3 ways to support workplace well-being during COVID-19
The coronavirus has created many struggles for employees to deal with, and some of the struggles will continue even after measures become lifted. Read this blog post to learn more.
Personal and professional worlds are colliding in ways that have never been seen before, leading employees and employers to navigate new challenges in uncharted waters. As employees continue to struggle with balancing work and personal obligations at home, they are dealing with emotional, physical and financial consequences from the pandemic. Some of these struggles will remain even after social distancing measures are lifted and the economy stabilizes, and they could have a lasting impact on people’s overall wellness.
While many companies are rightfully focused on the bottom line and maintaining business operations throughout the pandemic, it is equally important that they take steps to ensure their employees are supported throughout this tumultuous time. Employee well-being is directly tied to business health, which is why it is so important for organizations to optimize their benefits and deliver the right health and wellness offerings for their workers.
Reassess employee benefit programs
The pandemic is raising awareness that total wellbeing, not just physical health, is a key component to success for businesses and the economy. Employees that are facing at home pressures or feeling financially insecure may be less productive or distracted during the workday, which can impact company success. COVID-19 has hit companies hard. Many are looking for places to trim costs, but benefits and wellbeing programs are not an area they can afford to cut.
Diabetes, depression, mental health and financial stress are on the rise with the majority of employees dealing with unprecedented challenges like childcare, caring for family members who are sick or otherwise impacted by COVID-19 and general anxiety about their future. Cutting benefits programs now may save a few thousand dollars today only to spend tens of thousands of dollars on healthcare costs tomorrow.
Employers who understand the value of employee benefits programs will fare much better than those that guess which programs will be effective. This is an ideal time for businesses to re-assess their current well-being offerings to ensure the programs they are investing in align with the needs of their workforce. It’s also essential that employers make sure employees are aware of the wellness offerings available to them and how to use them. Therefore, it’s important for businesses to increase their communications to employees around wellbeing programs that can help provide physical, mental and emotional support through the pandemic and beyond.
Evaluate current and future employee needs
Not all people are the same, which is why one-size-fits-all programs fail. A successful well-being program should be personalized to best meet employees’ current and future needs. This can be difficult, especially when considering environmental and lifestyle factors, but with the right partner it can be done effectively. Many large employers are working with a partner that leverages social determinants of health data such as household composition, purchasing habits, education and income level and more, to identify individual employee needs.
Employers should also evaluate new types of resources to accommodate the “new normal”. Case in point: we have seen double digit increase in engagement with financial wellbeing and EAP resources. Telehealth and remote condition management programs are on the rise as well as stress management and resilience programs. For example, “Linda” has diabetes, so she needs to know the COVID-19 risks associated with her condition. She may also need extra support to ensure she is keeping up with her healthy eating and exercise regimen during quarantine. Connecting her with a remote diabetes program like Livongo or Virta Health can help Linda feel valued and stay on track. Or, “Tom” has been having severe back pain and his doctor recommends he have surgery to correct a spine-related issue. But not all health systems are offering elective surgeries right now, so he is better off with a telehealth pain management program like Telespine or Hinge Health, Physera and Simple Therapy.
This information allows employers to personalize the health and wellness plans they offer to employees and provide them with the right tools to make their healthcare journeys easier as they navigate this new way of life. Employers will also see the benefits in healthier, happier employers, increased productivity and potentially lower long-term healthcare costs.
Have a solid strategy for returning to work
COVID-19 return to work programs will require an increase in spending for heightened safety measures, such as enhanced cleaning and disinfection practices, employee daily temperature checks (which are now required by some states) and developing and implementing policies and procedures that address preventing, monitoring for and responding to an emergence or resurgence of COVID-19 in the workplace.
