Transforming the Narrative

Let’s explain insurers’ role in healthcare system checks and balances and how they protect our people.

Checks and balances are implemented to prevent one person, business or industry from having too much control and prevent nefarious activities from happening. These systems help reduce mistakes, prevent unfair actions and ensure best practices are followed.

We learned about them in grade school with how our government was established and as adults we appreciate these checks and balances in the financial industry. The idea of segregating duties and assigning responsibilities to different groups has been around since the Romans created the concept.

In accounting there are audits. In manufacturing there are quality standards and certification requirements. In retail, suppliers and businesses take inventory.

Insurance companies provide financial protection. They evaluate risks and assess losses. They collect premiums in exchange for taking on financial risk that the insured can’t afford on their own. Insurers create policies — setting coverage rules based on data. And they pay claims.

In healthcare, insurance companies and third-party administrators are also essentially auditors who maintain a system of checks and balances. Their role is to ensure that patients are not over or undertreated or over or underprescribed, and that people subscribing to a plan are getting the right care, at the right time, in the right place and at the right cost.

​Insurers and administrators are charged with making sure that healthcare providers maintain best practices. And those practices change daily. Consider the advancement of technology and its impact on healthcare and best practices. How research is released completely changes care protocols. Maybe we find out what was once a best practice after several years of following patients really is not a best practice. Then consider how long it may take for the latest best practices to permeate the system.

Insurers must filter data, disseminate best practices and hold healthcare systems accountable for doing what’s right. This is what we hire them to do. And sometimes, like with anything in life, we are told, “no,” and it’s for our own good. Insurers process claims — and review for clinical appropriateness which could lead to a denial for service.

Who wants to be told no? Who wants to be told a service is denied? What child likes to be told no by their parent… there are countless stories of public meltdowns. But I’m sure you can think of a number of situations over the years when the answer was no, you felt frustrated, and then later realized you were much better off for that no. There was a reason why and you appreciated it later.

When insurers issue a denial of coverage, there’s a reason why. It’s not arbitrary. It is explained – not a covered benefit, medical necessity, administrative error, lack of a needed referral, etc. We receive explanations of benefits as a transparent way of detailing what costs are covered. Consumers also have a right to multiple levels of appeal.

It’s important for our people to understand this.

As employers, we want our team members to access the best possible care and to get appropriate treatment so they can thrive. We want the same for their loved ones. Ultimately, insurance is designed to protect our employees and their dependents and ensure they are receiving quality treatment that meets current standards.

Sadly, a focus on denials and resentment toward insurers that are rightfully doing their jobs as a watchdog of healthcare best practices, has produced a wave of criticism. But there’s a critical perspective that does not seem to enter the conversation — and it’s about insurance companies’ checks-and-balances role in the healthcare system.

There’s always room for improvement. Insurers make mistakes. Providers make mistakes. So do we as employers, as do our employees. Sometimes there are clerical errors like incorrectly submitted paperwork that results in coverage denial. Yes, we have probably all experienced this.

I showed up to pick up an antibiotic for a sinus infection and was told I did not have coverage? What? I knew my healthcare benefits were active. It turned out the provider had a patient with the same name and different date of birth. The medical records had been transposed and coverage for the prescription was denied. After two calls the error was corrected, and the prescription was covered in accordance with the plan.

Other times a treatment is flagged and denied because there is more appropriate care. If this has not happened to you, you probably have been at a dinner party and heard a story of two. Most recently, I knew someone who was struggling with back pain and wanted back surgery before completing physical therapy. The person had to complete physical therapy, which we know improves outcomes, before having surgery. These are the scenarios insurers, providers, and patients face every day.

As healthcare best practices evolve, insurers are challenged to stay up on the latest standards for care just like accountants must understand new, complicated tax code changes. We rely on accountants as experts to sort through exemptions and credits to protect our financial health. We depend on insurers to essentially do the same.

Let’s reframe the conversation that insurers are providing important checks and balances for us, as their customers, and share this perspective far and wide. You play an integral role in transforming the narrative of health insurance.

And let’s continue the idea sharing, networking and engaging dialogue from this year’s In-Value-Able Conference, where we heard from empowering voices across the healthcare industry and entrepreneurial leaders who addressed how to make transformative choices.