Human Capital & Careers

Consumers Don’t Cause Health-Plan Woes, Study Finds

Most `esalated issues' are caused by administator or provider errors. StaffSeptember 5, 2001

When there’s a foul-up in health care, it’s most often not the consumer who’s at fault.

That’s the message that can be gleaned from new researh by Hewitt Associates, the Lincolnshire, Ill.-based consulting firm. According to a Hewitt release, 71 percent of reported “escalated issues” in health care, such as access to care or billing, were originated because of errors made by the plan administrator or provider of care, and not by the participant.

Hewitt consultants tracked nearly 2,500 plan issues — patient problems related to such things obtaining care or getting claims paid — from January 2000 through June 2001. Fifty-four percent of the issues originated with the plan administrator and 17 percent with the provider of care, while 29 percent originated with the employee or retiree.

“The results are surprising because many people, including health care experts, would guess that the exact opposite would be true,” said Marie Kobos, health management practice leader for Hewitt’s advocacy services. “This shows that many employees are taking the correct steps to resolve benefit plan issues, but still need assistance with an escalated issue in navigating the health care system, which can sometimes be both frustrating and complex.”

Eighty-six percent of reported issues were related to claims and 12 percent to access to care, with 2 percent attributed to “other.” Eight percent were critical, requiring resolution in 24 to 48 hours, while 92 percent were considered non-critical (not requiring immediate handling). Most of the critical issues arose because participants couldn’t get access to treatment, according to the Hewitt release.

Employer can expect that about 2 percent to 4 percent of their employees and retirees each year will experience an escalated issue which requires assistance, says Kobos.

“The good news is that the percentage is relatively small compared to the number of benefit plans that a large employer typically offers. But, the bad news is that these types of issues are very time consuming, emotional and complicated for the employee, which can lead to decreased productivity, morale, as well as overall dissatisfaction with benefits,” she adds.

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