to-understand language. Short segments with a question and answer period may be a good option to help avoid confusion. After any presentations, refresh the topic by emailing employees with benefit reminders and updates.

The key is to give employees the resources they need. They should know how to reach their insurance carrier, where to look for in-network providers and how to use their benefits book and explanation of benefits.

Insights Health Care is brought to you by Medical Mutual

How to use customer service to reduce your costs

Most people call customer service when they have a problem or a complaint. But proactively using customer service to get information or ask questions could help employers, and their employees, save on their health care costs.

“While some large group employers may have a customer service line dedicated to their account, small and midsize employers also can benefit from educating their employees about the customer service department,” says Karen Gotsch, manager of Customer Care at HealthLink, Inc.

Smart Business spoke with Gotsch about best practices for customer service in your health plan.

In an ideal world, how should customer service function for a health plan?

Ideally, customer service should function as a go-to resource for employees looking to get the most from their benefit coverage. Customer service can find providers that meet employees’ needs and participate in their health plan, ensuring they receive the highest level of benefits on medical services.

Customer service can also help employees determine what services are covered and whether or not they need pre-certification. Otherwise, employees could end up paying more out-of-pocket if they receive care that isn’t covered.

What’s the reality for many companies?

Many employees are still not well educated about their health plan and the best practices for maximizing their benefits. Employees often assume they’ll receive their full level of benefits, no matter which doctor or facility they choose, which isn’t necessarily true. They don’t always understand or take into consideration that there may be exclusions or limits associated with their health plan.

How should employers educate their employees about customer service?

Employers have a unique opportunity to educate their employees about their health plan benefits. Employers should focus on having the information readily available so it is easy to access when a question arises. Open enrollment is prime time to talk about benefits as most employees are engaged in the decision-making process at that time. It’s also important to use easy-to-understand layman terms and avoid terms that are highly technical when possible.

Employees need to be aware that customer service is available as a resource to help with any questions or concerns.

Do smaller companies concerned about resources and time need to take a different approach?

Employees should be educated about their health plan benefits no matter the size of the company or employee group — and it doesn’t have to take a lot of time and resources. Employers should utilize communication avenues they already have in place, such as their website, employee newsletters and other internal communications. Smaller companies that don’t have a corporate intranet or newsletter could try making benefit education a part of their next scheduled team meeting, or simply send an email out to their employees.

What are the benefits of being proactive?

Using customer service as a proactive resource can positively affect employees in a number of ways. Taking the time to find a provider that is a good fit and that participates in their health plan can lower out-of-pocket costs. They can also utilize customer service to determine what their out-of-pockets costs will be, whether or not certain procedures are covered and if there are pre-certification requirements.

This sort of education can ensure employees don’t receive a surprise bill, and it gives them the knowledge they need to review their Explanation of Benefits (EOB) for accuracy to avoid overpayment.

What else is important to know?

Employers should educate their employees about any self-service options, such as online bill pay or how to search for a doctor. These tools can save employees time and help them get the most from their health plan in a way that is easy and convenient.

Employees should always review their EOBs for accuracy before paying a bill. It is important for employees to understand that they may have different plans for different benefits so they know whom to call with questions. Keeping all of this important information together and easily accessible when calling customer service is also a great way to save time.

Insights Health Care is brought to you by HealthLink

Choosing the right health coaching program for your employees

It’s a fact that 75 percent of employer health care costs are the result of chronic diseases that have unhealthy behaviors as their root cause, according to the Centers for Disease Control and Prevention.

“The key to bringing down those health care costs? Change the behaviors that lead to the chronic diseases,” says Amanda Budzowski, MS, MPH, CHES, senior manager of Clinical Training & Development at UPMC WorkPartners and UPMC Health Plan.

“The question is, how? How to get employees to lose weight, eat better, get more active or stop smoking?” she says. “How to help them better manage their diabetes, high blood pressure or heart disease?

And the answer is: With help from a health coach.

“It turns out that many health insurance companies are now offering health coaching free to their members. That’s great news for employers,” Budzowski says.

Smart Business spoke with Budzowski about how to set up a coaching program to help change the employee behaviors that lead to chronic diseases.

What’s important to include in a successful health coaching program?

