What your company can do to tackle health insurance fraud

health insurance fraud article

Health insurance fraud is a serious problem for insurance providers and the greater health industry in general, amounting to “tens of billions of dollars” in losses every year. As discussed in our recently released Cost of International Health Insurance – 2017 report, healthcare fraud plays a significant role in driving up the cost of healthcare, and also leads to a subsequent rise in health insurance premiums. Here, we look at health insurance fraud and what can be done to minimize its impact.

What is health insurance fraud?

Medical insurance fraud can be defined asfalse or misleading information [that] is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policyholder‚ another party‚ or the entity providing services.

Simply put, insurance fraud is the act of misrepresenting facts or outright lying to make money from the health insurance system; potential offenders can be anyone – patients, doctors, hospitals, or even pharmacists. Popular examples of health insurance fraud include falsifying claims, misrepresenting the provider of service, and billing a non-covered service as a covered service.

There’s also abuse, which involves practices that are not deemed medically necessarily, or are outside acceptable standards of professional conduct, thus leading to unnecessary costs being paid (e.g. over-prescribing medications, ordering unnecessary tests, keeping patients at the hospital for longer than necessary).

The impact of health insurance fraud

There are many ways in which health insurance fraud can have an impact on employers and employees, including:

  • Increased health insurance premiums: Continuing challenges related to fraud is one of the main drivers behind increasing health insurance premiums. As premiums continue to increase, health insurance will quickly become unaffordable for both employers and individuals.
  • Cutbacks on benefits: As premiums become more costly, it is more likely that there will be cutbacks on the benefits included in employer-provided health insurance policies (e.g. the removal of dental cover, limits on who is covered, etc.
  • Increased copayments and deductibles: Copayments and deductibles are on the increase, as employees find themselves footing the bill for a higher proportion of their healthcare costs despite having insurance.

What can my company do to tackle fraud?

One of the most effective ways an employer can tackle health insurance fraud and abuse is by educating their employees. Employees should be aware of:

  • What is and isn’t covered by their group plan
  • What constitutes health insurance fraud and abuse
  • How fraud impacts employees and their benefits
  • How to spot fraud and abuse

Below is a checklist of what employees should keep their eyes on to protect themselves, their company, and the healthcare system at large from insurance fraud and abuse, and keep healthcare costs down for everyone:

  • Report any lost or stolen health insurance cards immediately
  • Fill out, sign and date one claim form at a time. Never sign empty or incomplete forms.
  • Always confirm the diagnosis and make sure it correlates with the information on the form
  • Question free offers (e.g. free tests, screenings, and treatments), especially when the healthcare provider asks for your insurance information
  • Know what’s covered and what is not covered by your health insurance
  • Alert the insurer of any suspected fraud or abuse

Partner with Pacific Prime today

By partnering with an insurance specialist like Pacific Prime, you’ll find that we not only help you source the most optimal group health insurance plan, but also answer any questions your employees may have regarding their benefits, or how to spot fraud. To learn more, contact our helpful advisors today, or check out our brand new corporate site.

Key metrics for the success of your group health plan

Group of people discussing their group health plan

Regardless of your industry, there are a number of components that make up the core of the most successful employment benefits packages, one of the most important (and in demand) being health insurance. The question here is how can you or your HR team judge the success of your plan while ensuring it is meeting the needs of your employees? Here, we discuss 7 key metrics that you can employ to help you gauge the success of your group health plan.

Metric 1 – Loss ratio

Calculated by taking the amount you pay (your premium) and dividing it by the amount the insurer pays out in claims, this ratio is essential in determining the health of your plan and is often used in calculating premium increases.

As an HR professional, knowing the ratio of your health plan and comparing it with industry standards can help provide you with a sound negotiation tool when it comes to negotiating premium increases or even coverage elements. In some cases, your current and historical loss ratio can even be used to provide a ballpark estimate on future premiums or premium increases.

Learn more about loss ratios in this article from Pacific Prime Hong Kong.  

Metric 2 – Average claims per member

Calculated by taking the number of claims submitted by the number of employees covered this will tell you, on average, how many claims are submitted each year by your employees. Comparing this to either an industry benchmark or historical average, this can gauge the overall utilization and satisfaction with your group health insurance plan.  

Tracking this metric also generates a wealth of useful group health plan data that can be used to help you not only better understand plan utilization. It also acts as a litmus test that can help to identify problems. For example, by tracking and analyzing the claims submitted by each person we are often able to help HR identify individuals who claim more than average along with individuals who are submitting costly claims.

