Health Insurance – Trends in Claim Handling The Market Conduct Perspective

CDI Market Conduct Exams Licensed health insurers (other than HMO) Once every 3 to 5 years May consist of interrogatories, data analysis, claim file review – or a combination of these

CDI Market Conduct Exams Patterns noted in our exam findings can provide insight for an insurer that wants to take a proactive look at its claim processing operations.

Explanations of Benefits (EOBs) For members and for providers, EOBs should: Be specific in terms of explanation for WHY the claim is being denied, or the payment is less than the amount billed; Include specific information that addresses the factual and legal basis for the action Avoid general reasons like “not covered”, unless citation to and explanation of policy provision is also provided.

Contested Claims and Appeals Q - When does the clock start for timely processing and payment, when more or new information is required to determine liability? A – Once the insurer has received the necessary information. Avoid establishing internal administrative procedures that create delay (i.e., mail routing rules, transfer between units or employees).

Mental Health Claims Separate entity to handle mental health claims – Increase in expertise, but creates opportunity for processing delays, and confusion for consumers. Look at internal processes for dealing with mis- directed claims. Does the company have a seamless process to transfer to specialty unit? Is clear info about what is happening with the claim given to member and provider?

TPAs and Benefit Managers Oversight!! Quality Control and appropriate oversight and of Third Party Administrators, Benefit Managers, and other vendors to whom you have contracted aspects of your claim processing is crucial to ensure you are being compliant.

Systems Issues Technology – It’s only a solution if it works! Take steps to make sure programming is complete and accurate for auto-adjudication; Ensure process in place for timely loading of updated provider contract schedules