With health coaching, employees and family members can work one-on-one, usually by phone or email, with a trained expert in behavior change. Research confirms that health coaching works.

When assessing a health plan’s health coaching services, look for:

  • Lifestyle expertise: The health coaching team should be able to help your employees with lifestyle challenges, such as losing weight, eating healthier, quitting smoking, increasing activity and lowering stress.
  • Health condition expertise: Health coaches should also have expertise in managing conditions such as diabetes, asthma, low back pain, depression and heart disease.
  • Comprehensive staffing: To ensure your employees are in good hands, the health coaching team should have licensed nurses, counselors, social workers, registered dietitians and exercise physiologists — preferably with medical director oversight.
  • Accessibility: Some health insurance companies can actually supply health coaches to your job site. Short of that, look for health coaches to be available full-time on weekdays via phone, email or live chat, with accessibility for teletype devices for the deaf, hard of hearing or speech-impaired.

What else should employers keep in mind?

Effective health coaching doesn’t happen by accident. It should follow a process much like this:

1) Health coach meets with client to define their personal wellness vision.

2) Health coach and client explore strengths and past successes as well as anticipated challenges and barriers.

3) Health coach and client determine health goals.

4) Health coach and client co-create solutions and a customized plan to get there.

5) Health coach checks in frequently to help client stay motivated and accountable.

6) Health coach celebrates with client when goal is accomplished.

Health coaching is a highly effective tool for changing the behaviors that lead to the chronic diseases that significantly increase employer health care costs. That’s why it’s so important to choose the right health coaching program for your employees.

Are there any secrets to getting employees to use a health coach?

There is a new strategy out there that is having a big impact on health coach usage, and that’s when a person’s doctor recommends health coaching. It’s one thing if a person self-directs to a health coach or if a health insurance company recommends the health coach, but it’s a different deal altogether if the recommendation comes from the doctor.

People believe their doctors and doctors get to know their patients over time. So there’s a relationship of trust that forms. Therefore, when a doctor says to a patient that it would helpful if he or she got some guidance and motivation from a health coach, that recommendation goes a long way. The patient is more likely to take action and sign on.

Insights Health Care is brought to you by UPMC Health Plan

How to complete your employee health coverage forms for the IRS

Last year, many organizations had to figure out the new rules for submitting information about their employee health coverage to the IRS. It’s that time of year again, and while the overall process is very similar some aspects have been adjusted since last year.

“Just like last year, different employers will have different requirements they have to meet,” says Amber Hulme, Medical Mutual regional vice president for Central Ohio. “To avoid fines for the business, or even tax penalties for employees, employers need to know which requirements apply to them this time around.”

Smart Business spoke with Hulme about what employers should do to understand the annual IRS reporting requirements and what they can expect for 2017.

What is the purpose of this reporting?

The reporting really consists of two parts. One helps the IRS prove that everyone in the U.S. has health insurance — or that they qualify for an exemption. The other is intended to make sure certain employers can offer ‘minimum essential coverage’ for their employees. To do all of that, the IRS needs to collect the appropriate information.

How do employers know which requirements apply to them?

First, look at funding type. If you’re fully insured, your insurance company will handle 6055 reporting for you.
Then look at how many full-time employees you have (including equivalents). That’s your ‘FTEs.’ If that number is 50 or more, you will need to report for 6056.

Self-funded employers usually have more work to do. They have to report for 6055, which includes collecting any missing Social Security numbers from employees and dependents. And they also have to report for 6056 if they have 50 or more FTEs.

How do insurance carriers handle 6055 reporting?

Insurance carriers are required by law to send 1095-B forms to all fully insured members. Those forms serve as their proof of coverage for the previous tax year. Then, if any of those members don’t have Social Security numbers on file for either themselves or a dependent, carriers are also required by law to contact members directly to collect that information. So employees might get requests to supply that type of information.

Has the process changed at all since last year?

The overall process is essentially the same, but the IRS has revised instructions on its website, IRS.gov. This year the deadline extensions are going to be different than they were in 2015. Generally speaking, any forms for employees need to be delivered to them by March 2, while forms submitted to the IRS are due by Feb. 28 if they are filed by mail, and March 31 if they are filed electronically.

Are the penalties the same for not complying?

