EOBs can be SOBs…

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Forum blog…more.

Prepared Patient Forum

Most importantly however, Trudy Lieberman is a senior, frustrated with Medicare, insurance companies and their efforts to simplify the understanding of coordinating care. In her article, More Confusion about those Insurance EOBs– This Time from Medicare it is quite clear that she has a hard time understanding how Medicare and insurance companies coordinate benefits…..and look what she did for a living! That should be a very powerful statement about how difficult it must be for seniors. Truth be told it seems ridiculous! If Ms. Lieberman is having difficulty than what chance does the average senior have? Why is it so difficult for Medicare and insurance providers to make the explanation of benefits,or EOBs comprehendible?

In case you’re new to Managed Care Consultants, here is a little information about us. We are a group of qualified health care professionals that take a lot of pride in educating seniors about Medicare and how they coordinate benefits with their current health plan. We host seminars, consultations, public speaking events and the like at retirement communities, senior centers and pretty much wherever seniors congregate. During my time working as a quality development specialist at a health insurance consulting firm I came up with the idea of starting my own educational resource guide for seniors when I began to notice a disturbing trend – More seniors, than I realized, were knowingly enrolling into health care plans due to lower premiums without understanding how benefits were coordinated with Medicare or what they would be financially responsible for. Health insurance agents didn’t take enough time to carefully explain what seniors were signing up for and why, they would simply send out the EOBs and wipe their hands clean. Insurance companies and agents are more concerned with enrolling a new member than they are in making sure the plan selected is in the best interests of the individual. This is a very big problem, not to mention extremely careless. Here’s a thought for you though….what other choice do seniors have? Many rely on income from Social Security which can be very limited and often puts them between a rock and a hard place when deciding between paying bills and buying food or continuing to pay rising health care premiums. This doesn’t leave them with much of an option. So they mull over countless pages of information regarding available health care plans in their area, and they try and compare them to the plans they currently have. They struggle to understand how they are similar, but more importantly how they’re different. Now, of course, if the premium is lower it looks more attractive, but why? Is there something that they are missing? Truth be told, yes. Well then what is it? This is what Managed Care Consultants strives to offer to the senior community. Knowledge and understanding.

As alluded to by Trudy in her article (which, if you haven’t please read) Medicare and insurance companies are a pain to deal with. When claims forms are delivered to the member, coordination between the insurance provider and Medicare is almost non-existant. There are separate forms for each which makes understanding who paid what more difficult. Whenever you as a consumer reach out to clarify this issue they either put you on hold, answer your question in a way that is still confusing, transfer you to another agent or refer you to your insurance company to answer your questions. This is time consuming and extremely annoying. All consumers want is clarification for a product they are paying for and they cannot even get that without jumping through hoops! Where is the customer service?!!! It’s no wonder seniors are fed up and angry. I don’t blame them, they have every right to be. They don’t have the time or the patience to deal with this….they are retired. They should be spending their time with grand children, their loved ones, traveling or enjoying life at this point in their lives. Instead, they are compounded with confusing claims statements about their health insurance plan and Medicare (which is a social insurance protection plan established for them!) Oh, by the way, did I mention that this was an EOB that was delivered after the ACA and Medicare made extensive efforts to simplify the wording? And yes, I did hold that piece of information on purpose. Here’s why….

Even after CMS and Medicare have made the effort to reach out to insurance companies in hopes of getting them to simplify the terminology used to explain benefit structure and financial responsibility in health care plans, their efforts have bore little fruit. It’s still a hassle to deal with. Most seniors wish they don’t have to, however, when living on Social Security seniors are pigeon-holed into forecasting their out of pocket expenses for the year regarding their health care. This requires an understanding of coordination of benefits: who pays what and how much. Seniors obviously aren’t getting this understanding from Medicare or their respective insurance company, which begs one to ask ” how do they find out, how do they educate themselves and where?”

I wish there were an easier way, and I will try my best to make it as simple as possible, but the only avenue I see as being effective is to educate yourself or those who manage your health care. As consumers nowadays, we are much more savvy than in the past. We do our homework….but to what degree, ever heard of buyers remorse? With regards to health care, key factors such as premiums, provider accessibility, and your provider’s relationship with the insurance company you are considering should be major determining factors when choosing a plan. This is extremely important because the ACA has allowed Medicare and CMS to monitor and regulate Medicare Fraud Waste and Abuse and in the short term they have saved Medicare beneficiaries billions of dollars. That could have been money out of your pocket. The more aware we as beneficiaries are about our financial responsibilities for senior health plans, the less likely the chance of being taken advantage of. This can only be achieved by educating yourselves about your entitlement rights and what you are responsible for financially. Managed Care Consultants has written a very informative piece titled, “Are You a Part of the Growing Trend?,” that does a fantastic job of highlighting different avenues for seniors to do just that: educate themselves about Medicare and take responsibility in simplifying their health care management.

The economy of this great nation has thrived off of a capitalistic approach to running business for decades, however, at a severe price (as our current economic status has clearly shown). America’s ‘business’ mantra, if you will, was to produce profit at any cost….even at the expense of those driving it. That approach has come back to bite us, you know where!… and unfortunately the ones suffering the most are the very ones who helped navigate this nation’s success and position it as a world power. Now, we can barely afford to care for their health. Pretty sad right? I know. Trying to find a solution to reduce health care costs is going to take time, something our current seniors don’t have too much of. So, in the meantime, to help contain costs and prevent unnecessary submission of claims, what is needed is the motivation to self educate. The more informed we are as consumers, the less likely the chances of being hoodwinked by insurance providers.

