Claims Avoidance Options for Driving Down Health Care Premiums

Insurance carriers typically bear the burden of blame for spiraling employee health-care premiums, but the problem is much more complex than a single culprit. In fact, the entire national health-care debate focuses on the wrong elements; we have a cost and price transparency problem, not an insurance problem.The issue comes down to affordability, with the imperative to create a strategy that allows employers to get a firmer handle on health-care costs. But to achieve this action, an assessment must be taken of the true cost drivers. What sometimes gets lost is that insurance is there to pay the claims submitted by providers and members, nothing more. In many markets, health insurers haven’t made an operating gain in years.

Let’s cut to the chase: The per-unit cost to provide care in the United States is four times the cost of comparable health-care systems. Couple high costs with little to no pricing transparency among medical providers and there’s no chance for true consumerism.Enter health claims avoidance programs, designed to create engaged shareholders who collectively reduce health-care costs without sacrificing access to superior health care. These programs combine consumer-driven health savings tools (e.g., HRA, HSA, PFA) with benefits for measurable and sustainable returns on investment.The emphasis is on redefining the medical provider, consumer, insurance consultant and employers’ roles as shareholders in the health-care system. The bottom line is to share the responsibility for how and where care is accessed while reducing costs – all without affecting the quality of services received. MRIs, for instance, are primarily performed in a hospital setting. Multiple service lines equal high overhead costs, translating into “hospital rates.” A health claims avoidance program can enter into an arrangement with a facility that exclusively performs MRIs, at a price as much as 60% less than the hospital-based machine.Telephonic access to physician consultations is another cost-saving avenue. Telephone-based medical care delivered by qualified physicians is on the rise, and according to the American Health Association, 70% of all emergency room visits could be handled telemedically.

A second-opinion program is another measurable/sustainable ROI in health-care delivery. Only 19% of people get second opinions, for any number of economic reasons, including high deductibles. An independent medical second-opinion program provides simplified access to high-profile medical centers/teaching hospitals, specialists and so on in collaboration with a patient’s attending physician team – often for little to no cost depending on the employers’ sponsorship level of the program. In some cases, this service can result in a financial ROI of as much as 600%. The savings in terms of life are priceless, as the third leading cause of death in the United States is due to medical errors.

Rounding out a cost-efficient employer health-care program is an online prescription drug program, which can help members identify discounts, coupons and subsidies available for their prescriptions.

Health insurance benefits should be designed to encourage cost awareness among employees, without discouraging appropriate services and care required.