From there, we help HR teams to work with these employees to help ensure they are receiving the support they need while ensuring claims do not massively impact the loss ratio.

Beyond that, this data can also help to uncover where your employees prefer to receive care. This information can be used to try to steer employees away from certain high-cost providers, or to identify whether the plan is actually meeting their health needs.

Metric 3 – Insurer/broker response time and claims processing time

Time, as you know, is money. Spending hours a day or month on chasing insurers or brokers for information or replying to employees who are having issues with plans can be not only frustrating but also take you away from working on other, possibly more important tasks. This is where this metric can help.

In truth, this metric can actually be made up of a number of similar metrics that when combined help you judge the overall level of service you are getting from an insurer. You can then compare this to your company and employee’s needs and judge whether the plan you have is actually working.

For example, many companies we work with will track things like number of claims vs broker/insurer response time, number of claims vs average time to settle a claim, number of claims vs employee complaints, and most importantly, when the insurer broker communicates.

Generally speaking, insurers with lower premiums will tend to have lower levels of service. Securing a plan like this will often save you money upfront, but if you have to spend half your day calling the insurer, not getting answers, waiting weeks for claims to be settled, waiting weeks for new members to be added, or old members to be removed, etc, you could end up actually paying more in the long run.

It is important to measure when the insurer or broker communicates important information to allow you to make timely decisions. For example, if they take a long time to provide claims details or renewal information this could leave you with little to no breathing room to find better coverage or negotiate for better premiums.

Metric 4 – The number of people covered by the group health plan

Commonly referred to by insurers as ‘participation rate’, this metric looks at the number of employees insured by a plan versus the number of employees eligible for the plan (achieved by dividing number of employees insured by number of eligible employees) and will often compare this percentage with a benchmark for similar businesses. In practice, this metric will actually vary for each company and is normally adapted to meet the type of insurance plan you have selected.

For example, in our experience, many companies are securing group health plans that cover inpatient care only. If an employee wants additional coverage for outpatient care the company will usually cover a percentage of the premium, say 50-80%.

Looking at the number of people who are securing additional coverage or have utilized extra coverage then comparing this to industry benchmarks can be a solid indicator as to the overall success of your plan. If you find that a higher percentage of employees are selecting to add additional coverage than the benchmark this will likely point to the fact that your plan is not being perceived by employees as useful. This, in turn, means it might be worth looking into upping benefits offered by your plan.  

Metric 5 – The ratio of dependents covered by your group health plan

This is certainly a metric that will not be used by all companies, but that said, it is an incredibly important metric for companies who extend their health insurance plan to employee’s dependents.

Calculated by taking the total number of participants and dividing it by the number of employees covered, this ratio can help determine whether you are covering more or less employee’s dependents.

It is important as, in our experience, it is often dependents who have the highest number of claims. This is especially true for children who are covered by the plan as children will statistically have to visit the doctor more often. In turn, this could have adverse effects on premiums your company pays.

If you find that you are ensuring more dependents per employee than is standard it might be worth looking into your plan and seeing whether this is having an impact on your premiums or claims.

Metric 6 – Employee demographics

This metric, calculated by looking at the number of employees and breaking them down into groups such as age, sex, location, etc., can be a major help in the search for group health plans and determining the overall satisfaction with it.

For example, knowing your the age groups of your employees can help you determine what types of cover will be most utilized and the potential medical issues your staff may seek care for. You can then search for plans that meet some of these needs or work to set expectations with existing plans.

Metric 7 – Questions asked  

Like some of the above metrics, this is really more of a series of different related measurements that can be tracked to help you with your plan. For example, by tracking the number of questions asked by new plan joiners, the number of questions asked by more senior staff, etc. you can gauge exactly how engaged people are with the plan.

If you see that new employees ask a fair number of questions regarding health benefits then it is probably a good indicator that there is confusion with the plan and better explanations/onboarding is needed.

It would also pay to track the types of questions asked and by whom. For example, if your team is getting a lot of questions about claims or benefit limits you this indicates that you might be spending an inordinate amount of time answering questions that could be avoided through better documentation. Beyond that, certain questions like “Can I keep my own doctor” could point to demand for a better provider network or potential areas where employees could be unhappy with the plan.

How can I set benchmarks and implement these group health plan metrics?

One of the best ways you or your HR team can implement and track the above metrics is to actually work with a broker like Pacific Prime. In truth, the majority of the above metrics are actually part of our corporate insurance service that we offer to all companies. Our team of corporate insurance experts strive to work with your business to ensure you and your employees have the most optimal coverage while reducing the amount of time you spend managing the plan and answering questions.