As businesses begin reopening workspaces, it is critical for leaders to have a solid employee engagement plan in place to keep workers safe. Be sure to clearly and effectively communicate new safety protocols to employees, so they can feel safe going to work as offices reopen. Invite employees to discuss any concerns they may have in an open forum or via a survey and involve them in problem-solving. Listen to their needs both personally and professionally as our lives will be complicated for months, and possibly years to come. It sounds cliché to say that people are companies most valuable assets. However, it could not be more true right now. It’s time for businesses to make employees’ wellbeing a priority and step up to the challenge of evolving their programming to meet current and future needs. Both the business and its employees will benefit.
SOURCE: Hinkle, C. (19 August 2020) "3 ways to support workplace well-being during COVID-19" (Web Blog Post). Retrieved from employeebenefitadviser.com/opinion/3-ways-to-support-workplace-well-being-during-covid-19
Creating an ‘urgent care first’ mindset for employee benefits
With urgent cares continuing to pop up everywhere, it’s important to guide your employees in adopting an "urgent care first" mentality. Continue reading this blog post to learn more.
Urgent care centers are popping up everywhere, which means getting quick healthcare is easier and more convenient for patients. But these centers could also help employers minimize expensive emergency room claims. That’s why it’s important to guide employees to adopt an “urgent care first” mentality.
The concept of urgent care has been around since the 1970s, but rising healthcare costs, especially for ER care, have spurred an increase in centers across the U.S. over the last decade. In fact, from 2014 through June 2017, the number of urgent care centers rose by nearly 20%.
Urgent care centers provide care for health problems that aren’t life-threatening, but can’t wait for an appointment with a primary care provider. No one wants to suffer with a sore throat all weekend. Many urgent care centers are staffed with doctors and nurses, and provide more advanced capabilities than what’s typically available at a primary care doctor’s office. For example, some urgent care centers give stitches, provide X-rays and even MRIs.
Patients can also get treatment at urgent care for conditions they’d typically see a primary care doctor for, such as the flu or a fever, mild to moderate asthma, skin rashes, sprains and strains, and a severe sore throat or cough — illnesses that produce unnecessary high claims if treated in an ER.
Still, when a severe sore throat and high fever strike on a weekend and the doctor’s office is closed, employees may gravitate to the ER because they’re sick and need help right now. That’s where the urgent care first mindset becomes good medicine. It typically costs the employer (and often the employee) far less if that sore throat is treated in an urgent care facility.
The high cost of ER care is enough to make anyone run a high temp. From 2009 to 2016 (the most recent data available), the average amount that hospitals billed insurance carriers for an emergency room visit more than doubled, from $600 to $1,322. By contrast, urgent care typically costs about $150 per visit. Members often pay a lower copay for urgent care visits, too.
The urgent care first mindset is starting to take hold. New data analysis from Aetna shows that as urgent care centers began to proliferate, ER visits for minor health issues dropped 36%, while the use of urgent care and other non-emergency health settings increased 140%.
However, the same study shows that plans only saw a decrease in ER visits if there were several urgent care centers in the geographic region where their employees lived. Awareness is key.
Fostering an urgent care first mentality
Employers can’t just include urgent care in a benefits plan and expect employees to use it. They need to design the plan to encourage use and follow up with plenty of education.
Education about the benefits of primary care versus urgent care versus the ER should take place during open enrollment and throughout the plan year so members understand the medical necessity and financial implications of each option. Including the closest urgent care centers to employees, as well as a list of services they provide, can help encourage them to adopt an urgent care first mentality.
A word of caution: not every nearby urgent care center is actually in-network. It literally pays for employees to keep a list of nearby in-network centers handy when that inevitable weekend sore throat strikes.
Reminders about urgent care before spring allergies, summer vacations, fall school physicals and flu season can also help encourage their use.
The too-low ER copay
Plan design is another important piece of the puzzle to help steer employees to the right level of care for their needs. It’s not that unusual to see a $100 copay for an emergency department visit. While no one wants to discourage ER visits for true emergencies, it makes sense to adjust the plan design to encourage primary and urgent care visits instead. That may mean a $20 copay for primary care, a $40 copay for urgent care and a $200 to $250 copay for ER visits — which is waived if the plan participant is admitted to the hospital.
