Are consumers to blame for health insurance misunderstandings?

According to a recent Hewitt Associates survey, health insurance plan administrators – not consumers are the ones to blame when it comes to misunderstandings and dilemmas with billing and access to care that the consumers have with their health insurance plans.

As a matter of fact, recent evaluations prove that 54 percent of health plan problems begin primarily from the plan administrator.  17 percent of the problems originate from the faults of the doctors.

The remaining 29 percent of the problems are the faults of consumers. Over an 18 month period, Hewitt Associates tested nearly 2,500 common health care problems and got those statistics.

Marie Kobos, a Hewitt Spokesperson, claims, “The results are surprising because many people, including health care experts, would guess that the exact opposite would be true. This shows that many employees are taking the correct steps to resolve benefit plan issues, but still need assistance with an escalated issue in navigating the health care system, which can sometimes be both frustrating and complex.”

According to the study, a whopping 86 percent of the problems originate primarily from health insurance claims. The study also shows:

• 12 percent of health insurance problems account to health care.

• Only 8 percent of the problems had to be dealt with over a long period of time such as 24 to 48 hours, therefore, none of them were considered “critical.” Other problems could have been resolved quicker. Those problems mainly involved problems with the health insurance care. Consumers were denied the necessary care because of these problems.

• Out of all of the problems, only 9 percent of them were involving dental care, 1 percent involved other care, and 90 percent involved medical care.

• Reprocessing of the insurance company was necessary for 51 percent of the health insurance dilemmas.

• Balance billing, all or part of the claim missing, claim denial based on medical necessity, or denial based on plan provisions were the major problems that required reprocessing of the health insurance company.

Many consumers are often misled when they think that billing and access problems occurred because of their personal faults. According to the evaluations made by Hewitt Associates, we can safely conclude that often times; the health insurance plan administrators are the ones to blame. However, when the consumers do something that later result to problems, we should not immediately blame it on the plan administrators.

Approximately 2 to 4 members of group health insurance plans are expected to experience some sort of health insurance problems, according to Kobos. “The good news is that the percentage is relatively small compared to the number of benefit plans that a large employer typically offers. But, the bad news is that these types of issues are very time consuming, emotional and complicated for the employees, which can lead to decreased productivity, morale, as well as overall dissatisfaction with benefits.”