How TikTok Can Make You a Better Health Insurance User
By Alison Nelson, Employee Benefits Account Manager
For better or for worse, the way people are getting their news and information has changed. Senator Mark Warmer from Virginia said in this viral video at a press conference, “With 100 million Americans daily on TikTok, on an average of 90 minutes a day, this is an issue. I imagine most of you would like your networks to get 90 minutes a day from 100 million Americans.”
Don’t get me wrong, there are a lot of downsides to people gathering their news and resources from social media. But surprisingly, there are also some positives. For example, let’s focus in on how TikTok is unexpectedly shaping the industry of health insurance.
With consumer habits being formed in the midst of funny cat videos, outfit inspirations, viral dances, and book recommendations, TikTok has slowly begun to function like a search engine. Sure, I can lookup things to do for my next vacation, but I can also lookup what an EOB is, what to do if a claim is denied, or how to get my medication for less money. Brokers, providers, and consumers alike are flocking to TikTok to share their tips and tricks for all things insurance. After scrutinizing some of my industry’s relevant content, I’ve got to say, some of the advice isn’t half bad.
Searching “health insurance” on TikTok will lead you to thousands of videos, most with the goal of helping consumers understand their insurance and teach them about available resources in an easily digestible manner. Below are a handful of topics I saw within a few effortless scrolls.
- What to do when you turn 26 and come off your parents’ health insurance plan
- Individual health insurance
- Insurance basics
- What is HIPAA
- HSA tips and tricks
With an increasing amount of Gen-Z (born from 1995 to 2009) in the workplace, and with Generation Alpha close behind (they’re already 13 years old), it’s important for professionals in all industries to meet the consumers where they want to be met, which, usually means online. The attention-grabbing style of TikTok makes topics like health insurance more palatable to our new workforce generations, and even to the older workforce who never fully understood what they had.
This abundance of health insurance resources on TikTok makes it obvious that this industry is changing. Consumers are savvier than they have ever been. This is incredibly exciting in terms of the educational effort insurance brokers like RISQ Consulting have been striving for. As a health insurance broker, I can’t emphasize enough how important knowing the basics of insurance is.
While I would caution against believing everything you see on TikTok, it is great to see an influx of information readily available to help you learn. Naturally, I always recommend discussing insurance with a licensed professional (preferably one from RISQ Consulting 😊) but, if nothing else, TikTok has proven itself to be a great place to start. It’s amazing to see more and more people take an interest in their healthcare and the healthcare system, after all, knowledge is power.
- Published in Blog
Virtual Second Opinions
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
There may be a time in employees’ lives when they receive a medical diagnosis or feedback they feel uncertain about. Second opinions allow patients facing medical challenges to seek additional medical information on their condition, which can provide clarity and other treatment options available. With the increase in the popularity of telehealth, there is even the option of virtual second opinions, which can provide convenience by saving employees time and travel.
A virtual second opinion can help ease some of an employee’s stress after a serious diagnosis or when looking for a diagnosis for ongoing symptomatic issues. It can be difficult for a patient to find an appointment, especially if they need specialty care. Therefore, offering health coverage that includes virtual care gives a more accessible and efficient option for care. This article explains the additional benefits of receiving second opinions virtually.
Benefits of Virtual Second Opinions
Access to a second opinion can help relieve worry about diagnosis or treatment uncertainty. A virtual second opinion can provide easier access to different opinions, creating peace of mind for a patient. Additional benefits to this virtual care option can include:
- Improved patient care—The most significant benefit patients find from seeking a virtual second opinion is an improvement in overall care. This is due to having access to a large library of doctors nationwide. No matter where a patient is located, they may potentially receive access to any specialist they need.
- Increased timeliness—Receiving a virtual second opinion is often more efficient than going in person to receive one. The virtual process may allow patients to receive in-depth care and a treatment plan from a physician in about two weeks; in contrast, in-person visits are booked months out in most cases.
- Individualized care—It’s easier to make informed health decisions when all the facts are present. With a virtual second opinion, doctors can take the facts and ease patient anxiety by answering questions and creating a clear plan.
- Expanded care—Offering the benefit of virtual second opinions to employees helps those who live in areas of the country that do not have adequate access to health care.