For high-deductible health plans paired with a health savings account, the savings can be even more drastic; patients may pay $200 for an urgent care visit versus $1,200 for an ER visit.
The combination of education and plan design can help curb unnecessary ER visits, which could help employers control healthcare increases from plan year to plan year. For health issues that crop up during off hours, the urgent care first mindset is good for both employers and employees, who will ultimately save time and money.
SOURCE: O'Conner, P. (5 July 2019) "Creating an ‘urgent care first’ mindset for employee benefits" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/creating-an-urgent-care-first-mindset-for-employees
Digital health revolution: What we’ve learned so far
Digital health devices provide personalized feedback to users, helping improve their health. Continue reading this blog post to learn more about the evolving digital health revolution.
The promise of the digital health revolution is tantalizing: a multitude of connected devices providing personalized feedback to help people improve their health. Yet, some recent studies have called into question the effectiveness of these resources.
While still evolving, many compelling use-cases are starting to emerge for digital health, including a set of best practices that can help guide the maturation of this emerging field. In the near future, many people may gain access to individual health records, a modern medical record that curates information from multiple sources, including electronic health records, pharmacies and medical claims, to help support physicians in care delivery through data sharing and evidence-based guidelines.
As these advances become a reality, here are several digital health strategies employers, employees and healthcare innovators should consider.
Micro-behavior change.
Part of the power of digital health is the ability to provide people with actionable information about their health status and behavior patterns. As part of that, some of the most successful digital health programs are demonstrating an ability to encourage daily “micro-behavior change” that, over time, may contribute to improved health outcomes and lower costs. For instance, wearable device walking programs can remind people to move consistently throughout the day, while offering objective metrics showcasing actual activity patterns and, ideally, reinforcing positive habits to support sustained change. Technology that encourages seemingly small healthy habits — each day — can eventually translate to meaningful improvements.
Clinical interventions.
Big data is a buzz word often associated with digital health, but the use of analytics and technology is only meaningful as part of a holistic approach to care. Through programs that incorporate clinical intervention and support by care providers, the true value of digital health can be unlocked to help make meaningful differences in people’s well-being. For instance, new programs are featuring connected asthma inhalers that use wirelessly enabled sensors to track adherence rates, including frequency and dosage, and relay that information to healthcare professionals. Armed with this tangible data, care providers can counsel patients more effectively on following recommended treatments. Rather than simply giving consumers the latest technologies and sending them along, these innovations can be most effective when integrated with a holistic care plan.
Real-time information.
One key advantage of digital resources, such as apps or websites, is the ability to provide real-time information, both to consumers and healthcare professionals. This can help improve how physicians treat people, enabling for more customized recommendations based on personal health histories and a patient’s specific health plan. For instance, new apps are enabling physicians to know which medications are covered by a person’s health plan and recommend lower-cost alternatives (if available) before the patient actually leaves the office. The ability to access real-time information — and act on it — can be crucial in the effort to use technology to empower healthcare providers and patients.
Financial incentives.
Nearly everyone wants to be healthy, but sometimes people need a nudge to take that first step toward wellness. To help drive that engagement, the use of financial incentives is becoming more widespread by employers and health plans, with targeted and structured rewards proving most effective. From using mobile apps and comparison shopping for healthcare services to encouraging expectant women to use a website to follow recommended prenatal and post-partum appointments, financial incentives can range from nominal amounts (such as gift cards) to hundreds of dollars per year. Coupling digital health resources with financial rewards can be an important step in getting — and keeping — people engaged.
The digital health market will continue to grow, with some studies estimating that the industry will exceed $379 billion by 2024. To make the most of these resources, healthcare innovators will be well served to take note of these initial concepts.
SOURCE: Madsen, R. (14 March 2019) "Digital health revolution: What we’ve learned so far" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/digital-health-revolution-what-weve-learned-so-far?brief=00000152-14a5-d1cc-a5fa-7cff48fe0001
What HR pros should know about clinical guidelines
Sets of science-based recommendations, also known as clinical guidelines, are designed to optimize patient care in areas such as screening and testing, diagnosis and treatment. Read this blog post for what HR professionals should know about these guidelines.
