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, 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.

How organizations can benefit from healthier employees

The overall success of your organization depends on the people you employ. Without them performing their jobs at a high level each day, productivity — and your bottom line — would most certainly suffer. That’s why it’s so important to keep your employees happy and healthy. A workplace wellness program is an excellent way to help accomplish both of those goals.

“A wellness program can be an effective way to engage employees and promote healthier lifestyles,” says Veronica Hawkins, Medical Mutual vice president of Statewide Accounts. “Plus, it can be tailored to incorporate an array of health-related activities based on an organization’s needs and budget.”

Smart Business spoke with Hawkins about workplace wellness programs and the many benefits organizations can enjoy if they choose to make the investment.

What do workplace wellness programs involve?

Programs can vary in size and scale and offer things like health education, disease management programs, health screenings, fitness classes, fitness center memberships and more.

Offering a health assessment is a good place to start. A health assessment is a survey that asks questions about employees’ health and fitness. Questions about smoking, frequency of doctor’s appointments, exercise habits and health conditions can give your organization an idea of what to include in your program. For example, if there is a high percentage of diabetes among your employees, you may want to offer a diabetes management program.

Additionally, a health assessment can provide you with some insight into what your employees would like in a program. There may be a high interest in fitness classes or fitness center memberships. Or employees might like the convenience of on-site health screenings.

Your organization can also offer incentives to increase participation. By setting goals for your employees and offering rewards for achievement, you can get employees engaged and excited about being involved and getting healthier.

Can these programs help lower health care costs?

Studies show a significant percentage of health care costs could be linked to employees’ poor lifestyle choices. Tobacco use, unhealthy diets and a lack of exercise can increase the risk of chronic disease and lead to a variety of costly health problems. Organizations that invest in a wellness program could see a reduction in medical claims, disability costs, workers’ compensation claims and absenteeism due to illness.

Helping employees learn about their health can help them and your organization save money. The more they understand their risk factors, the more likely they may be to make positive changes to help improve their overall health.

How do employees benefit?

Recruiting and retaining talented people isn’t easy. Many organizations are now looking for unique perks to set them apart from the competition. A wellness program is one way to demonstrate a real commitment to the health and well being of employees. That can result in increased job satisfaction among staff members and stronger retention rates.

A wellness program can also help build camaraderie among co-workers. Employees can participate in a variety of non-work-related activities or simply go to the gym together. Competition and encouragement can go a long way toward helping people change their lifestyles and make better decisions.

What’s the bottom line?

More and more organizations are becoming believers of wellness because they see a difference.

Wellness programs can help employees feel better. When they feel better, it helps improves their morale, their mental outlook and their productivity. It also helps them live healthier lives, which in turn reduces absenteeism and medical claims.

Sure, there is a cost involved in setting up a wellness program, but it’s really an investment in your employees and in the future of your organization.

Insights Health Care is brought to you by Medical Mutual

Telehealth: What’s in it for employers and employees

Various forms of telehealth — whereby patients access medical care remotely using telecommunications technology — have been around for years. But these days its popularity is accelerating exponentially, and employers need to take note.

Smart Business spoke with Kim Jacobs, vice president of Consumer Innovation at UPMC Health Plan, about the state of telehealth, and what it means for employers and employees.

Why is telehealth’s popularity accelerating exponentially?

A big reason for its increasing prevalence is that technology now makes it easier than ever for patients to access care using their smartphones anytime, from anyplace.

Another key driver: The health care industry is now figuring out how to fairly and consistently reimburse providers for the service. Therefore, providers are now incentivized to offer it.

On the payer side, health plans are increasingly supportive of the practice because they see it as value-based care that improves the patient experience, improves health outcomes and is far less costly than ER and urgent care visits, for example.

Why should employers want to see telehealth included in their health benefits package?

As for employers, the reasons to include telehealth in their health insurance benefits package are numerous and significant. They include:

  • Improved care. It’s simply another option for employees, especially those who live in rural areas where nearby health care options are less prevalent.
  • Lower cost. Surveys show that the average cost of an emergency room visit is $700, with urgent care visits averaging $150. The average cost of a telehealth visit is $40.
  • More convenience. Increasingly, telehealth access is 24/7. All you need is a smartphone, tablet or computer, and you can access care instantly.
  • Better health. Because it’s quick, convenient and relatively low cost, employees are more likely to seek medical care when they need it, instead of putting it off until things become more serious — and expensive.
  • Higher productivity. A visit to the doctor or urgent care center can take half a day or more, which results in significant time away from work — at the expense of productivity. A telehealth visit takes mere minutes.
  • Better employee retention. With telehealth becoming more and more popular, employees are seeing it as a necessary part of their benefits package. If employers don’t cover it, employees will notice.