- Eased anxiety—Virtual second opinions can ease the anxiety and stress of employees that may have received a diagnosis or care option they’d like analyzed in-depth. It can also empower an individual to take charge of their health and increase overall health literacy.
It’s important to note that there are different virtual second opinion program levels available. For example, these programs can include quality care for cancer and musculoskeletal disorders. Other programs offer care from specialists and subspecialists, such as surgeons and oncologists, that may be required for a patient’s care.
Summary
The level of care offering needed at each organization will vary, so it’s important to survey the needs of employees to find out which coverage options will receive the most use. Providing the option of virtual second opinions can give employees comfort in knowing they have access to additional care when they need it most. For more information on virtual second opinions, contact RISQ Consulting today.
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A Primer on Medical Stop-loss Insurance
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Catastrophic and unexpected health care claims are on the rise. This increase in catastrophic claims is, in part, the result of medical and pharmaceutical advances, such as specialty drugs and cell and gene therapies, as well as medical price inflation. As a result, many employers with self-funded health plans are actively looking for ways to minimize their financial exposures to potentially catastrophic claims. A common strategy these employers have leveraged is purchasing stop-loss insurance.
This article provides a general overview of stop-loss insurance and outlines some considerations for employers to keep in mind when deciding whether to purchase this coverage.
What Is Stop-loss Insurance?
Generally speaking, stop-loss insurance helps self-funded employers protect themselves from higher-than-anticipated health claim payouts by limiting their exposure to employee medical claims that exceed a predetermined amount. In other words, such coverage can prevent abnormal claim frequency and severity from draining employers’ financial reserves.
Stop-loss insurance plays an important role in helping employers manage their health care costs and protecting against unexpected or catastrophic claims, as it sets a ceiling for the amount they pay in health claims. This coverage is not a form of medical insurance, but rather a policy employers can purchase to manage their financial risks.
How Does Stop-loss Insurance Work?
Under a stop-loss insurance policy, an employer’s claims liability is limited to a certain amount (also called an attachment point), therefore ensuring abnormal employee health claims do not drain the employer’s financial reserves. An employer can add stop-loss insurance to an existing plan or purchase it independently.
If an employer’s health claims exceed a predetermined amount, their insurer will usually reimburse them for all additional claims. For example, if an employer has a stop-loss insurance policy with an attachment point of $500,000, their insurer will typically begin providing reimbursement after the plan’s claims exceed $500,000. It’s worth noting that since stop-loss coverage only reimburses an employer for claims that exceed their policy’s attachment point, the employer is initially responsible for paying employee claims before they reach the established cost ceiling.
Types of Stop-loss Insurance
There are two types of stop-loss insurance: individual (or specific) and aggregate (or total claims). Understanding the difference between individual and aggregate stop-loss insurance can help self-funded employers evaluate and determine which coverage best meets their needs and reduces their financial exposures. Because health plan usage can be unpredictable, some employers choose to purchase both individual and aggregate stop-loss insurance to provide their organizations with maximum financial protection.
Individual Stop-loss Insurance
Individual stop-loss insurance limits an employer’s liability when an individual employee’s medical claims exceed the attachment point. As such, this coverage can protect employers against unexpectedly high claims from individual employees.
Aggregate Stop-loss Insurance
Aggregate stop-loss insurance can help safeguard employers from the total sum of health claims for an entire group of employees rather than any one individual. Under this coverage, an employer is usually reimbursed when their expenses for all employees’ medical claims exceed the attachment point for the plan year.
Stop-loss Insurance Considerations
Each organization is unique. Deciding whether stop-loss insurance is necessary depends on an organization’s specific needs, workforce characteristics and risk tolerance. Reviewing all relevant factors (e.g., rates, policy terms and potential exposures) can help employers decide whether purchasing this coverage makes sense. Employers can consider the following factors when evaluating whether to purchase stop-loss insurance.
Understanding the Attachment Point
The attachment points for individual and aggregate stop-loss insurance differ. Generally, the attachment point for an individual stop-loss policy is a specific dollar amount. As a result, an employer is only responsible for an individual employee’s claims up to that amount.