Your employees and their family members frequently face tough questions about their healthcare: How do I know when it’s time to get a mammogram? When does my child need a vision screening? Should I get a thyroid screening? If I have high blood pressure or diabetes, what is the best treatment for me?
For the providers who care for them, the key question is: How do we implement appropriate, science-backed treatments for our patients, testing where needed, but avoiding potentially harmful or unnecessary (and expensive) care? The answer is to seek guidance from and use clinical guidelines —along with existing clinical skills — wisely.
Clinical guidelines are sets of science-based recommendations, designed to optimize care for patients in areas such as screening and testing, diagnosis and treatment. They are developed after a critical review by experts of current scientific data and additional evidence to help inform clinical decisions across a spectrum of specialties.
Based upon this process, guidelines are then released by a number of sources and collaborations, including academic and non-profit healthcare entities, government organizations and medical specialty organizations.
From preventive care to treatment protocols for chronic conditions, guidelines provide a framework healthcare providers use with patients to help guide care. However, it’s important to note that clinical guidelines are not rigid substitutes for professional judgment, and not all patient care can be encompassed within guidelines.
The impact on healthcare and benefits
Clinical guidelines are used in myriad ways across the healthcare spectrum, and providers are not the only ones who utilize them. Insurers also may use guidelines to develop coverage policies for specific procedures, services and treatment, which can affect the care your covered population receives.
To illustrate a key example of an intended impact of guidelines on health plan coverage, consider those issued by the U.S. Preventive Services Task Force, whose A and B level recommendations comprise the preventive services now covered at no cost under the mandate of the Affordable Care Act.
As another example, the National Committee for Quality Assurance, which accredits health plans and improves the quality of care through its evidence-based measures, uses the American Heart Association guidelines when creating its quality rules for treating high cholesterol with statin drugs.
Other examples exist among commercial coverage policies. For example, some cancer drug reimbursement policies use components from nationally recognized guidelines for cancer care.
Because science is rapidly changing, guidelines are often updated, leading insurers to revisit their policies to decide if they will change how services and medications are covered for their members. Providers and health systems may modify processes of patient care in response to major changes in guidelines and/or resultant changes in payer reimbursement.
Not all guidelines are updated on a set schedule, making it even more important for providers and organizations that rely on guidelines to stay on top of changing information, as it can have a direct impact on how they work. Attending conferences, visiting the recently established ECRI Guidelines Trust, and regularly reviewing relevant professional association websites and journals can help ensure needed guidelines are current. Lack of current information can affect care decisions and potential outcomes for patients. Those who have access to the most up-to-date, evidence-based information are able to work together to make well-informed healthcare decisions.
Why it matters for employers
As employers or benefits consultants, it’s critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.
Further, by combining information from relevant guidelines and data from biometric screenings, health risk assessments, claims and other sources, it’s possible for clinical advocacy and other decision support providers to identify employees with gaps in care and generate targeted communications (through a member website and/or mobile app) to help them take action to improve their health.
Clinical guidelines are science distilled into practical recommendations meant to be applied to most patients for quality healthcare. By maintaining current, relevant guidelines, organizations and providers who work with your covered population can ensure that all parties have the key information they need to make the best decisions for their health.
SOURCE: Sivalingam, J. (18 March 2019) "What HR pros should know about clinical guidelines" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/what-hr-managers-should-know-about-clinical-guidelines?feed=00000152-a2fb-d118-ab57-b3ff6e310000
Move over mainstream: Alternative health options a road to better value
A number of employers are seeking alternative ways to get better value for their healthcare spending. Read this blog post to learn more about alternative health options.
While employers may be the largest purchasers of healthcare outside of the federal government, rarely does one organization have enough influence when negotiating with the powerful health plans and provider systems. As a result, employers — and ultimately the consumers for whom they purchase healthcare services — pay the price.
