Benefits Compliance is Everyone’s Job

Introduction

Benefits compliance is more than a set of legal obligations; it presents HR professionals with an opportunity to protect those we serve—people who come to work every day and who depend on their benefits to secure and improve their lives and their family’s. They are our coworkers,. friends, neighbors and community members.

As such, benefits compliance belongs to everyone. It’s about doing your job right for all the right reasons.

Start by Taking Inventory

While protecting the rights and privacy of employees and members in your benefits system is a shared responsibility across your organization and your vendors, HR/benefits professionals fill a special role in ensuring compliance. It all starts with knowing how to navigate the rapidly changing landscape of health and welfare regulations at the state and federal levels.

That’s why we developed the Businessolver Compliance Inventory. Updated three to four times per year, this guide helps HR professionals navigate nearly 100 state and federal compliance issues, including easy-to-follow instructions for sending required notices to plan participants.

While the primary audience for this resource is benefits administrators, the real winners are the employees they serve. By helping HR professionals understand their responsibilities under a myriad of quickly evolving regulations, their employees’ rights are preserved and their privacy protected.

Find Opportunity in Obligation 

Benefits professionals are well-versed in compliance issues and often regard them as obligations that yield few, if any, opportunities to improve benefits’ cost-effectiveness or overall benefits strategy. Failing to comply with COBRA notice requirements, for example, can result in a fine or an excise tax of $100 per person per day per violation. 

Occasionally, though, a regulation comes along for which the potential opportunities far outweigh the burden of the obligation. A good example is the Transparency in Coverage Rule. Finalized in late 2020, the rule seeks to allow Americans to more accurately predict their health care costs by helping them find and filter care providers within their network and location, and with respect to the amounts paid toward their deductible and out-of-pocket maximum  

With effective dates staggered across a three-year period, the new regulation methodically peels back the curtain that has obscured the personal and macro-economics of health care for decades. And for benefits professionals, there’s never been a better opportunity to increase employees’ engagement in their health care and pharmacy benefits. 

Empowering employees with resources like these not only helps them make more informed decisions, it also provides employers with the opportunity to save on their health care and pharmacy costs. Just consider these trends:  

While the Transparency in Coverage Rule may seem burdensome, in the world of benefits compliance, there’s never been a clearer return on investment

Find Opportunity in Obligation

Benefits professionals are well-versed in compliance issues and often regard them as obligations that yield few, if any, opportunities to improve benefits’ cost-effectiveness or overall benefits strategy. Failing to comply with COBRA notice requirements, for example, can result in a fine or an excise tax of $100 per person per day per violation.

Occasionally, though, a regulation comes along for which the potential opportunities far outweigh the burden of the obligation. A good example is the Transparency in Coverage Rule. Finalized in late 2020, the rule seeks to allow Americans to more accurately predict their health care costs by helping them find and filter care providers within their network and location, and with respect to the amounts paid toward their deductible and out-of-pocket maximum

With effective dates staggered across a three-year period, the new regulation methodically peels back the curtain that has obscured the personal and macro-economics of health care for decades. And for benefits professionals, there’s never been a better opportunity to increase employees’ engagement in their health care and pharmacy benefits.

Don’t Get Caught by Surprise

Another example of a compliance issue having a positive impact on employees and employers alike is the No Surprises Act. Signed into law in late 2020, this long-awaited regulation protects patients from previously unforeseeable or unavoidably high medical costs.

Intrinsically connected to the Transparency in Coverage Rule, the No Surprises Act has been a high-priority and bipartisan issue for decades. It is intended to address three scenarios where a participant receives a large medical bill through no fault of their own:

  1. A plan participant has an emergency medical condition that lands them in an out-of-network hospital or emergency room. Because it's out-of-network, they receive a balance bill.
  2. A participant schedules a procedure at an in-network facility but , without knowledge or consent, receives treatment from an out-of-network provider (e.g., an anesthesiologist) . As above, they receive a balance bill.
  3. A participant is transported by an air ambulance service provider, often following a car crash or other emergency that renders them unconscious. Unfortunately, very few of these providers have negotiated with even the largest insurers, resulting in out-of-network bills of more than $40,000 per ambulance ride.

By not holding plan participants liable under these scenarios, employees—and employers in most cases—are protected from unforeseeable or unavoidable medical costs.

How big a deal is this? Simply put, pretty big. Consider these statistics:

  • 44% of Americans have received a surprise out-of-network bill.
  • Among those , 68% said the bill was difficult to pay.
  • 11% said they could not pay the bill at all.
 