What is the very latest with telehealth, and what should employers keep an eye on?

The technology is going to keep getting better. The interface between patient and provider used to be primarily by email, text or phone. Many telehealth operations are now switching over to real-time, face-to-face video chat.

This opens up some amazing possibilities. Now, a doctor can literally do a skin rash assessment, for example, while you point your smartphone camera to your arm. Or the doctor can have you say ‘ah’ and look down your throat by way of your laptop camera.

Also, in some cases, a telehealth-based provider can now send an instant email to your primary care physician (PCP) about your visit, so your PCP stays in the loop. In other cases, the provider can send a prescription to your local pharmacy for pickup right after your visit.

We will see more and more of these advances, and they all have the potential to positively impact employee health and productivity.

Given all this, it’s no surprise that the percentage of U.S. large employers that offered a telehealth benefit to their employees rose from 48 percent in 2015 to more than 70 percent in 2016, according to the Wall Street Journal. That percentage is sure to go higher in 2017 and beyond.

Insights Health Care is brought to you by UPMC Health Plan

Myths about self-funded health plans

Historically, self-funded health plans have been most effective for very large corporations. But with the rising cost of health care over the past 10 years, at a rate of nearly 10 percent, other alternative-funded solutions have become a viable option for many employers, even those with smaller employee populations.

Today, it is estimated that 61 percent* of companies within the U.S. self-fund at least a portion of their health plan, and since the passage of the Affordable Care Act (ACA) in 2010, there are even more benefits for employers who are willing to explore alternative-funded solutions to provide quality health benefits to their employees.

Smart Business spoke with Susan French, director of marketing at HealthLink Inc., about what employers really need to know about self-funded health plans.

What does the self-funding environment look like today, compared to five or 10 years ago? What do you expect for the future?

The ACA actually brought an increased interest in alternative-funded options for small group employers because many were unsure about offering an ACA-regulated plan. Also, alternative-funded options aren’t subject to certain taxes and mandates and are typically less expensive than fully insured plans.

As employers become increasingly more informed and involved in the health care benefits they purchase and offer to their employees, they are demanding more for their money. As insurance premium rates continue to rise, employers will also continue to seek new and innovative solutions to meet their needs. Alternative-funded options offer a variety of arrangements and the high-level of flexibility that employers are searching for.

Why would an employer consider moving to an alternative-funded option?

One of the key advantages to alternative-funded arrangements is increased cash flow. With an alternative-funded plan, an employer pays claims as they are incurred, rather than paying fixed monthly premiums to cover services that may or may not have been rendered. For many employers, this can positively impact their cash flow.

Another advantage that attracts employers is the flexibility to customize the benefit offering to fit their employee population. In an alternative-funded arrangement employers can work with the consultant and third-party administrator of their choice to build the plan they want.

There are also a variety of other cost-containment and reduction opportunities that can be particularly effective in an alternative-funded arrangement.

What are the most common misconceptions that you spend your time debunking?

Many employers are open to exploring new options and breaking away from the way health plans have ‘always been.’ Therefore, it’s far more productive to concentrate on educating employers that there may be a better way to control their spending.

Typically, misconceptions are easily disproved by focusing on the advantages of alternative-funded arrangements, such as the ability to use data to analyze fixed and variable costs to affect outcomes, as well as the opportunities for provider collaboration and enhanced cost containment.

How do the most effective companies handle the risks of a self-funded health plan?

Employers deal with risk all the time — this is nothing new. Alternative-funded arrangements often include an additional layer of stop loss insurance that outlines risk, protects against high-dollar claims and limits the amount of claim expenses an employer is liable for. As with many aspects of business, employers who are comfortable and strategic with handling risk are often the most successful with alternative-funded plans.

What else do you wish employers understood about self-funding?

There are many different types of alternative-funded arrangements, so employers shouldn’t focus solely on traditional self-funded solutions only. There are arrangements that act more like fully insured plans but can still offer employers the flexibility and security of a financial backstop they are looking for.

In today’s health care market, the savviest employers should be open to exploring all their options before deciding what is best for their company.

* 2014 Kaiser Family Foundation Employer Health Benefits Survey


Insights Health Care is brought to you by HealthLink Inc.

