Health insurance: the one thing every employee needs their employer to provide, yet can never find as far as the perfect plan that works for their life. 

If you’re an employer, you’re tired of employees’ discontentment with their benefits and feeling like your broker doesn’t offer them the services they need–or a fair price for them. If you’re an employee, you’re tired of watching your hard-earned dollars disappear in deductibles and out-of-pocket expenses and copays. Even worse, you don’t understand the full extent of your coverage or what exactly you’re paying for.

In a market seemingly dominated by a lack of transparency, cookie-cutter health insurance plans and confusing hospital billing, there is a solution. Transparent healthcare that adequately shows you where every dollar goes and how your vendors use those monies isn’t just attainable, it’s the new law for employers who serve as plan fiduciaries for employees.

Here, we’ll break down five essential steps for building a transparent health insurance model.

Step 1: Employee Feedback is Essential

Truly understanding what your employees want and need in their benefit plan starts with, well, listening to your employees. Consider, for a moment, how your organization currently handles complaints and feedback about health insurance benefits. Are all employees directed to your Human Resources department? As an employee, do you feel like your valid complaints are often overlooked or not sufficiently addressed?

If you’re an employee…

Advocate for yourself and better benefit options. Do your research and learn about other health insurance options out there, keep track of issues you and your colleagues are running into and look for viable paths to follow to respectfully bring your concerns to the attention of leadership. 

If you’re an employer…

Create appropriate channels for employee feedback. Whether this is in the form of a survey, regularly scheduled public meetings or open office hours with you and your HR/benefit administration department, show your employees you care about them and give them a space to safely express themselves.

Step 2: Audit Each Claim for Unbundled CPT Codes, Erroneous Charges or Fraudulent Billing

At ClearChain Health, one of the most common forms of erroneous charges we see from hospitals is unbundled CPT codes. 

CPT, or Current Procedural Terminology, codes are used by hospital billing departments to create uniformity in insurance billing. When a procedure requires a variety of different aspects, these may all be bundled together using one CPT code. However, in an effort to get more money from certain procedures, a hospital billing department may unbundle this CPT code into multiple different CPT codes and charge separately for each aspect of the procedure.

Having an auditing process in place to view your bills and see where a CPT code may have been unbundled can prevent price gouging like this.

Step 3: Opt for a Direct Relationship to Your Medical Provider, Instead of a PPO Model

If you have a health insurance plan through your employer that is from a major traditional broker, odds are your plan uses a Preferred Provider Organization (PPO) model. In a PPO model, brokers negotiate contracts behind the scenes with hospitals and healthcare providers to create special rates for their member groups.

While this sounds like a good idea in theory, it oftentimes prevents patients from exploring less expensive options for care because they’re locked into their PPO model and can only go somewhere that is in-network.

If your employees are growing increasingly frustrated with their network model, consider working with a broker that supports a direct relationship between employees, employers and healthcare providers. This way, your employees can select and nominate who they want covered by their plan, instead of being limited to a certain network.

Step 4: Work With Vendors Who Support Transparent Pricing

Take a moment to consider the vendors you work with in your health insurance plan. Do they provide clear billing to you and help you fully understand what you’re responsible for cost-wise? If not, start working with vendors and healthcare providers who are as committed to transparent pricing as you are.

Step 5: Stay on Top of Healthcare Transparency Laws

As we discussed in a recent blog post, there are currently major regulations happening at the federal level for both hospitals and employers to promote transparency in healthcare and health insurance pricing. These include:

  • The Hospital Price Transparency Rule, effective Jan. 1, 2021
    • Under this rule, hospitals must provide patients with their costs for services. This way, patients can understand how much medical care will cost them and plan accordingly with their finances.
  • The Transparency in Coverage Rule, effective July 1, 2022
    • Under this rule, employers as plan fiduciaries must provide employees with accurate pricing information for all medical providers included under their plan. This way, employees can clearly see their options within their provider network and make the best financial decisions.

Staying on top of laws, rules and regulations like this is critical to maintaining the health of your plan. In fact, the Transparency in Coverage Rule is actually part of a three-year plan, with new regulations to be introduced in 2023 and 2024. You must make sure you’re always in compliance not just for your own sake, but for the wellbeing of your employees.

For more information about your responsibilities as an employer with the developing transparency regulations for plan fiduciaries, our partner organization Waypoint Benefit Solutions, is currently publishing a blog series about how these changes impact both employees and employers. Visit the Waypoint Benefit Solutions blog and follow along each month for new content.

Transparent Health Insurance Created Just For Your Employer Group

At ClearChain Health, our model utilizes a direct relationship between you, your medical provider and your health insurance. By eliminating the outdated PPO network, auditing claims for billing compliance, working exclusively with vendors who support our price transparency standards and investing in employee benefits education, we make companies more competitive and provide better health insurance for lower costs. Learn more about our competitive model and contact us today!