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February 8, 2001

UPMC Health Plan rep defends organization against complaints

Responding to charges of billing errors, a UPMC Health Plan representative denied the severity of the problem before a University Senate committee last week.

Don Williams, the UPMC Health Plan's primary representative for the Pitt account, was invited to the Senate benefits and welfare committee meeting Jan. 31 to respond to allegations that the health plan was derelict in addressing billing problems.

Nathan Hershey, president of the University Senate, has criticized UPMC Health Plan for improperly billing members, overbilling them and failing to correct billing errors in a timely manner. Hershey has weighed in on the issue at recent Senate Council and Faculty Assembly meetings, as well as in other forums, including the University Times (see Jan. 11 issue).

At the Jan. 30 Faculty Assembly, the Senate president said that explanation of benefits (EOB) forms frequently contain errors that apply charges to members that should be picked up by the health plan. He also said some double-billing instances have been reported, where members are improperly charged a co-payment twice.

Williams acknowledged that there have been billing problems. He also acknowledged that he did not know how widespread they are. But he insisted that the health plan was acting in good faith and was taking proactive steps to alleviate the problems, both on the individual and systemic levels.

Also attending the benefits and welfare committee meeting was James Edgerton, Human Resources assistant vice chancellor for Compensation and Benefits. Hershey and others have charged Human Resources with not being aggressive enough in following up employees' complaints, a charge Human Resources denied.

Hershey did not attend the benefits and welfare committee meeting.

Pitt entered into a three-year, sole-provider contract with the health plan last July 1. There are about 12,000 Pitt employees and dependents covered under three UPMC Health Plan options — comprehensive (deductible), point-of-service (POS) and enhanced HMO.

"I did want to address a couple things brought up recently by Professor Hershey," Williams told the benefits and welfare committee. "But first I want to say, we are absolutely committed to providing quality customer service to Pitt faculty and staff."

As evidence of that commitment, Williams said the health plan has a dedicated services hotline number (1-888-499-6885) and sends a customer service representative to campus the third Thursday and Friday of each month to meet by appointment with employees who have problems or questions.

"We want members to understand, we have dedicated reps to serve them specifically," Williams said. "There are only two accounts we do that for and we can track more specifically those issues an individual has. Calling the hotline number is better for us, it's easier for us if they come there first, and we believe it's better for the members. So we publish the hotline number in every way possible."

Williams said the health plan will begin publishing a newsletter this spring geared to the Pitt market.

He said the health plan has an in-house integrated team that meets daily to root out problems. "We have a team, involving all the functional areas, from member services to our claims shop to claims referral [personnel], that review open issues brought by members of the University in order to reach closure on specific issues. At the same time this team is looking for any trends that may be there. They file reports, which are reviewed weekly by a senior management team to see if those trends are being identified."

If a particular health care provider, for example, has been the focus of recurring billing complaints, the health plan will send advisers to the provider to help iron out the complaints and look into the information systems that may be at their source.

"And while we're not out there doing their billing or sending out information for them, we do educate them on the proper policies and procedures to follow," he said.

According to Williams, the most common billing problem is with point of service customers. "Customers who do not properly coordinate their care through their designated primary care physicians or the physicians themselves who do not properly process the claims or individual health care providers who do not code the proper information — these can all lead to errors on the EOBs."

Williams said the explanation of benefits forms themselves reflect only the information that has been provided, sometimes from a number of sources. "Some of the problems have been characterized as EOB errors, which is somewhat of a misnomer," he said. "The explanation of benefits is simply a summary that comes back to the member of what's being paid to their provider, what's not being paid, and if it's not being paid, why."

Williams said a number of factors could lead to mistakes on the form, at least some of which are beyond the health plan's control. Occasionally, a billing problem arises when a provider uses outdated insurance information on file, for example.

"Another example is POS participants who went to a provider and who didn't coordinate their care with the PCP (primary care physician) and the EOB spells that out. That's not necessarily an error on the EOB. Or, the claim may have come through in a way that it was processed or coded that was correct, but the information on the claim was incorrect, so [the bill] actually got paid based on what was on the claim, but it does not represent what happened in actuality."

Another example, he said, is a processed claim that does not list the PCP as a coordinator, for instance, when the PCP authorizes a referral. "If for some reason that name didn't get on the claim file, the member would have been [held] responsible for the deductible and, where applicable, the penalty insurance as if [the treatment] wasn't referred.

"We see a number of issues like this, similar to ones Professor Hershey has pointed out. The simple fix to that is to call this [to the health's plan attention], mention the referral and it gets re-processed and corrected."

Williams said health plan reps also meet with Human Resources benefits officials weekly.

Edgerton, who attends that meeting, described it as intense and productive. "We have an excellent working relationship. We meet with the health plan officials to ensure that issues are being addressed," he said. "The first part of the meeting also is open to members of this [benefits and welfare] committee to bring concerns to us and the health plan."

Edgerton said Human Resources had been alerted to a problem where UPMC Shady-side had been charging a second $10 co-payment for a facility visit, in addition to the appropriate $10 co-payment charged for a doctor's visit. "As soon as we heard about that, we called the health plan and they put a stop to that."

Williams said that the health plan was compiling a list of members who were double-billed by UPMC Shadyside; those members will be reimbursed.

"Finally, we remind members that every time you use a service, show them your [health plan I.D.] card. It never hurts to help make sure they have the most current information on file," Williams said.

— Peter Hart

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