Instead of taking these lumps of coal sitting down, there are a growing number of employers on the cutting edge of healthcare purchasing seeking alternative ways in 2019 to get better value for their healthcare spending. They are looking for the diamonds in the rough.
In more than half of the healthcare markets in the U.S., providers have merged reducing competition and leaving employers and consumers with little choice for their care. Employers must stop insisting that health insurance products provide access to the broadest network of healthcare providers — if providers know they’ll be kept “in network” no matter how they behave, employers and payers further reduce their negotiating position. Employers also should band together to be sizable enough to call the shots, but this rarely happens.
While this lack of market power and influence is a major frustration for employers, it’s far from the only one. Educated employers also know that the healthcare system produces uneven quality and high prices have nothing to do with excellent care. The amount an employer pays for a service merely represents the relative negotiating strength of the health insurance carriers and providers.
As prices continue to drive healthcare cost growth, Americans are finding their healthcare unaffordable and are willing to trade choice for affordability. Many Americans no longer view having the ability to pick any doctor they choose as essential if it means increased premiums and cost-sharing that comes at the expense of other basic needs. These shifting attitudes represent an opportunity for employers seeking diamonds to pursue the following new healthcare benefits options. Here are some.
Narrow networks: Health insurance plans built around a narrower network that cuts out care providers who are outlandishly expensive or have a particularly poor record on quality. Alternatively, center a smaller network around a direct contract with an accountable care organization selected for its potential to deliver higher quality and value. More commercial health insurance carriers and lesser known third-party administrators are offering and supporting these options. Premiums and cost-sharing are typically lower for the consumer than with broader network plans.
Centers of excellence (CoE): Steer patients to designated high-quality providers with expertise in a given medical area who are willing to enter into an alternative payment arrangement or offer a more reasonable price in return for more patients. Make CoEs attractive through more generous coverage or make them mandatory if employees want an elective or non-emergent procedure (e.g., bariatric or spine surgery). Either way, employers reduce the risk that employees will receive subpar or low value care.
Alternative sites of care: Increase access to and use of alternative sites of care including onsite or near-site clinics and telehealth services. These enhance the convenience of primary or behavioral healthcare for employees and can help the employer better control referrals to overpriced hospitals or specialists.
So, move over mainstream. When it comes to the tactics employers use to purchase healthcare, alternative is likely to become less fringe. Narrow networks, CoEs or alternative sites of care may not solve all of the frustrations. But employers’ pursuit of these new models sends a strong signal that lumps of coal aren’t going to cut it. Employers are on the hunt for a shinier, more attractive set of solutions.
SOURCE: "Move over mainstream: Alternative health options a road to better value" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/opinion/move-over-mainstream-alternative-health-options-a-road-to-better-value?brief=00000152-1443-d1cc-a5fa-7cfba3c60000
Developing guidance could free employers from ACA mandate
A future path for employers to avoid ACA employer mandate penalties was outlined in a recent IRS notice. Read this blog post from Employee Benefits News to learn more.
A recent IRS notice provides a future path for employers to avoid ACA employer mandate penalties by reimbursing employees for a portion of the cost of individual insurance coverage through an employer-sponsored health reimbursement arrangement.
While the notice is not binding and at this stage is essentially a discussion of relevant issues, it does represent a significant departure from the IRS’s current position that an employer can only avoid ACA employer mandate penalties by offering a major medical plan.
Here is everything employers need to know.
Background: As described in more detail in a previous update, the ACA currently prohibits (except in limited circumstances) an employer from maintaining an HRA that reimburses the cost of premiums for individual health insurance policies purchased by employees in the individual market.
Proposed regulations issued by the IRS and other governmental agencies would eliminate this prohibition, allowing an HRA to reimburse the cost of premiums for individual health insurance policies (individual coverage HRA) provided that the employer satisfies certain conditions.