To learn more about our group health plan service, visit our new corporate site today.

What makes a good group health insurance company?

Tick boxes for a good group health insurance company

So you’ve set out to find a truly great group health insurance company to handle your organization’s insurance needs. Your team is focused on securing the absolute best possible group health insurance plan both for themselves, their colleagues and the company as a whole, but they begin to realize that finding the right group health insurance company can make all the difference in the world when it comes to finding great long term value from any potential insurance policy.  We all know generally that providing excellent customer service should be a priority for any company that we work with, but what specifically should you be looking for in an insurer? To aid anyone who is in a situation similar to the one above, Pacific Prime is proud to present this feature on what you should look out for when it comes to finding the best group health insurance company.

Group health insurance company experience

If there’s one characteristic that is common among the best group health insurance companies in the world, it’s experience. Putting in leg work and elbow grease over an entire career’s worth of time can really give an insurance agent the know how to get just about any task accomplished efficiently. The relationships that are forged with other insurance professionals can really help an agent’s clients out of some sticky situations. Now, take this individual experience and spread it across an entire company and it’s easy to see where the collective knowledge of a group health insurance company can be a force to be reckoned with. Here are some additional points with regards to experience:

Familiarity with industry

When you’re shopping for group health insurance, it will come as no surprise that you will be better off choosing an insurer that has knowledge and experience within your organization’s particular sector. This is because the group health insurance company will then be familiar with the specific problems that organizations like yours faces on a regular basis. As well, an insurer should be versed in handling an organization of the same size as yours. If they mostly have experience with individual medical insurance policies, they may not be able to handle the workload that a large group policy may require.

For instance, an insurer that is familiar with insuring schools will know all the in and outs of insuring teachers, as well as the importance of addressing your policy requirements at specific times of the year. After all, schools run on a schedule that other businesses don’t, so getting insurance needs done and dusted before the summer break is important. There are many small aspects like this that need to be considered for every industry, and an insurer unfamiliar with yours is much more likely to overlook something that a more experienced insurer would not.

Claims data analytics

Once you’ve actually secured your policy from your group health insurance company, that isn’t the end of the transaction. A group health policy requires regular communication with your insurer combined with ongoing maintenance. This is because the policy will inevitably be used, and claims will be made on it by your members. The thing about these claims is that they can be studied to give insight into the future of your policy. By establishing claims trends, an experienced insurer can then determine if your benefits are serving you as well as they should, and clue you into any potential premium rises way before they actually happen. As well, plan administrators can be notified by the insurer if your employees aren’t using their insurance enough, or if the plan is used far more than originally thought.

Benchmarking

Once enough data has been collected about your organization, how will you know how you stack up versus similar or competing organizations? A competent group health insurance company or broker will be able to provide exactly this type of information. Pacific Prime, for example, has established such a large portfolio of clients over 17+ years of operation that we can confidently explain to our potential members exactly what kinds of benefits they should have to keep up with competitors or how their plan is performing vis-à-vis others in their sector.

Group health insurance company approach

Despite the above section, even a newer group health insurance company can be effective. Sometimes it’s all about their approach to the market and how they regard their clients that makes all the difference. With this in mind, you should be looking for an insurer with some of the following qualities:

Negotiation

When renewal time comes up for your group health insurance policy, negotiations can be tough. This is one of the main points where utilizing an insurance broker will be of special value to you, as they can help you negotiate terms of your next policy with your group health insurance company. Negotiating on your own, you will not have the unbiased advice that comes with a broker, and it will be on your staff to analyze your claims data to try to recognize if you’re getting a good value with your current plan. Pacific Prime’s mantra during the negotiating process is to always look out for our members’ best interests, and not those of the insurance provider.

Manage premium cost and stability

Going right along with negotiations are managing premium costs. At negotiation time, most of the time a group health insurance company is going to want to raise premiums, as medical costs tend to raise year-over-year and other factors are taken into account. What your organization will want is proof that a premium rise is justified, and that it’s not time to switch to another insurer.

Fortunately for Pacific Prime members, they will be able to address potential premium increases armed with knowledge. They will either know that the increase is appropriate, or they will be able to dispute the rise, backed up with facts and statistics that support their argument. Thereby keeping premiums low and, hopefully, avoiding switching insurers on too frequent a basis.