Provider Guidance

Employees and dependents who aren’t regular health care consumers have many reasons why they aren’t. Some don’t have a primary care physician, while others lack the means to get from their residence to a healthcare provider, they might even be a part of the 80% of Americans who fail to seek routine preventive care each year because they are too busy or confused by the healthcare system.

Whatever the reason is, infrequent health care consumers run the risk of making less-than-optimal decision when they eventually find themselves in the position of needing care. And, this can be expensive. In fact, the Agency for Healthcare Research and Quality estimates that 13% to 27% of emergency room visits in the U.S. could be managed in physician offices, clinics and urgent care centers, saving $4.4 billion annually.

Right care, right time, right place

Even when the situation isn’t urgent, people find themselves in the position of not having all the information needed to make optimal decisions regarding where to seek care. According to the Kaiser Family Foundation, nearly one in five inpatient admissions includes a claim from an out-of-network-provider. Meanwhile, countless others find themselves unnecessarily readmitted to the hospital after failing to seek care from a provider participating in the health plan’s center of excellence program.

Self-service to the rescue

To ensure their employees receive the right care from the right provider, more employers are turning to services that help their employees find, evaluate and book appointments with high-value providers in their network and geographic location. Today’s self-service technologies can help employees:

  • Identify in-network providers.
  • Schedule one-time and recurring appointments.
  • Locate urgent care centers.
  • Take advantage of telemedicine options.
  • Find high quality hospitals for inpatient care.
  • Identify cost-effective imaging services.
  • Maximize appropriate use of primary care for common health needs
  • Arrange care through highly experienced outpatient surgery centers

Claims Support

According to a study by the American Medical Association, inaccurate health care claims waste $17 billion annually in administrative inefficiencies. A random sampling of approximately 2.4 million electronic claims also found an average error rate of 19.3% among health insurers. And, another study found that administrative tasks associated with avoidable errors, inefficiency and waste in the medical claims process resulted in an average administrative burden of $2.36 per claim—a cost often borne by patients and their employer-sponsored health plan.Although insurance carriers have made headway in reducing error rates, the employee experience with health care claims continues to be compromised by several factors, including:

Surprise billing. A 2019 survey found that 44% of Americans have received a surprise out-of-network bill. Among those who had, 68% said the bill was difficult to pay, while 11% said they could not pay the bill at all.

Denials. With initial claim denial rates hovering around 9%, employees are spending a lot of time—often on the clock—talking to their provider, insurer or HR team to sort out why their claim was denied. Meanwhile, providers are spending an estimated $8.6 billion annually in appeals-related administrative costs.

Decreased benefits literacy. Prior to COVID-19, just over a third of employees indicated they were confused about their benefits. Mid-pandemic, however, almost 40% of employees reported high levels of confusion—an increase of over 25%.

Prior authorization. While requiring documentation to determine the medical necessity of certain drugs, tests and treatments is vital to controlling medical spend, 28% of physicians say the prior authorization process required by health insurers has led to serious or life-threatening events for their patients. Oftentimes, the patient finds themselves in the uncomfortable—and confusing—position of coordinating the flow of information between their health plan and the provider just to get approval to receive care.

Billing complexity. The typical explanation of benefits (EOB) features at least a dozen pieces of information presented in a format and using language that can be more confusing than a mortgage, lease agreement or bank statement. The current procedural terminology (CPT) codes are downright intimidating, while the tables related to charged amounts, negotiated rates, and cost share breakdowns is enough to give someone nightmares about impossible-to-solve story problems in math class.

Following the money

Similar to care navigators, claims support representatives (i.e., advocates) can greatly improve the employee experience. Unlike care navigators, however, these highly trained professionals focus more on the financial side of receiving care. Today’s claims advocacy services do this by:

  • Analyzing billing documents to uncover coding errors or troubleshoot issues related to network status.
  • Providing advocates with access to each employee’s real-time benefits information.
  • Ensuring advocates have a deep understanding of the complex claims process, including CPT codes.
  • Helping employees through the manual claims filing process when necessary (e.g., for out-of-network services).
  • Establishing relationships with providers and health plans for expedited claims resolution, including reimbursements.
  • Helping employees work with third-party entities, such as disability and workers’ compensation carriers.
  • Working with providers and health plans to proactively address common claims filing errors.
  • Ensuring prior-authorization rules have been followed and assisting where necessary.
  • Helping employees negotiate terms with providers or establish payment plans.

