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Claims and Health Plan Reviews

Hoodles health plan Claims review


When reviewing health plans online, Claims demanded it’s own category all together and with good reason.  After all, most people are confused when they purchase health insurance plans and it’s really when the claims start coming in that a person gets the real impression of what it is they are paying for.  The Claims process is also a measure of how much a carrier “manages” care and deals with the confusing world of EOB’s (Explanation of Benefits).  Let’s take a look at how to write or read health plan claims reviews.


What exactly is a Claim?

First of all, what is Claims.  Claims is the process of a carrier paying out on covered benefits according to your health plan policy.  That should be easy enough but like with all thing insurance, it’s rarely is.  The policy itself is very difficult to comprehend since it’s primarily written by and for attorneys.  Yes, we all recognized terms like deductibles and copays but there are so many if, and’s, or buts that it can be difficult to know how the policy will actually pay out.  On top of this, you have networks, prior authorizations, and all sorts of “road-blocks” to common sense.  It’s amazing that it works as well as it does (even if we don’t like to admit) with a solid carrier.  The new MLR rules under health reform require that 85 cents on every premium dollar must go directly to care (doctors, hospitals, RX, labs, etc).   That’s 100’s of billions of dollars each year.  Health plan claims are much more common than with other types of insurance (think auto, home, life…hopefully) that the system is a little better built but there are always glitches.


Ummmm…how do I read this thing?

The first part of the claims process is the EOB or Explanation of Benefits which is the form from the carrier explaining (hopefully) how they paid out on a given claim.  If there’s an issue, that’s the first place to see it.  EOB’s can be very dissapointing to the recipient (they only paid what??) but some times this requires additional effort to clarify something about the medical care received.  In a way, this additional effort (a call to the claims department, etc) is a small failure of the claims process for that carrier if it doesn’t result from the member not understanding how their benefits worked (which is an error of the marketing, sales departments).  Either way, our first goal in reviewing the claims experience for a health plan is the initial EOB.  Is it easy to understand?   Does it provide clear language or jargon?  Keep in mind that most of what’s on there is probably required by law which can complicate things as much as clarify them.  Did the carrier pay out the way we thought they would?  Did they decline services that seem like they should have covered?  This figures into the review.  If there are questions or issues with the health plan claims, how can we resolved them?


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We’ve all been there.  You call in and after 5 transfer, you get someone who doesn’t know what you’re talking about.  The phone line then goes dead.  It’s horrible and how a carrier resolves claims issues is as important as any other aspect that we may review them on.  These days, in most industries, it seems like a small blessing when someone can just handle your problem right away.  It’s actually unsettling.  This needs to figure into the claims health plan review as well since the EOB first line will not always be correct.  Make sure to review your health plan for others to read so we can all hopefully avoid the long phone waits to the sounds Celine Dion Musac.

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