How stop-loss insurance can reduce the risk involved in self-funding

As more businesses look at self-funding as a way to control their health care costs, it’s not uncommon for stop-loss insurance to be part of the discussion. In fact, according to a recent study from QBE Solutions, 60 percent of self-funded employers now have stop-loss insurance.

While some businesses choose to forgo stop-loss to avoid the extra monthly premium costs that come with it, many others have determined it’s a necessary measure to protect their business from unexpectedly high claims.

“Organizations assume more risk when they self-fund, but most want safeguards in place to protect their business,” says Amber Hulme, Medical Mutual regional vice president for Central Ohio. “While insurance carriers have set products to offer, there is also typically a fair amount of customization involved in terms of the contract. It’s important to get all the pieces right.”

Smart Business spoke with Hulme about how stop-loss insurance works, why it could be a valuable tool for organizations that fund their own health benefits and what types of contract decisions could make a big difference in the long term.

What is stop-loss insurance?

Stop-loss insurance limits risk for a self-funded employer when one employee has a catastrophic claim, as well as when claims for the entire organization are higher than a set amount. It insures the employer, not employees or other health plan participants.

Stop loss policies are initially written as indemnity policies. In others words, the employer pays the claim and the carrier then reimburses them.

How does it work?

Well, there are two types of stop-loss insurance — specific and aggregate. Specific stop-loss limits the amount an organization would have to pay for an individual claim from a specific employee. Usually an organization pays a monthly premium based on how many covered employees it has.

Aggregate stop-loss limits the total amount the organization will have to pay in claims, for all of its employees for the full length of the contract.

Most choose to have both types of stop-loss insurance to cover both scenarios.

Why is stop-loss getting more attention lately?

One reason is because self-funding is getting more attention, especially for small businesses that have 50 or fewer employees. In 2018, those businesses may lose the transitional or ‘grandmothered’ status that has kept them exempt from many aspects of the Affordable Care Act.

Stop-loss insurance is one of the most crucial elements of a self-funded health plan, because it’s the best way to help the plan limit its risk. So, as more organizations take on the financial risk of self-funding their employees’ health care coverage, stop-loss will continue to be a critical component.

What factors should organizations consider?

There are several contract provisions that organizations need to understand and take into account.

One of the most important aspects involves a practice called lasering. When insurance companies give a quote or a rate renewal, they might place a higher deductible on certain individuals or even exclude them from coverage. That’s called lasering. Organizations need to understand their insurer’s policies on lasering, and how it might affect their coverage when it’s time to renew their contract.

Is there anything else to consider?

One of the biggest factors in stop-loss, and self-funding as a whole, is to know your population. Most insurance companies need to know about any employees with a history of high claims or any known health risks before they will even give a quote. It’s a good idea for organizations to be prepared with that information ahead of time.

There are various types of stop-loss coverage available, so start by talking to your insurance carrier or other stop-loss carriers to find out which options make the most sense.

Insights Health Care is brought to you by Medical Mutual

Is your corporate wellness program EEOC compliant?

There’s a good reason why more employers are offering wellness programs than ever before. The advantages are well documented — a successful wellness program can increase productivity, lower health care costs and reduce absenteeism among workforce.

In addition, a wellness program can boost employee satisfaction and loyalty, which helps with recruitment and retention.

Employer-sponsored wellness programs often involve participating in health risk assessments and biometric screenings to determine risk factors for chronic conditions. Some employers and health insurance plans offer incentive to employees who participate in wellness programs or achieve certain health outcomes.

“There’s been some concern that using incentives to boost participation may violate federal law, relating to Title 1 of the Americans with Disabilities Act (ADA) and Title II of the Genetic Information Nondiscrimination Act,” says Tom Drennan, director of EAP Account Management at UPMC WorkPartners.

In May, the U.S. Equal Employment Opportunity Commission (EEOC) issued final rules to amend the regulations and offer guidance on how to implement them.

Smart Business spoke with Drennan about what employers need to know to offer wellness programs that are compliant with federal law.

How exactly must wellness programs be designed, under this final guidance?

Wellness programs must be designed to promote health and prevent disease. Employers can’t collect information simply to have it or to calculate future health-related costs.

Wellness programs that collect health information — typically through health risk questionnaires and medical tests and screenings — must use this information to create a program that addresses at least one of the employee’s identified conditions.

If the wellness program collects information but does not provide advice that helps participants improve their health, it does not meet the requirements of a well-designed program.

Employers must also tell employees in writing how their medical information will be obtained, used and disclosed. The EEOC has created sample notices for employers to review.

Can employers make employees participate in a wellness program? What kinds of incentives are allowable?

Participation in wellness programs must be voluntary.