Personalized Health Communication

In the U.S., where 5% of the population consumes 50% of total health care costs, benefits administrators and risk managers understand the value of helping their employees stay as healthy as possible for as long as possible. This is especially true of those with chronic conditions, whom the National Institutes of Health say account for 85% of health care spending.

However, some employers are reluctant to address even the most basic, yet consequential, health behaviors due to employee privacy concerns—a fear often driven by the regulatory environment. While quite rational, this fear can paralyze HR teams from doing what’s right by the health of their employees, not to mention their bottom line.

Why it matters

First, employers have a vested interest in the health of their employees, especially if their health plans are self-funded. From a purely economic perspective, strategic and targeted health communications are justifiable, as long as they are HIPAA compliant.

More importantly, however, offering help to those employees who need it most is an expression of employer empathy—a trait many organizations lack. In fact, 92% of employees say organizations should do more to address the overall well-being and needs of their employees.

Then, there are the less urgent—yet no less consequential—situations that make a strong case for targeted health communications. These include local or global disease outbreaks, age- or gender-based health screenings, financial well-being reminders, mental health promotions and more.

Trust through technology

Fortunately, today’s data-driven technologies provide HR teams and employee wellness professionals with a variety of tools to conduct effective and empathetic outreach to employees in the right place and at the right time. And they can do so while protecting the individual’s private health information from unauthorized access through services such as outsourcing, thereby allowing HR teams to separate themselves from sensitive data. Today’s benefits technology can:

  • Build and maintain a unique profile for each employee based on demographic data, health and pharmacy claims and benefits ecosystem activity.
  • Analyze claims data to identify members experiencing a gap in care, such as overdue screenings, office visits or prescriptions.
  • Deliver messages year-round through employees’ preferred communication channels, such as push notifications, text messages, email or print.
  • Facilitate rapid response to urgent situations (e.g., natural disasters, disease outbreaks, etc.) by connecting impacted employees with available benefits and local resources.
  • Send only the most relevant messages based on strategic variables (e.g., demographics, claims history, etc.), thereby preventing “message fatigue.”
  • Maintain list accuracy in real time through automated data refreshes to ensure you’re reaching the right people, right now.
  • Track employee engagement through opens and clicks via a real-time dashboard so you can measure return on investment.

Telemedicine

In early 2020, the U.S. experienced a revolution—or perhaps a revelation—in the need for remote care in a socially distanced world. Faced with the prospect of exposing themselves or others to COVID-19, a Johns Hopkins study found that 20% to 30% of Americans stopped going to community physicians, while the Commonwealth Fund reported that 60% of Americans stayed away from ambulatory care centers.

Meanwhile, telemedicine (a.k.a., telehealth or virtual visit) services exploded. According to FAIR Health’s Monthly Telehealth Regional Tracker, telemedicine claim lines increased 4,347% nationally, from 0.17% of medical claim lines in March 2019 to 7.52% in March 2020.

Telemedicine takeaways from 2020

In an otherwise bleak financial year for employers, the increased use of telemedicine in 2020 was good news, as remote care services have been shown to result in significant cost savings. A recent study showed that telemedicine saves an estimated $19 to $120 per traditional patient visit. And, diverting patients from emergency departments with telemedicine can save between $309 to over $1,500 per visit.

Overcoming utilization barriers

Despite employees’ newfound comfort level with seeing a provider in a virtual environment, telemedicine’s potential remains largely untapped. Some barriers to adoption, like access to broadband internet, are beyond employers’ control.

Other factors, however, are very much within employers’ spheres of influence. Here are some tips.

Consider a direct relationship with a telemedicine provider.

Prior to the pandemic, employers who relied on their health plan’s embedded telemedicine benefit saw utilization rates of only 2% or 3%. By contrast, those who established a relationship with a direct-to-employee telemedicine provider and promoted the benefit for front-door episodic care saw utilization rates of 15%.

Ensure integration with your benefits platform.

Linking directly to your preferred telemedicine carrier within your benefits portal and mobile app eliminates employee confusion of knowing where to start. Ensuring that your benefits platform plays nicely with your preferred telemedicine service through single-sign-on functionality removes complexity and provides a seamless employee experience.

Maximize eligibility awareness.

Let employees know they’re eligible for virtual care services. Start by creating excitement during your benefits fair and keep reminding your employees of this benefit throughout the year. Consider campaigns tied to cold and flu season, mental health awareness month, company-wide health challenges and other opportunities.