For aggregate stop-loss insurance, the attachment point is usually a percentage of expected claims. The typical attachment point for aggregate stop-loss insurance tends to be between 120% and 125% of expected health claims. In any case, a stop-loss insurance policy’s attachment point can vary depending on factors such as the employer’s size, employee demographics and overall risk profile.
Evaluating Coverage Limitations
Stop-loss insurance plans are medically underwritten; therefore, an insurer may refuse to cover certain conditions or require higher claim thresholds for those conditions. For example, if a plan enrollee consistently has high-cost claims, a stop-loss insurer may refuse to continue to cover that enrollee or require a higher claim threshold for the enrollee. This practice is known as lasering.
Additionally, since stop-loss contracts typically last for one year, an employer’s high-cost claimants may only be covered for a few months before the insurer excludes them from the policy upon renewal. Thus, the employer will likely be financially exposed to those claims the following year.
Monitoring Increasing Costs
While stop-loss insurance can help employers reduce their financial exposures when health claims are higher than anticipated in a given year, the cost of such coverage can increase annually. Rising claims can also make it more difficult to obtain rates from other providers.
Ensuring Stop-loss Coverage Aligns With Health Plan Provisions
Some stop-loss policies may exclude certain medical treatments or classes of individuals covered by employers’ health plans. Consequently, employers may be on the hook for expensive claims that aren’t covered under their stop-loss policies. Therefore, employers should consider reviewing their stop-loss policies and health plan provisions to ensure they align to limit their potential financial exposures.
Summary
Selecting the right insurance policies can have major financial repercussions for employers. Having sufficient coverage can lower employers’ insurance costs, reduce their risks and keep their workers healthy. Stop-loss insurance can make all the difference in helping employers mitigate their financial risks, especially as catastrophic health claims are increasing. Understanding stop-loss insurance will allow employers to make the best policy decisions for their respective organizations.
For more health care resources, contact RISQ Consulting today.
- Published in Blog
High Deductible Health Plans
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Enrolling in a high deductible health plan (HDHP) allows you to place pre-tax earnings in a health savings account (HSA). Then, you can use these saved funds to pay for medical, dental and vision care, and most medications.
The Basics of HDHPs
Many people enroll in an HDHP, a health insurance option that does not cover your first dollar of medical expenses. Instead, these plans have a high deductible that must be met before most services are covered at 100 percent. In general, the deductible must apply to all medical expenses (including prescriptions) covered by the plan. However, plans can pay for “preventive care” services on a first-dollar basis (with or without a copay), including routine prenatal and well-child care, child and adult immunizations, annual physicals, mammograms, pap smears, etc.
HDHPs and HSAs: Their Connection
An HSA is an account that can be funded with your tax-exempt dollars, by your employer, or by both, to help pay for eligible medical expenses not covered by your insurance plan.
Anyone who meets the following criteria is eligible for an HSA:
- Covered by an HDHP, and not covered by any other plan that is not an HDHP
- Not entitled to Medicare benefits
- Not eligible to be claimed on another person’s tax return
After visiting your physician, health care facility or pharmacy, your medical claim will be submitted to your HDHP for payment. Then, you can use your HSA to pay for out-of-pocket expenses that were not covered by your plan. Or, you can simply save your money in your HSA for future medical costs.
For more information on HSAs, ask RISQ Consulting about their HSA flyer!
Why Enroll in a HDHP and Open an HSA?
- Once your deductible is met, most medical costs are covered at 100 percent.
- Contributions to and withdrawals from HSAs for qualified expenses are tax-exempt
- Ability to save for future medical expenses
- Funds roll over from year to year
- If the account is through your employer and you leave, you take it with you.
- You control and manage your health care expenses.
Contributions Are Easy!
Once enrolled in an HDHP, you (and your employer if the account is through your job) can make contributions to your HSA. Remember though, your total contributions are limited annually.
If you make contributions, you can deduct them (even if you do not itemize your deductions) when filling out your income tax return.
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Coping With A Serious Diagnosis
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Getting an unexpected health diagnosis can flip your world upside down. Upon receiving a serious diagnosis, you must evaluate treatment options and consider how it will affect your life, health, job and finances. On top of all that, you will also need to manage the emotional toll receiving a diagnosis may have on your well-being.