The preamble of the proposed regulations noted that the IRS would issue future guidance describing special rules that would permit employers who sponsor individual coverage HRAs to be in full compliance with the ACA’s employer mandate. As follow up, the IRS recently issued Notice 2018-88, which is intended to begin the process of developing guidance on this issue.
On a high level, the ACA’s employer mandate imposes two requirements in order to avoid potential tax penalties: offer health coverage to at least 95% of full-time employees (and dependents); and offer “affordable” health coverage that provides “minimum value” to each full-time employee (the terms are defined by the ACA and are discussed further in these previous updates).
Offering health coverage to at least 95% of full-time employees: Both the proposed regulations and notice provide that an individual coverage HRA plan constitutes an employer-sponsored health plan for employer mandate purposes. As a result, the proposed regulations and notice provide that an employer can satisfy the 95% offer-of-coverage test by making its full-time employees (and dependents) eligible for the individual coverage HRA plan.
Affordability: The notice indicates that an employer can satisfy the affordability requirement if the employer contributes a sufficient amount of funds into each full-time employee’s individual coverage HRA account. Generally, the employer would have to contribute an amount into each individual coverage HRA account such that any remaining premium costs (for self-only coverage) that would have to be paid by the employee (after exhausting HRA funds) would not exceed 9.86% (for 2019, as adjusted) of the employee’s household income.
Because employers are not likely to know the household income of their employees, the notice describes that employers would be able to apply the already-available affordability safe harbors to determine affordability as it relates to individual coverage HRAs. The notice also describes new safe harbors for employers that are specific to individual coverage HRAs, intending to further reduce administrative burdens.
Minimum value requirement: The notice explains that an individual coverage HRA that is affordable will be treated as providing minimum value for employer mandate purposes.
Next steps: Nothing is finalized yet. Employers are not permitted to rely on the proposed regulations or the notice at this time. The proposed regulations are aimed to take effect on Jan. 1, 2020, if finalized in a timely matter. The final regulations will likely incorporate the special rules contemplated by the notice (perhaps with even more detail). Stay tuned.
This article originally appeared on the Foley & Lardner website. The information in this legal alert is for educational purposes only and should not be taken as specific legal advice.
SOURCE: Simons, J.; Welle, N. (17 January 2019) "Developing guidance could free employers from ACA mandate" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/developing-guidance-could-free-employers-from-aca-mandate?brief=00000152-14a5-d1cc-a5fa-7cff48fe0001
The case for self-funded health benefit plans and reference-based pricing
Small businesses are starting to explore self-funded plan designs that use reference-based pricing. Continue reading for more about self-funding and reference-based pricing.
Self-funding and reference-based pricing are hot topics with small businesses. They are so popular, in fact, that a recent survey shows an overall increase in their 2019 projection of small employer clients having a reference-based pricing health benefit plan design. Small businesses are seeing these savings, and they’re starting to explore how reference-based pricing can help them, too.
Before we get to why self-funded plan designs that use reference-based pricing are becoming more popular for small businesses, let’s review the basics.
Reference-based pricing is a methodology of calculating payment to providers for covered treatments and services using a “reasonable fee” based on a reference point. A common reference point is the Medicare fee schedule. Some self-funded health benefit plans calculate the reasonable fee as a percentage of the Medicare fee schedule to determine reimbursement for services rendered.
Bottom line: Self-funded health benefit plan designs that use reference-based pricing can allow for a great deal of flexibility with a variety of arrangements and overall cost-savings.
So, what’s behind the recent trend toward reference-based pricing for smaller employers? A few key factors.
First, a self-funded health benefit plan design that uses referenced-based pricing can mean less expensive coverage for employees and employers.
When coupling a self-funded health benefit plan with stop-loss insurance, reference-based pricing provides an affordable way to extend coverage to employees through lower employee contributions. So, employees are happy because they’re saving money.
And employers are happy, too, because they’re allowing for more coverage to more employees. There’s a refund potential for employers if claims dollars are less than funded. There’s also a premium tax savings of around 2% since self-funded claim dollars are not subject to state health insurance premium taxes.