The EEOC states that in order for a program to be voluntary:

  • Employers can’t make employees participate in a wellness program.
  • They can’t penalize employees for not participating.
  • They can’t make health benefits conditional upon participating.

The incentives for not participating in a wellness program can’t exceed 30 percent of self-only coverage.

How did the EEOC address privacy concerns?

Employers generally can’t have access to an individual employee’s health information.

The existing confidentiality requirements that are part of the ADA rules haven’t changed. But two new ones have been added:

  • An employer may not require an employee to agree to disclose medical information or waive any confidentiality protections as a condition for participating in a wellness program.
  • Any data gathered by the wellness program and then shared with employers must generally be in aggregate form that isn’t likely to disclose the identity of individual employees, except as necessary to administer a health plan.

Tracking how wellness programs use personal information can be tricky for human resources professionals. There are many advantages to working with a company that is experienced in keeping your company compliant.

Insights Health Care is brought to you by UPMC Health Plan

How to use tiered and narrow networks to control health care costs

If you’re an employer, chances are you’re looking for ways to control health care costs, yet still provide high-quality coverage to your employees.

Health insurance plans with restricted networks are becoming an increasingly popular option for businesses looking to curb rising employee premium costs. When done right, they can save money without sacrificing quality. However, limited networks can confuse even the most astute employer — not to mention employees.

Smart Business spoke with Kimberly Cepullio, VP Sales, Account Management and Product Development, UPMC Health Plan, about restricted networks, including some questions to ask as you weigh the choices for your health plan.

What’s the difference between narrow networks and tiered networks?

In a narrow network a health insurance carrier contracts with select doctors and hospitals that charge lower prices, or have a track record of quality. By steering a greater volume of business to these providers, insurers can negotiate lower prices. The savings are passed on to employers and their employees in the form of lower premiums. The tradeoff for lower premiums is less choice for members.

A variation of the narrow network is a tiered network, which offers a potential compromise. In this plan design members have access to a broad network of providers. Within this broad network, health care providers are ranked based on cost — and quality. Differing cost-sharing arrangements drive members toward certain providers.

Members have the lowest cost share when they receive care from level one providers. Their out-of-pocket costs are higher when they see providers in other levels. This type of plan lets your employees decide whether to incur higher costs to see their preferred provider, or have a lower cost share and see the network’s preferred providers.

What kinds of questions should employers be asking when considering tiered or narrow networks?

  • Does the network encourage improved patient outcomes? The main objective of tiered or narrow networks is to lower costs for employers and members. Some plans also seek to improve patient outcomes by incentivizing its preferred providers to provide coordinated care and achieve certain quality metrics. For example, a shared saving arrangement ties provider payment amounts to the ability to stay within budget while meeting quality standards.
  • Is there an adequate pool of providers for the patient population? Normally this isn’t a problem but employers need to be careful here. For example, some narrow networks offered by some insurers may not include providers who offer highly specialized care. For some patients, especially those with complex health conditions, such restrictions can be problematic.
  • How well do your employees understand their options? Many members choose a plan with a narrow network because of the lower premiums. People may not understand the tradeoff between choice and price. Make sure your insurer has a communication plan to explain what it means to choose a narrow network. Before committing to a plan, employees should be able to search for doctors in the network they’re considering to see if their doctor accepts that plan.

In general, including a tiered network plan among your insurance offerings to your employees is a smart move. It incentivizes employees to seek medical care at preferred or low-cost tiers. That’s a good thing for them and for you.

The key is to not limit the employee’s ability to get the care he or she needs from the provider that is in the best position to provide that care. Therefore, it is especially important that employees with unusual or complex medical conditions take extra care when it’s time to select a tiered plan. Once they choose their plan, their complex condition may force them to pay a higher cost to have that condition treated at a non-preferred provider. Again, this is why communication is key to making wise choices.

Insights Health Care is brought to you by UPMC Health Plan

How organizations can become better prepared for open enrollment

Fall is upon us and we’re getting closer to the end of 2016. That usually means it’s time for health insurance open enrollment for the coming year. This can be a confusing and stressful time for many employees. Is there anything organizations can do to make the process go more smoothly?

“Research shows that employees are not as well-informed about their benefits as human resources (HR) professionals might think,” says Veronica Hawkins, Medical Mutual vice president of Statewide Accounts. “There are a variety of ways organizations can communicate better and make the rollout of health care plans easier.”

Smart Business spoke with Hawkins about the ways organizations can help their employees understand the process, while also helping them become better health care consumers.

