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How to Help Employees Handle Healthcare Claims

It is often a challenge for employees to navigate the healthcare claim process. The lack of knowledge or experience to handle the hurdles in the claim process is the biggest reason that leads to delayed claim payments and denied claims. Employees may fail to continuously follow up when their healthcare claim is unexpectedly denied and erroneous claims denials happen more often than expected.

Therefore, the HR department in a company can be a valuable source for their employees in this situation and guide them through the healthcare claim process.

This article covers the benefits and drawbacks of HR playing a role in the healthcare claim process of employees, plus easy fixes for common causes of late or rejected healthcare claims.

Benefits of helping employees handle healthcare claims?

Helping employees handle problematic healthcare claims is beneficial for achieving better business outcomes for two reasons:

  • Save time and improve productivity. With HR representatives helping employees handle insurance-related problems, it may translate into less company time wasted and allow employees to focus more on core work tasks and improve productivity. 
  • Monitor the insurer's performance. Helping employees resolve claim problems offers a great opportunity for HR to monitor the insurer's performance. Frequently late or mistakenly denied claims can be a sign that your carrier is underperforming and it is time to make a change.

It is in employers' best interest to help employees with their health care claims. Helping employees solve healthcare claim issues can not only increase their overall satisfaction with the company by avoiding struggles and frustrations, but it can also help maintain employee morale and make the company a trusted go-to resource.

Drawbacks of Helping with Employees' Healthcare Claims

Although it can be beneficial for employers to help employees with their healthcare claims, there are some drawbacks:

  • Time. Helping employees sort through the claims process can be time-consuming and become a burden for the HR department if employees start turning to HR as their first point of contact with a claim issue, rather than trying to call the insurer and solve the problem themselves.
  • Potential liability issue. Helping employees with health care claims may expose employers to discrimination charges under the American Disabilities Act or liability related to privacy laws. Although many lawyers maintain that this risk is minimal, it would always be a good idea to consult legal counsel first. As a precautionary measure, employers can require employees to sign privacy waivers before helping with any health care claim issues.

Common Healthcare Claim Problems & Solutions

According to HR Magazine, many claims disputes arise from five common problems that are not only easily resolved, but also often preventable.

  • Cause #1: Employee not providing their current health plan information during their health care visit. This could be because employees lost the new insurance card, forgot to show the provider the new card or didn’t provide insurance information at all.
    • Solution: When distributing new cards, remind employees to keep it with them, dispose of old cards and always show the card when seeking health care. Follow up with regular reminders throughout the year.
  • Cause #2: Claim getting denied because the provider coded it incorrectly. For example, attributing a claim for circumcision to a mother, rather than her newborn son. Another reason could be that a provider failed to indicate that a particular therapy or treatment is medically necessary.
    • Solution: When inquiring about a denied claim, be sure to check that the claim was coded correctly. If it was an error on the physician’s part, ask the provider to resubmit the corrected claim. Also, encourage your employees to know their benefits and act accordingly - for instance, knowing if therapy is covered only if deemed “medically necessary,” and then ensuring their provider indicates it as such.
  • Cause #3: Employees have coverage through two plans (theirs and their partner’s). They may be confused as to how their dependents are covered, which can lead to mistakes regarding which insurance information they give their child’s provider or cause disagreement between the two insurers regarding who should pay.
    • Solution: Educate employees about navigating double coverage situations; for instance, children generally have primary coverage through the plan of the parent whose birthday comes first in the calendar year. Give other specific examples to help employees understand their coverage.
  • Cause #4: Healthcare claims confusion resulting from insufficient or overly complex communication from the employer. Benefits are confusing for employees to start with, and benefits communication documents are often written at too high a level to make sense to many employees. This either results in employees misunderstanding their benefits information or failing to read it at all due to its complexity.
    • Solution: Help your employees understand their benefits. Communicate in clear, direct ways and provide multiple opportunities for employees to learn and ask questions. Make plan documents available to them year-round, coordinate benefit meetings prior to open enrollment and make available other resources for employees (carrier website, online or phone support, your company website, HR, etc.)

Final Thoughts on Helping Employees with Health Care Claims

Helping employees handle healthcare claims can be a useful tool to improve employee morale and further increase productivity and employee performance. However, there are some potential risks employers should pay close attention to while getting involved in the health care claim process. 

If you ever encounter difficulties resolving a problematic claim situation on your own, it's always wise to seek out professional guidance from an HR service provider to facilitate a productive conversation and get to the bottom of an issue.

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