This article explores the general stages of grief one may go through after receiving a serious diagnosis and tips for coping with the news.
The 5 Stages of Grief
Grief is an experience that can completely consume you mentally, physically and emotionally—and it doesn’t just happen with the traditional sense of loss. The grief that accompanies a life-changing diagnosis is complex.
Psychiatrist Dr. Elisabeth Kubler-Ross proposed a framework referred to as the “five stages of grief”: denial, anger, bargaining, depression and acceptance. Consider the following five stages of grief that you may experience following a serious diagnosis:
- Denial—Denial is the act of rejecting reality. It often comes first in the stages of grief because the mind and body have to work to process the significant life change. In this stage, you might downplay the severity of the situation to cope by rejecting pain, ignoring symptoms or hiding symptoms from loved ones.
- Anger—A strong emotion you might experience is anger. This feeling may be directed at yourself, your doctors or even the world. This phase is helpful since anger allows you to start feeling again and examine how you feel about the situation.
- Bargaining—Though this stage isn’t the same as denial, bargaining may feel similar because you’re thinking of how the situation could have gone differently. This is considered the “what ifs” stage, and people often seek a second onion hoping for different results.
- Depression—Grief and depression go hand in hand. You may pull away from loved ones or feel sad or lonely. When faced with a serious diagnosis, you may also be mourning the loss of your former and healthier self and the life that went with it.
- Acceptance—The final stage is achieved when you’ve come to terms with the diagnosis and have stopped any internal fights against it. You accept your life will be different and start taking steps to manage the condition better and improve your health.
These stages are attempts to process change and protect yourself while you adapt to a new reality. Once you’ve cycled through these stages of grief, you’re more likely to be open to coping strategies.
Tips for Coping With a Diagnosis
You’re likely to be flooded with a wide range of emotions when given a serious diagnosis. Everyone responds differently, but consider the following ways to take control of the situation:
- Give yourself time to process the news. You’ll likely need to go through the five steps of grief—which takes time—to work through any emotions. Don’t hold back on sharing your feelings with family members and friends.
- Get the facts. Learning as much as possible about your condition and treatment options is essential. Ask for resources from your doctor or pharmacist and search reputable online sources (e.g., government websites, condition-specific websites and medical journals).
- Create a support system. It can be helpful to have a network of people (e.g., family, friends, neighbors and others with the same diagnosis) to lean on and talk to during your treatment or recovery. Remember that it’s OK to accept help during a difficult time.
- Focus on healthy habits. Talk to your care team to understand the best lifestyle choices, nutrition and exercise options for your condition. Maintaining a healthy lifestyle can also help improve your energy level and mood.
- Stick to your daily schedule. Routine is important, and staying busy can positively impact your mental health. Just as you’d schedule time for work or social activities, be sure to include sufficient downtime to recharge.
- Make time for your favorite activities. What has been comforting before your diagnosis will likely still ease any worries. If needed, modify your activities to still participate in them. Don’t dwell on your limitations or compare your situation with how things used to be.
Depending on the diagnosis and your health situation, be open to trying new activities or other coping strategies. For example, journaling or seeking a professional mental health provider can be healthy outlets to help you navigate the condition and move forward mentally.
Summary
It isn’t always possible to prepare for life-changing news, and it’s a learning process to figure out how to cope with a difficult health diagnosis. However, you can find a way to adapt to the changes coming with some time and patience.
As you cope with a serious condition, it’s crucial to prioritize your physical, mental and emotional health. If you’re struggling to stay positive most days or are held back by fear and anxiety, it may be helpful to seek professional help. Bring up any concerns to your doctor or use the Substance Abuse and Mental Health Services Administration’s National Helpline by calling 800-662-HELP (4357).
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Tips for Effective 2023 Open Enrollment Communication
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Now more than ever, employees are looking to their employers for guidance on navigating their available benefits and how to stretch their dollars further. As such, effective open enrollment communication is critical this year. According to a Voya Financial survey, nearly one-third of American workers (31%) eligible for benefits admitted they don’t fully understand any employee benefits they selected during their most recent open enrollment period. However, employees are likely paying more attention this year as they also navigate record-high inflation and work to maximize every hard-earned dollar.