” Simplify Your Healthcare Management.”

Medicare. How many seniors that are enrolled understand its benefits? ….. Not as many as you think. For a program established by this government FOR its seniors, they sure don’t make it easy for them to understand how to make the most of their healthcare options. The government and independent providers refer beneficiaries to Medicare to inquire about coordination of benefits between health plans and retiree benefit programs. Questions such as: “Who pays for which services first?” and “How much will I pay?” This referral system would work except for one, lousy problem…… Beneficiaries are left to remain on hold until they decide to hang up.

For what it’s worth, I think it’s important to understand, and applaud Medicare and Social Security for trying to be efficient in streamlining the customer service aspect of their business. By implementing automated systems beneficiaries can opt out of waiting for a live agent and just follow the prompts to get the desired answers to their questions. Initially that sounds great, but what if the beneficiary has a special circumstance? As in most instances when beneficiaries reach out, their questions require a full and thorough explanation, therefore making the computer-generated system ineffective. So where are the beneficiaries left to seek advice from now? Social workers at Retirement Communities, Skilled Nursing Facilities (SNF), and Human Resources departments of Employer Retiree Plans are all viable resources. They are educated enough to answer these questions. Unfortunately, however, those resources end up spending the majority of their time filing claims forms for the beneficiary. So who is left making sure the individuals understand how their Medicare options work and how Medicare coordinates benefits with their current or prospective health, employer or retiree plans? Anybody???

Would it be callous to associate this frustration to a rat trapped in a maze? I understand that may seem a bit cold, but it is really quite accurate. The answers for seniors are available but only after exhausting every avenue, which has their own fair share of obstacles and hurdles, making the process akin to the rat lost in a maze. This only frustrates beneficiaries, confusing them even more and overall makes matters worse.

What good is a system if its own beneficiaries cannot access it efficiently?

Herein, lies the problem. Many may say the responsibility of maintaining one’s own healthcare management falls upon oneself. Agreed. Individuals should not have to rely on others to make their important healthcare decisions due to the inaccessibility of designated resources. Beneficiaries want to be aware and cognizant of the options available to them and how to make the most of their choices so they can meet their individual healthcare needs. The “Designated Resources,” used to handle the inquiries about Medicare health plans, both Medicare and Social Security, respectively, are incapable of handling the demands of 80 million seniors. And so, millions go without ever fully understanding how Medicare, an integral part of their healthcare that contributes to their well being, truly works. This lack of direction, with regards to healthcare management, can be very dangerous.

Millions of beneficiaries enroll into healthcare plans without completely understanding how it affects their financial responsibility. They enroll into plans expecting a level of coverage that is different than what the insurance company will provide. Or worse yet, the beneficiaries’ projected Out-of-Pocket-Expenses for the year are far greater than forecasted. Where will the additional income come from? One begs to question where the lack of communication occurred….

The 21st century consumer market place demands delivery upon receipt. If you pay for something, you expect to get something else in return; that particular mindset is warranted. In insurance, for example, those things can be customer service, specific coverage and to pay when they, the insurance company, say they will (claims).

As a consumer, one would like to place blame on one faction versus the other, but a lack of communication could very well have stemmed from both the insurance company and the consumer. The insurance provider can make a contract so confusing, that the consumer doesn’t bother to read it all. And, well,…. just that. The consumer fails to read the ENTIRE contract or Summary of Benefits, (SOB), for those of us in the insurance industry. Therefore beneficiaries are confused as to their responsibility upholding a contract they do not understand. Hence, misunderstandings occur leaving beneficiaries confused and frustrated.

Misconceptions and misinterpretations of shared responsibility plans can lead to unwarranted claims as well. This is a major contributor to what ties up the claims departments. Claims that shouldn’t be filed are, and the one’s that should take precedence are held up, slowing down the efficiency of distributing claim payouts where they need to go. As I’m sure we can all infer, unfortunately now the individuals that are in dire need of that payout have to wait.

The insurance industry is a business, and therefore beneficiaries should approach the task of choosing a viable health plan based on their needs in the same manner, analytically and cost-effectively. By gaining a better understanding of how cost-sharing plans actually work, beneficiaries can more effectively forecast their annual Out-of-Pocket-Expenses and budget accordingly. If they are cognizant of what Medicare covers versus what they don’t cover, they are now aware, or at least in a better position to make the necessary adjustments to bear the financial responsibility, (in theory).

So then what’s the solution? Good question. What seniors need is for someone to provide an ACCESSIBLE resource within establishments and communities that will allow them easy access to the answers for their healthcare management questions. Managed Care Consultants is “THAT” resource.

Managed Care Consultants provides many different forms of educational services to the retirement community of your establishment. Through seminars, consultations, blogs and emails retirees of your institution will have 24-hour access to the answers they seek. Qualified health professionals are committed to consulting with beneficiaries about the different scenarios they may encounter when dealing with coordinating benefits between Medicare, Healthcare providers and Retiree and/or Employer plans.