Improving access to care with insurance navigation

 

Among the many challenges of the U.S. healthcare system is navigating insurance.  From finding care to understanding costs, navigating health plans can be as, if not more, painful than dealing with illness itself. Recent research illustrates that 35% of employees don’t understand their benefits; 33% of employees don’t understand their medical bills; and 62% of employees feel their employers don’t serve as a resource for their health benefits-related questions.  Juxtaposed by the fact that healthcare benefits is one of the most important components of employee satisfaction and retention (third on the list after salary and positive work environment according to Met Life’s Employee Benefit Trend’s 2019 study), it’s clear that insurance navigation is a critical gap that needs to be addressed.  By arming people with better information and advocating for their needs along the way, insurance navigation improves access while lowering costs which, in turn, ensures employees are more likely to get the care they need.

 

Insurance navigation cases typically fall into one of three categories:

  1. Benefits explanation: Helping employees understand what their benefits cover and their estimated costs for receiving care; 
  2. In-network provider search: Helping employees identify and access high quality in-network specialists; and
  3. Claims and billing: Helping employees file claims and resolve third-party billing issues

Here are examples of cases we have worked on in each of these categories that illustrate how insurance navigation improves access to care.

BENEFITS EXPLANATION

An Eden Health member was concerned that an elective prenatal screen her doctor had recommended wouldn’t be covered by her insurance so she was planning to skip it.  We spoke with her insurance company and verified that insurance would cover 90% of the cost, leaving her responsible for the remaining 10%. We also let her know she could do the test at a lab or at her provider’s office where she’d also have a copay for the visit.   Armed with this information, the member decided to proceed with having the prenatal screen at a nearby lab.

 

IN-NETWORK PROVIDER SEARCH

An Eden Health member needed help finding an in-network therapist who could help them with managing day-to-day life stresses.  They wanted to find someone experienced with LGBTQ needs and located near their home. We found a nearby counseling center with two in-network therapists specializing in LGBTQ concerns available the following week.  The member accepted the referral and began seeing a therapist.

 

CLAIMS AND BILLING

A patient received an unexpected $1,500 bill for anesthesiology services provided as part of a surgery.  Prior to the procedure, the patient had asked that all providers in the surgery be in-network so the bill came as a surprise.  We reached out to her doctor’s office multiple times and eventually spoke with the billing team. We confirmed the bill had been incorrectly issued, leaving the employee with a $0 balance.  

 

When dealing with a medical need, navigating insurance complexities need not be an additional burden.  To learn more about how insurance navigation can help your employees, contact us.




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We built Eden Health, a direct-to-employer medical practice, to help companies of all sizes make their employees feel important, valued, and welcomed, while getting the care they need in a cost effective way.

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