Many of today’s workers want help understanding how much money to put aside for retirement, emergency savings and health care expenses. That means employers have an opportunity to shine by effectively communicating and guiding employees throughout the open enrollment process and even the rest of the year.
As the 2023 open enrollment season approaches, employers are poised to provide their employees with resources and digital tools they can use to better understand and act with more confidence when making benefits decisions. This article highlights communication tips for employers.
Communicating With Employees
Educating and informing employees about their benefits package is an integral part of open enrollment. Effective communication is critical to educate and inform employees about new, returning or expanded benefits options. Consider these eight communication tips:
- Start early. Get the word out early about benefits offerings so employees have ample time to understand their benefits, consult with family members and determine their needs for the following year. There’s no such thing as communicating “too soon” about enrollment. Research shows that repetitive messaging and reminders increase the odds of an employee seeing enrollment information and understanding the upcoming benefit changes and how they work.
- Develop key messaging. After solidifying benefits options, employers need to plan their communication strategies. The first step is figuring out key messaging, focusing on new or updated benefits offerings, and developing FAQs to address common concerns quickly.
- Select a mix of appropriate channels. Just as many workplaces operate in a hybrid model, employee communications can be successful when done in a similar manner. For example, digital channels can help distribute and house information virtually, allowing employees to access it when and where they need it. Chat functionality with benefits vendors can also be a helpful digital tool to assist employees in figuring out which benefits they need. Alternatively, there’s still a time and place for companywide on-site meetings and mail-to-home print communication. Postcards and other mailers are still relevant and can serve as a reminder to discuss and review benefits options at home. Every workplace is different, so it comes down to selecting various channels that are relevant and engaging to each organization’s specific employees.
- Keep it simple. It’s vital to simplify any benefits information being shared. Employees don’t need to know everything, so employers should highlight what’s necessary to understand about the benefit and the information to help them decide if they need it. Links or attachments could explore the benefits further and offer the fine print.
- Make it digestible. It’s crucial to catch employees’ attention and present the key message immediately before they lose interest. Traditional benefits booklets can be lengthy; instead, employers could deliver bite-sized information to employees through methods such as videos and emails. If all open enrollment information is given at once, it’s easy for employees to become overwhelmed and, ultimately, disengage with employer-provided information. Digestible communication makes it easy for employees to know what to focus on and take action.
- Use real-world examples. When possible, employers can put benefits offerings in context with real-world scenarios. Employees can relate to stories, so find ways to bring the options to life. For example, instead of describing telemedicine as a 24/7 benefit, highlight that an employee could get health care answers in the middle of the night when they or a child are running a high fever. The chances of employees needing to use health care benefits during the next year are highly likely, so help reiterate the importance of complete coverage.
- Avoid jargon. Avoiding HR or benefits-related jargon is best to help make benefits easier to understand. Additionally, many benefits are acronyms, so employers should help decode and explain the alphabet soup to employees.
- Personalize communication. Ultimately, employers want to engage employees with open enrollment information, and a personalized approach can help. It’ll depend on the workforce and their working environments, but employers will likely need to segment their employee audience and tweak messaging so it resonates. For example, open enrollment methods and communication would look different for remote, on-site and nonwired employees.
Benefits can be complicated. Although open enrollment is the most pivotal time to highlight benefits to employees, employers have an opportunity to educate employees throughout the year. Ongoing communication after open enrollment can help encourage employees to understand and utilize the benefits available to them.
Summary
Educating and informing employees about their benefits options is an important part of open enrollment. Effective employee communication is an ongoing process, but it comes down to helping employees feel well-informed about their benefits options and confident about their choices.
Reach out to RISQ Consulting for additional open enrollment support, including employee communication resources.
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What Employers Should Know About Prior Authorization
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
Prior authorization—also referred to as preauthorization, preapproval or precertification—is the process by which medical providers must obtain approval from a patient’s health plan or insurance before administering specific medications, treatments or procedures. This process aims to protect patient health and improve affordability by reducing unnecessary medical expenses. Both medical and prescription drug plans use prior authorizations.