Moreover, self-funded health benefit plan designs that utilize reference-based pricing may also include transparency reports with aggregate health claims data and demographic information, which allow employers to better manage costs. Overall, anytime you can design a plan that’s beneficial for employees and employers, it’s a win.
Second, reference-based pricing can provide employees more flexibility when it comes to choosing a provider. Typically, an important feature of any health benefit plan design for employees is the ability to choose the provider they want. Some self-funded plan designs that use reference-based pricing give employees the chance to pick the provider that’s right for them. And, when employees are happy with their health plan, employers are usually pretty happy, too.
Finally, self-funded plan designs that use reference-based pricing can help employees become smarter healthcare consumers because of all the transparency and choice involved. When employees better understand the healthcare processes and system, costs come down for both the employee and employer. In fact, just understanding their coverage better may help employees better use their health benefit plans.
For example, using telemedicine when appropriate, establishing a relationship with a primary care doctor and using client advocacy services can all help employees better utilize their health benefit plans. In the end, employees get smarter about how they manage their care, and employers win with reduced costs.
These factors are driving more small businesses to consider reference-based pricing self-funded health benefit plan designs with stop-loss insurance. And, for good reason. These plan designs can give employers the opportunity to offer their employees affordable health benefits, provide more choice in their health plans and providers, and encourage more employee engagement. While moving to reference-based pricing may be too big of a leap for some employers, self-funding continues to provide a means for employers to offer comprehensive major medical health benefits at lower costs.
SOURCE: MacLeod, D. (6 December 2018) "The case for self-funded health benefit plans and reference-based pricing" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/the-case-for-self-funded-health-benefit-plans-and-reference-based-pricing
The benefits issue that costs employers big: Ineligible dependents on company plans
Frequently, roughly 10 percent of enrolled dependents are ineligible for the healthcare programs. Continue reading this blog post to learn more.
Are you paying insurance premiums for people who aren’t qualified to be on your company plan?
For some employers, too often the answer is “yes.”
In our experience, we find that nearly 10% of dependents enrolled in employee health and welfare plans are not eligible to be in the program. And for a company with a couple of hundred employees that spends around $2 million a year on benefits, ineligible dependents can become a significant financial issue.
When employers pay for ineligible dependents, costs increase for them and employees. Unfortunately, it’s an all-too-common issue that employers need a solid strategy to combat.
So how do ineligible dependents get enrolled in the first place? There are a couple of common ways that employers end up paying health insurance premiums for ineligible dependents. The most basic factor is a change in a person’s situation — children pass the age of 26, spouses get jobs, people get divorced, etc. — and the employee is unaware of the need to notify the plan sponsor. Most often, these situations arise because the employer doesn’t have a process in place.
But some situations are more nefarious: An employee mischaracterizes someone as a dependent. They may claim that a nephew is a son, or that they’re still married to an ex-spouse. In either of these situations, the employer loses.
Prevent ineligible dependents with best practices
Prevent paying for ineligible dependents by putting into place best practices that begin when a new employee joins the company.
During onboarding, investigate each potential plan member when the employee applies for insurance coverage. That means seeking documentation — such as marriage certificates and birth certificates — to verify that a person is, in fact, married, or that their kids are their kids and not someone else’s. Following these processes at the outset prevents the awkwardness of having to question employees about their various family relationships. Nobody wants to ask a colleague if the divorce is final yet.
To make it easy for employees to verify everyone’s eligibility, provide access to a portal where they can upload scans or images of relevant documents. This will also make it easier to track—and keep track of—onboarding documents and dependent audits when the time comes.
Once this best practice is established, it’s important to conduct periodic dependent eligibility audits, as required by ERISA. The employer can conduct an audit or hire an external auditor. This decision is usually driven by the size of the workforce.
The most logical time to conduct an audit is during benefit enrollment. Employees are already considering options for the next plan year, and they likely won’t be confused by the need to submit verifying documents. (During this exercise, it’s also a good idea to ask plan participants to verify beneficiaries on employer-provided life insurance.)