Employers are subject to fines of $260 per instance, which is up slightly from last year. It’s also a flat rate now — instead of a range based on the intent behind a mistake or omission.

And like last year, employees could see money come out of their next tax return if the IRS doesn’t have all the Social Security numbers it needs from them. So even if your organization isn’t required to file, it’s smart to help your insurance carrier collect what it needs.

Any other reminders as organizations prepare?

Just make sure you know which forms you have to submit and what information is required. If anything is missing, it’s better to know sooner than later. And, as with any forms submitted to the IRS, it’s always a good idea to consult with a tax adviser or legal counsel.
In addition, keep in mind that these requirements are tied to a provision of the Affordable Care Act (ACA). So any changes to the ACA under the Trump Administration could affect what organizations will have to do.

Insights Health Care is brought to you by Medical Mutual

How health care fraud has changed in the electronic age

In the electronic age, fraud is a major concern. As consumers become more engaged in making informed health care decisions, health care fraud has evolved. Your employees’ understanding and concerns about fraud needs to evolve as well.

“Nearly every aspect of life can be conducted online and is susceptible to hacking and theft. The health care industry is shifting toward more web-based services, such as telehealth. More online services provide more opportunities for criminals,” says Howard Levinson, DC, CFE, AHFI, clinical fraud director, Special Investigations Unit, at Anthem, Inc.

Smart Business spoke with Levinson about how employers can impact the risk of fraud.

What fraud are you seeing in health care?

The majority of health care providers submit their claims for payment electronically. More than 1 billion claims are submitted annually to Medicare. Private payers process hundreds of thousands of claims on a daily basis. For the most part, that volume is handled by sophisticated computer software, and in many cases a human eye never sees it.

Fraudsters can generate claims for fictitious patients just by entering data into billing software. They can submit claims for services that were never rendered. Unscrupulous providers, who know a service wouldn’t be covered, may purposefully enter incorrect data. For example, a large sports medicine practice was aware a certain joint injection wasn’t covered by a health plan. In order to have the treatment paid by the plan, however, the provider submitted an alternate code for a service that was covered. The plan’s investigators discovered the scheme during an audit. The overpayment for the miscoded service was nearly $1 million.

In addition, the Affordable Care Act (ACA) mandated electronic medical records (EMR) as the standard. EMRs have proven effective and efficient in documenting patient care but have also created opportunities for fraud. An unscrupulous provider can cut and paste patient visit information that isn’t timely or accurate, or create an entirely fictitious EMR to submit as a claim for payment.

Investigators are challenged by the time it takes to identify fraudulent records. They must review individual records to compare visit information and look for potential duplicates or cloned information. If suspicious information is detected, the investigator then must interview patients, physicians and their staff.

Also, the audit function of most EMR systems keeps track of all patient visit entries, entry changes and every time someone accesses that EMR. While this function helps identify potentially cloned or copied patient visits, lab findings or symptom descriptions, some programs don’t have an audit function or the provider can turn it off.

How can employers help minimize the risks?

Employers should educate their employees about health care fraud, waste and abuse. Federal and state agencies offer educational materials and services, so tap into these and make them readily available to employees.

Employers should ensure their network and systems are secure and adhere to the latest security guidelines. Require company-wide education on computer and mobile security standards and advocate for the use of strong, regularly updated passwords.

Also, educate employees on potential scams such as phishing emails, online pop-up ads or links that seem legitimate but have attachments that shouldn’t be opened.

What are other best practices?

Employees should take the same safety measures they would with their financial information. Also, they should be suspicious of anyone offering anything in exchange for personal and health care information, such as free medical equipment, whether via an unsolicited phone call or what appears to be a legitimate television ad.

They should review all medical bills, Medicare summary notices and explanation of benefits to make sure the medical services listed were received and are being accurately billed. If unusual or questionable charges appear, they should contact their health care provider or health benefits plan.

Criminals are targeting health care and their methods are getting more sophisticated and complex. Make sure you educate your employees on the potential tactics used by criminals and the high cost of fraud, waste and abuse in the health care industry.

Insights Health Care is brought to you by HealthLink, Inc. HealthLink is a fully owned subsidiary of Anthem, Inc., one of the nation’s leading health benefits companies.