Understanding prior authorization can enable employers to assist their employees in receiving effective care. It may also aid organizations in reducing their overall medical expenses by helping employees avoid unnecessary or delayed treatment and denied claims. This article discusses when prior authorization is required and explains the benefits of the process, including patient protection, the reduction of medical expenses, and the prevention of drug misuse and fraudulent care.
When Is Prior Authorization Required?
Prior authorization may be required for some treatments and medications before a patient’s health plan or insurance will provide full or partial coverage. It is most commonly required when medications or treatments:
- May be unsafe when combined with other medicines or treatments
- Have lower-cost, effective alternatives
- Are used only for certain health conditions
- Are frequently misused or abused
- Are used for cosmetic purposes (e.g., Botox)
Once a preapproval request is submitted, it’s reviewed by a health plan’s doctors or clinical pharmacists. The health plan may approve the request, deny it, request additional information or suggest a less costly alternative. Patients can request that the health plan’s decision be reviewed if they don’t agree with the prior authorization response.
Health plans tend to have different rules regarding when prior authorization is required. If a patient fails to obtain the required prior authorization, their health plan may reject the claim even if it was medically necessary and would otherwise be covered.
Prior Authorization Protects Patients
Approximately half of all adverse drug events (ADEs) are preventable and caused by prescription errors, according to research from the National Library of Medicine. The Institute of Medicine reports that ADEs have an annual cost of about $21 billion.
Prior authorization combats these issues by helping to ensure patients receive the proper medication at the correct dosage. To do this, health plans partner with medical professionals to identify efficient and effective treatments, improve patient health outcomes and reduce medical expenses for the health care system as a whole; clinicians and individuals who work for health plans use a patient’s medical claims history and their knowledge of the health care system to make certain patients are prescribed safe medications at the appropriate dosage while identifying and limiting preventable harmful drug interactions. By using this data, health plans are able to determine which treatments will improve patient health and deliver the greatest value.
Even for patients who use a specific or specialty medication regularly, prior authorization can identify new treatment options. This can be especially important for children, as they may benefit from a new treatment or adjusted dosage as they age. Because specialty medications require additional care and safety precautions, prior authorization also helps individuals with complex and chronic medical conditions, such as cancer, rheumatoid arthritis and multiple sclerosis, by regularly reviewing dosages or treatments.
Prior Authorization Reduces Medical Expenses
Prior authorization can help reduce overall medical expenses by identifying lower-cost alternatives for medications. Health plans are able to review a patient’s pharmacy benefits and find generic drugs and biosimilars the medical provider may not be aware of. Generic drugs are bioequivalent and manufactured under the same standards as brand-name medications. These drugs are as clinically effective as their higher-cost brand-name counterparts but can cost 30% less, according to the Food and Drug Administration (FDA).
This price difference is due to the requirement that brand-name drugs must be extensively studied before they are approved. Conversely, generic drugs, which are copies of brand-name medications, do not require similar studies and, as a result, can enter the market at a lower price. The use of generic drugs has saved the health care system approximately $1 trillion over the last decade, according to the FDA.
Prior Authorization Prevents Drug Misuse and Fraudulent Care
Preapproval can prevent the misuse of prescription drugs by stopping certain medicines from being dispensed; health plans utilize prior authorization to help prevent addiction to potentially dangerous and habit-forming drugs. For some patients in drug misuse prevention or management programs, such as those for opioid misuse, prior authorization can be a powerful tool for treating and preventing addiction. Health plans use precertification to explain potential addiction risks to patients being prescribed new medication or treatments that could be potentially harmful. Additionally, they can alert health providers of potential contraindications, such as when prescribing opioids to patients taking prenatal vitamins or to individuals using certain medications to treat mental health conditions. This helps limit the amount of potentially dangerous and addictive medications prescribed to patients.
Moreover, prior authorization can act as a check on health care fraud. Fraudulent care occurs when an individual or group of people knowingly falsifies treatment plans or medical records, resulting in unauthorized payments. Prior authorization helps reduce instances of fraudulent care by ensuring patients receive proper treatment and dosage of medicines and that treatment is not being duplicated.
