Human Capital Management, Total Rewards

Insurers Denied 1 in 5 Claims for In-Network Services

/ August 17, 2022 August 17, 2022

How do you ensure this doesn’t happen to your employees?

The health insurance world is incredibly complex and difficult to navigate, often leaving people feeling helpless and paying for services that aren’t always billed accurately. A recent survey reported that marketplace insurers denied nearly one out of every five claims (18%) submitted for in-network services in 2020. Although it’s not entirely clear why these in-network claims were denied, at least 72% were likely due to administrative or paperwork errors and other issues. Of these denied claims, consumers only appealed just over 1% of those denials, leaving thousands of dollars unspoken for.

The stress of these claims can be daunting for both an employee and an HR team. As an employer, you might be wondering how you can support employees in understanding their benefits and ensure they are being billed accurately. One way to do this is by utilizing your benefits broker and their client care team. At Exude, we are up and running 24/7 so that your employees can contact us directly whenever they have questions or need support in resolving a claims issue. We always recommend that if an employee gets an unexpected bill to hold off on paying it and call us first so that we can validate if you should have received it in the first place.

Working with a dedicated service team, who have experience navigating complex claims and dealing with carriers, will save your employees an average of 290 hours of their time and a lot of frustration.  Your Client Care Specialist is not only going to keep track of the claim with the carrier but will also keep the employee in the loop providing regular updates on where the claim stands. Should a claim be denied with the carrier and an appeal be needed, they will help draft the appeal letter for you and then submit and track the appeal with the carrier until it is approved or denied. Exude’s Client Care Specialists see all claims through to completion and strive to receive the best possible results on behalf of your employees.

As inflation continues to rise, having a dedicated team to support your employees can provide real and meaningful value and savings. Over the last twelve months, Exude’s Client Care team has fielded 12,000+ client service cases and successfully resolved these issues by returning an average of 72% of the billed amount back to the employee. In 45% of these cases, we returned 100% of the billed amount. This level of service allows employees to focus on their day to day jobs and therefore leads to improved levels of engagement and increased productivity. Additionally, as organizations continue to fight for top talent, having attractive employee benefits and service remains a differentiator amongst top employers.

Advocating for you

A Client Care Specialist was contacted by an employee of one of our clients, whose 17-year old son urgently needed to obtain a very expensive medication. The insurance company was denying the claim, and at a retail price approaching $30,000 per dose, the member could not afford to pay out of pocket. The medication is used to manage a critical health condition and the employee was told that if they did not obtain the medication, they would need to remove her son’s colon within the next week. That type of major surgery would not only be dangerous and complicated, but would have lifelong consequences for the son.

Exude’s Client Care Specialist jumped into action and escalated with the appropriate parties. After helping to coordinate four different peer-to-peer meetings between the doctor and insurance company, she used creative thinking and tenacity to explore every possible way to advocate for this young man. After hours of phone calls and many days of stress, she was able to obtain approval from the insurance company. The son is now receiving the prescription and will not need to have the surgery.

Having a dedicated team to support your employees when they receive unexpected bills (that are usually due to administrative errors) is just one way we fight for what’s right on behalf of our clients’ employees. You can rest easy knowing that your employees will have someone advocating on their behalf, preventing them from spending their well-earned money on bills that should be covered by their healthcare plans and enabling them to focus on helping your organization achieve its mission.

Want to offer your employees this level of service, care, and compassion? Contact us today.