Why is open enrollment so confusing for employees?

Most employees don’t consider themselves to be very knowledgeable about health insurance. They’re also unsure about when they can make changes to their plans. Less than half know they can change their benefits because of qualifying life events, like marriage, divorce or the birth of a child.

This shows that employers can do a better job of informing employees of their options.

What should organizations ask of their carrier?

After an organization has made the decision about which health insurance plan to purchase for employees, it can be difficult to make sure employees understand what’s available to them. Employees often have a lot of questions during open enrollment.

It’s the carrier’s job to provide a variety of materials and support to help these employees better understand their benefits. Some will schedule on-site meetings with employees to answer questions and review plan benefits. Organizations should definitely take advantage of these options since they can help save a lot of time and effort.

How can organizations communicate better?

Surveys show one-on-one meetings, direct mail pieces and information on the organization’s website are the top three most preferred communication methods. One-on-one meetings won’t be possible for every organization, but a more personal touch throughout the open enrollment process can reduce anxiety and lead to better understanding.

Bringing in a benefits counselor is another good option. This can be someone who works for an employer or is brought in from a broker or third-party benefits administrator, or TPA, to be a point person for all benefits questions. Having an expert available to guide employees through the open enrollment process can improve their experience.

Organizations can use their own Intranet, internal websites and HR platforms to provide employees with important information about their benefits. Some companies even handle their open enrollment online, which younger employees appreciate.

Organizations should also take advantage of any online tools offered by their carrier. These tools can help members better manage their health care, keep an eye on deductibles, find providers and more, to help control their costs.

What are some other best practices?

The open enrollment period shouldn’t be the only time during the year an organization talks about its benefits program. Employers can make an effort to keep an open dialogue and remind employees to take advantage of their benefits. This will help prepare them to select benefit options each year based on their needs and those of their families.

It’s a good idea to write about employee benefits regularly in employee newsletters or on an internal blog. These are easy ways to remind employees of the value of their benefits program.

Insights Health Care is brought to you by Medical Mutual

Utilization management: The effect of pre-admission and post-discharge planning on health and costs

“Many employers and their health plan members assume that a utilization management program’s only goal is to approve or deny medical procedures and save costs for the health plan. In reality, utilization management programs are designed to help members navigate the health care system and achieve optimal medical outcomes in the most timely and cost effective manner possible,” says Dr. Jay Moore, senior clinical officer at HealthLink, Inc.

“To achieve this,” Moore says, “utilization management teams provide medical necessity recommendations and aid members in making medical treatment decisions, but they also provide important pre-admission and post-discharge outreach that can positively impact a member’s health and help contain costs.”

Smart Business spoke with Moore about what employers need to know about utilization management.

How do utilization management programs typically work?

Providers send a notification when they have a patient who is being admitted to the hospital or is being considered for an elective admission in the future. The request for services is compared against evidence-based policies to ensure the care is safe, appropriate and high quality. When this is verified, the service is approved.

If the service is not approved, an explanation is provided to let the patient and doctor know why the decision was made. Specific resources are also provided so that the evidence that underlies the decision is readily available. If the patient or physician disagrees with the decision, simple processes exist to submit more information or appeal the decision. This process usually results in the patient receiving the safest, highest-quality care that is evidence-based and effective.

Why might health plan members mistrust or have wrong assumptions about these programs?

The focus in these reviews is always on medical appropriateness, quality and safety. If a procedure or hospital admission is in the best interest of the patient, it is approved. Members may not always be aware of why a procedure or admission was approved or denied, they only know the end result.

Members who are unsure about these decisions can take a more active role in their health by talking to their doctor or contacting the utilization management team to learn more about the review process and discuss their case.

How should utilization management be employing pre-admission and discharge planning? How will this impact member health and plan costs?

Discharge planning from the hospital should begin as soon as the patient arrives. Utilization management teams should work with hospital staff to address any needs the patient might have before leaving the facility.

With this sort of proactive planning, care gaps may be avoided and members can receive the highest quality medical service.

If this doesn’t sound like what happens with a business owner’s health plan, what should he or she do?

A utilization management team should be dedicated to providing the highest quality, safest and most effective care to members. This reduces health care waste and allows members to receive high quality care. If this is not happening, the employer contact their broker or network to discuss medical management options.

Is there anything else you’d like to share?

Medical management programs as a whole can be really effective in helping employers, and their members control their health care spending. They shouldn’t assume that their health plan has all the right programs in place.

Employers need to take an active role in the health plan they are offering their members and work with their broker or network to explore their options for medical management programs.

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