Help employees think beyond episodic care.

While the pandemic made a strong case for seeing a doctor for conditions such as colds, injuries, infections, and other intermittent care, telemedicine’s capacity for meeting ongoing health needs has remained largely unnoticed. Make sure your employees know that telemedicine can be used for treatment such as mental health counseling, chronic disease management and even some types of physical therapy.

Optimize utilization in the moment of need.

Ask your benefits administration vendor to help you think through opportunities to remind employees of telemedicine services based on their touchpoints with members or the data in your system. For example, can their member services representatives be trained to recommend telemedicine when employees call for help finding a doctor?

The advantage of direct access

Is telemedicine here to stay? Within health care systems, it would appear so. A recent survey of hospitals and other providers reported that 92% currently offer telehealth services, or plan to roll them out by the end of 2021.

Is telemedicine here to stay? Within health care systems, it would appear so. A recent survey of hospitals and other providers reported that 92% currently offer telehealth services, or plan to roll them out by the end of 2021.

Five Tips for Creating a Personalized Benefits Experience

Rising health care costs, a complex health care system, and low benefits literacy make a good case for a more personalized employee benefits experience. By helping your employees activate the right benefits and programs, you can dramatically reduce your health care spend, while increasing employee loyalty and engagement through this strong demonstration of empathy.

But you must also ensure that the execution of these technologies and services is, itself, empathetic. It isn’t enough to simply make these value-added services available. To realize a real return on investment, you need to provide your employees with an experience that integrates personalized services alongside their core electable and non-electable benefits. In short, you must create awareness, convey value and help employees to get started.

To do so, here are five tips.

1. Bring everything together under one roof.

To create a benefits experience that supports positive health outcomes while creating greater employee engagement, the importance of integration cannot be understated. Employees are much more likely to use provider guidance, telemedicine and other self-service options when they’re integrated directly into their benefits portal and mobile app.

The same can be said of more “high-touch” services like care navigation and claims advocacy. When you allow your employees to get started via your benefits platform or the member services number they use for other benefits-related issues, you make the right choice the easy choice.

2. Maximize automation, algorithms and artificial intelligence.

Today, we expect technology to play a role in nearly all our consumer experiences. From engaging with our preferred retailers to accessing streaming media services and everything in between, we have come to expect the three A’s—automation, algorithms and artificial intelligence. Our benefits experience should be no different.

When looking for a vendor to help you execute your personalized benefits strategy, make sure to find out how they use algorithms to determine when and how to conduct employee outreach, whether they use personas to send automated messages to subsets of your employee population, and whether they use artificial intelligence applications, such as a 24 to help employees.

3. Employ an omni-channel communication strategy.

Today’s HR teams must think like marketers. Omni-channel refers to a marketing strategy that combines content, personalization and technology to create an enjoyable consumer experience. In the retail environment, for example, a customer can be shopping online from a desktop or mobile device, or by telephone, or in a brick-and-mortar store and the experience is seamless.

In the , an omni-channel approach implies employee-centric content that is simple, educational and inviting. Also, omni-channel benefits communications are personalized, based on each employee’s preferred communication channels and life stage. Lastly, an omni-channel approach to benefits relies heavily on technology to engage with employees when and where they want.

4. Ensure you have real-time visibility into utilization.

Today’s data-driven technology has changed the way employers gain insight into how their employees are using their electable benefits. With just a few clicks or a call to their client services team, employers can access periodic or ad hoc reports to gain visibility into real-time metrics like eligibility, changes due to qualifying life events, service center call volume and much more.

When offering services such as those described in this page, make sure your vendor and benefits technology can generate real-time reports on the metrics you care about, such as engagement rates (e.g., email open or click-through rates) and other indicative data points that demonstrate increased activation into the benefits and programs you make available, not to mention return on your investment.

5. Create your own ecosystem.

The rapidly growing popularity of the technology and solutions featured in this white paper has resulted in a wide variety of vendors from which to choose. Some may offer two or more types of these personalized services, while others specialize in only one. That’s good news for you, as it allows you to select service providers based on your organization’s unique needs and business goals.

In creating the right mix of services, also consider how well each vendor integrates with the core technology you’d like to use to engage employees. If you plan on using your benefits administration platform to host these non-electable benefits, for example, ask your vendor whether they have preferred vendors that can help create a seamless delivery experience.

 

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