Understanding Healthcare Benefits

General, HealthcareBy 2017-07-30T23:22:07+00:00 On December 29th, 20130 Comments

Will your healthcare benefits take care of you?

Not if you don’t understand how to use them or how they function.

Take for instance the Public Employee Benefit Board (PEBB). Not even Washington State’s Office of the Insurance Commissioner or its Health Care Authority can explain it. The situation is so bad that the Insurance Commissioner’s Statewide Health Insurance Benefits Advisors (SHIBA) cannot explain it. Even state university human resource (HR) professionals cannot explain it to state employees.

So what are your chances when you need to understand it?

And it is not just PEBB, this is true of most health insurance plans. It is not only true in Washington, it is the same in much of the country.

You, like many others, may be working for healthcare benefits, but will your benefits work for you when needed? Maybe not. So what are they really worth?

Costly and valuable as they are — even potentially life saving — healthcare benefits won’t work well for you if you don’t already know how to use them when they are needed. Chances are that unless you have already used them extensively, you won’t know how they operate until confronted with a health crisis, when it may be too late.

Take a minute to think about it: whom would you call? What would you do if a vital prescription you needed today were denied? What is your deductible for an emergency craniotomy that is being schedule for you next week? Who could help you to navigate a complex system of treatment in a huge hospital: exactly what phone number would you call and whom would you ask to speak to? What could you read and how would you find it quickly?  Whose responsibility is it to tell you? Where would you search for the person or information to help you?

If you think your doctor knows, you are probably mistaken. If you think your employer’s human resources (HR) department has the answers, that’s unlikely.  Your insurer may know, but that depends on who you talk to at the insurer’s and you may discover your actual insurer is not who you think it is. And how much time and energy can you expend in the midst of your health crisis?

If this all sounds implausible it, and much worse, is not. This was my experience in a healthcare insurance system I was in for 10 years. Then one day in August 2009 I confronted these very circumstances and didn’t know where to turn.

If the patient is to derive the maximum value of her benefits, she must know exactly what they are and how to receive them on time. If the beneficiary doesn’t understand her benefits or is too incapacitated to manage them, she is denied their value and the care and treatment they were intended to provide. So has she received the compensation for which she was working?

For the incompetent or incapable patient accessing and managing her benefits may require a surrogate. Theoretically this surrogate could be a caregiver, healthcare provider, insurer, benefits manager, case manager, advocate or a host of others depending on the organization.

In fact, though, most of the burden falls on the patient or caregiver, neither of whom is sufficiently well positioned or knowledgeable enough to do it well.

So for most of us it goes undone or is done haphazardly, and so benefits are squandered, and care and treatment are degraded or lost. Patients suffer unnecessarily, caregivers struggle with issues that detract from providing care, and healthcare providers are denied the full care and treatment resources to which full benefits would entitle them.

Employer HR representatives and health insurers are central to resolving this calamity. Health insurers provide the benefits and HR departments administer them for employees. Neither communicates routinely with the patient during the course of treatment. Neither instructs, informs, or explains how the system of benefits functions and is to be used in the care and treatment of the patient/employee.

Many individuals, nowadays, are working for benefits, mainly healthcare benefits. In almost every case benefits are a significant part of compensation, compensation that is often deferred for a long time for healthy employees. When the time comes to redeem these benefits the employee often receives only cents on the dollar because the benefits and their use are not well understood. Too often too, the employee needs the benefits at a time in her life when she is least competent and capable of dealing such matters. She must rely on others at such a time, none of who possess the needed knowledge. Nowhere to be found at such times are her benefits administrators or her health insurance providers.

What currently passes for administering employee benefits, administering healthcare insurance benefits, and healthcare providers administering patient rights and benefits, is implementing and managing legally mandated laws, rules, and procedures. Little is offered or provided that is not mandated and what is mandated is of little consequence to a sick or dying employee/patient.

HIPAA, the Health Information Portability and Accountability Act of 1996, is an example of a legislated healthcare law. It produces no benefits in caring for a patient or treating a disease, yet it is universally practiced and enforced by healthcare providers. Significant resources are devoted to publicizing and enforcing the privacy rule that could be better spent instructing patients in how to use their healthcare plans.

I’ve seen a healthcare provider panic stricken at the prospect of failing to enforce HIPAA who never even blinked at the prospect of denying a dying patient life saving medication.

Caregivers could do themselves and their patients a great service by supporting healthcare reform that instructs them about the functioning and use of their healthcare plan.

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