Some employers — again, depending on the size of the workforce — will conduct random sample audits of 20-25% of their employee population. Obviously, the larger the sample size, the better. Benefits administration platforms typically streamline this process.
What happens when employers identify an ineligible dependent?
Many employers offer workers an amnesty period during which an employee can come forward to say they have someone that should be taken off the plan. If the plan sponsor identifies an ineligible dependent, employees are typically offered a one-time pass. Then, they must sign an affidavit attesting that they can be terminated if it happens again.
If the employer has processed insurance claims for an ineligible dependent, they can declare fraud and seek back payment of claims payouts. Again, most in this situation prefer a more benevolent approach and will ask the employee to make monthly differential payments until the account is even. Conducting regular dependent eligibility audits as part of the benefits administration process needs to be handled with finesse for the good of organizational culture.
Some employers may shy away from conducting audits out of concern for creating awkward situations. But frankly, it’s the plan sponsor’s job to help them navigate the waters, educate them and keep them engaged in the process by becoming their best advocates. This will not only help enhance the efficiency and accuracy of employee benefit offerings, but it will result in a smoother ride for everyone involved.
Ensuring that a health and welfare benefits program follows eligibility best practices is the responsibility of the plan sponsor. But employees have a share in that responsibility, too.
SOURCE: O'Connor, P.(28 November 2018) "The benefits issue that costs employers big: Ineligible dependents on company plans" (Web Blog Post). Retrieved from:
Healthcare waste is costing billions — and employers aren’t doing anything about it
Providing your employees with healthcare insurance is expensive. A large chunk of healthcare costs is being wasted by the healthcare industry, according to a new survey. Read on to learn more.
Providing the workforce with healthcare coverage is expensive, but a new survey of 126 employers suggests a large chunk of that cost is being wasted by the healthcare industry on treatments patients don’t need.
The healthcare industry wastes $750 billion per year on unnecessary tests and treatments, according to a survey from the National Alliance of Healthcare Purchaser Coalitions and Benfield, a market research, strategy and communications consulting firm. Some 60% of employers don’t take steps to manage their healthcare plan’s wasteful spending, despite the fact that the same percentage of employers view it as a problem, the survey says.
“While waste has long been identified as a key concern and cost contributor, employers are operating blind and need to look at a more disciplined approach to address top drivers that influence waste,” says Michael Thompson, National Alliance president and CEO.
Employers are under the impression that prescription drugs are the culprit behind the spending waste, and they are, just not as much as other services. Around 54% of health spending waste is caused by unnecessary medical imaging tests, such as MRIs and X-rays, the survey says. Specialty drugs, unnecessary lab tests and specialists referrals are also major money pits.
However, the survey data isn’t suggesting these procedures and treatments shouldn’t be covered by employer health plans. The tests and treatments are potentially life-saving, they’re just used more than they should be. Sometimes previous test results can help with a current diagnosis, but medical staff don’t always check patient files before ordering new tests.
Most employers don’t monitor unnecessary healthcare spending. The 34% of employers who do rely entirely on their healthcare vendors to do it for them, trusting that it’s being taken care of.
“The idea of reducing waste in the healthcare system can be overwhelming,” says Laura Rudder Huff, senior consultant for Benfield. “While employers ask themselves: ‘Where to start?’ this is an issue where even small steps matter. Employers can begin by collecting data to identify where the inefficiencies are in their workforce and community and use assets such as vendors and organizations like coalitions to realize market improvements.”
The survey also recommends employers enlist the services of Choosing Wisely, an organization that counsels patients and employers on healthcare plans and medical treatments.
SOURCE: Webster, K. (7 November 2018) "Healthcare waste is costing billions — and employers aren’t doing anything about it" (Web Blog Post). Retrieved from https://www.benefitnews.com/news/healthcare-waste-is-costing-billions-and-employers-arent-doing-anything-about-it