Customized service teams

Many times people will find that they do not get the service they need from a group health insurance company for one of two reasons. The first is that they are assigned a single person to assist them with their insurance plan. While this person may have all the experience and knowledge in the world, sometimes having only a single point of contact to work with will be overwhelming for them, and your plan performance may suffer as a result.

On the other hand, you could be given access to the entirety of the staff that an insurance company has, yet be left without a particular person to hold accountable. This means that, when you’re in need of insurance advice, you may have to explain who you are and what your problem is to somebody that is not familiar with your organization at all.

To avoid both of these issues, it’s best to find a company to work with that will provide you with a bespoke team that will be very familiar with your organization’s specifics. By having a number of people assigned to you, but also limiting the people responsible for your plan’s performance, a balance between knowledge and responsibility can be maintained.

With all of the above points in mind, we are confident that you will find that Pacific Prime are the insurance experts that you should be working with. Not only do we have all of the points above in spades, as a broker we are also in a unique position to offer you plans from the industry’s top insurers. This will save you much time and energy when searching for a new group health insurance plan, because you will not have to sift through all of the insurers and plans on the market to determine which fits you the best. Our agents will find and present the best available options to you, combined with the advice that you can only get from an experienced, multinational insurance broker.

Our agents are available today to help you find the best possible group health insurance company. Contact us today for a plan comparison and free quote!

Pacific Prime launches new corporate section for global businesses

corporate section

Never ones to rest on our laurels, Pacific Prime Insurance Brokers is proud to announce the launch of a new section on our website, PacificPrime.com! The new corporate section is an enhanced one-stop shop for all business insurance needs! If your company has any questions related to group health insurance, international health insurance or any other related topic, be sure to check out this new section, the homepage of which can be found here.

So what’s on offer? Let’s find out:

Insurance solutions

What kind of group health insurance coverages are out there? In the insurance solutions portion of the corporate section, find out about the various facets of group health insurance plans and why you might want to consider each for your employees. Medical insurance does not just mean coverage for medicine, hospital stays and surgeries. There are a number of other benefits that you can consider. This includes dental, vision, wellness, maternity, disability and life insurances, and more!

Outside of these above solutions that will address the needs of your employees, Pacific Prime also provides in this section information about some of the business-specific benefits that every company should know about, including:

  • Property insurance
  • Liability insurances
  • Group travel and accident insurance
  • Professional indemnity insurance
  • Business interruption insurance

With information on comprehensive medical and corporate insurance solutions, this page is a great place to start when searching for group and corporate insurance information.

Our approach

Lots of companies sell insurance for businesses and other organizations. Where Pacific Prime really shines, however, is in our methodology. With over 17 years of insurance broking experience, we now have the various processes that our members use down pat. Not only in assisting with making claims, but also when going through other planning and analysis. Not only do we provide policy broking service, but also consulting and plan administration, which you may not get with other brokers.

Even our closest competitors cannot match the technological advantages that Pacific Prime provides, including:

  • Census and premium management/accounting tools
  • A claims management tool
  • A document management platform

These in-house systems are all yours to take advantage of at zero additional costs versus going with an insurance company directly.  Check the ‘Our approach’ page to start to find out about why Pacific Prime will be your preferred choice.

Partners

As a corporate insurance broker, everything that we offer is one consideration, but it’s still only one piece of the equation where your insurance needs are concerned. We work with a good number of the world’s best global insurance companies, as well as the most highly regarded local insurers in the countries where our offices are located. Our ‘Partners’ section is the place where corporate members can go to find out more about our relationships with insurers.

Beyond the insurers we work with, you can also find out about some of the prestigious members that have made Pacific Prime their choice for group health and corporate insurance benefits. Learn some of the industries that we have the most experience with, such as professional service firms and schools. Then dig a little deeper to find out how our experience translates to advantages for our members when it comes to negotiating plans with insurers at renewal time or analyzing claims data.

Corporate section resources

The last part of the corporate section to mention is our resources page. Here, for corporate members that like to stay up to date on the latest in international insurance data, Pacific Prime regularly publishes reports related to various important industry trends including the cost of health insurance, international medical insurance inflation, and industry trends. Want to know how insurance in the countries in which your organization operates compares to policies found in other areas? Look no further!

Purchasing corporate insurance is no small decision. Pacific Prime recognizes this and wants to make sure that you are delivered the plan which best fits your needs, at a value that fits your budget. We have created the new corporate section to give a great introduction to what we can offer you, but there really is no better way to figure that out today than to contact us! Do so now and get advice directly from one of our insurance advisors. They can provide you with a plan comparison and free quote.