Potential Drawbacks of Prior Authorization
Despite the benefits prior authorization can provide, the process’s requirements are controversial because they can often lead to delayed treatment and negative patient outcomes or hinder patient progress. For patients with chronic or complex medical conditions requiring extensive treatment and high-cost medications, prior authorization can be an obstacle to receiving needed care.
Additionally, the process for obtaining prior authorization in terms of which services require prior authorization varies by insurer. These requirements often burden physicians and their staff. In fact, according to a 2021 American Medical Association survey, most physicians characterized the administrative burdens of prior authorization as high or extremely high.
Conclusion
Prior authorization can act as a safeguard to keep individuals healthy by ensuring appropriate and effective medications are being prescribed. It can also help make health care more affordable by providing patients and providers with coverage information and lower-cost alternatives.
For more health care resources, contact RISQ Consulting today.
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Understanding Individual Coverage Health Reimbursement Arrangements (ICHRAs)
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
You may have heard of health reimbursement arrangements (HRAs) before. These are employer-sponsored savings accounts that reimburse you for certain medical expenses.
An individual coverage HRA (ICHRA) is similar—it uses funds from your employer to help pay for certain medical expenses. However, there are some important features of ICHRAs that you should understand.
This article explains more about ICHRAs and how they may be used.
Comparing HRAs to ICHRAs
As previously stated, HRAs reimburse you for certain medical costs. Such expenses might include those associated with doctor visits, medical procedures and prescriptions, depending on the plan. To qualify for an HRA, you must be enrolled in your employer’s group health plan.
ICHRAs are a bit different. These accounts can reimburse you for certain medical expenses, your insurance premium or both. Whether your ICHRA will cover both your premium and medical expenses (or just one) will vary by employer.
ICHRA Eligibility
To qualify for an ICHRA, you must enroll in individual health coverage using a Health Insurance Marketplace (Marketplace), a private insurer, Medicare or another method. In other words, you cannot be enrolled in an employer’s group health plan and qualify for an ICHRA.
Additionally, any dependents (e.g., a spouse or children) you have on your individual health plan would also be able to use ICHRA funds.
How ICHRAs Work
On a very basic level, here’s how an ICHRA works:
- You obtain individual health coverage through a Marketplace or another method rather than purchasing health coverage through your employer.
- Your employer contributes a set amount every month into your ICHRA so you can be reimbursed for certain expenses as they are incurred. Contributions and reimbursements are both tax-free. Your employer decides which expenses are eligible for reimbursement under the plan’s terms.
- Unused funds at the end of the plan year may go back to the employer or carry over, depending on the plan.
It’s as simple as that!
More Information
Speak with HR to learn more about the ICHRA options available to you.
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Understand Your Rights Against Surprise Medical Bills
This article is from RISQ Consulting’s Zywave client portal, a resource available to all RISQ Consulting clients. Please contact your Benefits Consultant or Account Executive for more information or for help setting up your own login.
The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.
Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front before your visit. If you disagree with your bill, you may be able to dispute the charges. Here’s what you need to know about your new rights.
What Are Surprise Medical Bills?
Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost-sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.
People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.
What Are the New Protections if I Have Health Insurance?
If you get health coverage through your employer, a Health Insurance Marketplace or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
- Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
- Ban out-of-network cost-sharing (such as out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
- Ban out-of-network charges and balance bills for certain additional services (such as anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
- Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).
What if I Don’t Have Health Insurance or Choose to Pay for Care on My Own Without Using My Health Insurance (Also Known as “Self-Paying”)?
If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before you receive it.
What if I’m Charged More Than My Good Faith Estimate?
For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill.
What if I Don’t Have Insurance From an Employer, a Marketplace or an Individual Plan? Do These New Protections Apply to Me?
Some health insurance coverage programs already have protections against surprise medical bills. If you have coverage through Medicare, Medicaid or TRICARE, or receive care through the Indian Health Services or Veterans Health Administration, you don’t need to worry because you’re already protected against surprise medical bills from providers and facilities that participate in these programs.
What if My State Has a Surprise Billing Law?
The No Surprises Act supplements state surprise billing laws; it does not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply.
For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers, and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process.
As another example, if your state has an All-Payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-Payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.
Where Can I Learn More?
Still have questions? Visit CMS.gov/nosurprises or reach out to human resources.
- Published in Blog
