Health insurance coverage has
become a heavily regulated environment that — while it has made life complicated for health insurers —
has made great strides to protect the
consumer. Still, a business owner
needs to be careful about selecting the
right health insurance provider to
make sure that the health care coverage is the right fit for the business and
its employees.
“Despite it being a heavily regulated environment, a business owner should not
throw caution to the wind when selecting a
provider,” says Lisa Davies, senior director
of corporate compliance for AvMed Health
Plans of Gainesville.
Smart Business spoke with Davies about
the key issues facing health care at the
moment, and the steps a business owner
can take in selecting the right health care
provider.
Could you name the key issues facing health
insurance companies and how they affect
businesses?
From my perspective, there are significant challenges related to staying in compliance with state and federal rules, laws
and regulations.
In Florida, both the AHCA (Agency for
Healthcare Administration) and the DFS
OIR (Department of Financial Services
Office of Insurance Regulations) receive
regular reports from health plans and
also perform routine audits of those
plans.
On the federal side, insurers who hold
Medicare Advantage and Part D contracts
are subject to oversight by HHS OIG
(Health and Human Services Office of the
Inspector General), CMS (Centers for
Medicare and Medicaid Services) and its
contractors.
Additionally, since Florida insurers must
be accredited by an external quality
organization (such as National Committee
Quality Assurance), health insurance
companies need to meet or exceed standards for excellence in operations and
support processes and procedures of the
plan.
What kind of impact do all these regulations
have on the consumer?
They have a very positive impact, as they
benefit from having a partner whose operations and performance are closely monitored by any number of external parties.
How can a business go about choosing an
insurance company in this environment?
Businesses should either have a strong
internal component of their operations or
engage a knowledgeable partner, such as a
broker or consultant, to assist them with
the process of making a selection.
Additionally, they should either meet with
prospective partners or be active participants in the broker or consultant review
and selection.
That said, there is at least one caveat
about selecting a broker, particularly for
small businesses that need to rely on brokers to buy their insurance products. There
have been significant problems in this state
with unlicensed brokers. Therefore, business owners need to make sure that the broker they are using is reputable and agency
licensed. Do this before you get into a relationship with a broker and find out too late
that a business is not covered adequately.
How can a business make sure that a health
insurance company complies with all the
rules?
As we discussed, health insurance companies function in a very heavily regulated
environment. Deficiencies of companies
that fall short of meeting their regulatory
or accreditation requirements will appear
in publicly available reports and plan
rankings.
Plans that continue to be poor performers are subject to sanctions, and penalties
such as suspension of enrollment, and
administrative supervision or plan closure
for extreme cases. This is something that
can’t be hidden from public view since all
of these reports are publicly available. If a
plan is not meeting regulatory requirements, the first thing that happens is that
agencies will suspend enrollment.
Should a business perform due diligence
before selecting an insurance company?
Here are three critical steps.
- Develop a questionnaire that may be
used in the pre-selection process. Ask for
supporting documentation from the plans.
Include in your request the health insurers
Code of Conduct; description of the
Compliance plan and program; and the formal Notice of Privacy Practices and
Confidentiality procedures. - Look to financial performance rating
companies such as AM Best or Weiss for
their evaluations of stability and financial
strength. - Visit public and professional sites where
information is made publicly available. In
Florida, we have several excellent sources
for this type of objective data. These include
www.floridacomparecare.gov, which provides information on quality of care, member satisfaction, coverage areas, accreditation status and more.
LISA DAVIES is the senior director of corporate compliance for
Santa Fe HealthCare and AvMed Health Plans (www.avmed.org)
based in Gainesville. Reach Davies at [email protected] or
(352) 337-8782.