ANALYSIS: Translating gobbledygook from health insurers

Introduction

Having trouble understanding what your health plan actually covers? Confused about what to do if the plan refuses to pay for care your doctor says you need? Convinced your insurer goes out of its way to make that “explanation of benefits” statement incomprehensible?

Welcome to the club — a big and growing club. Despite paying lip service to the importance of communicating in “plain English,” insurers are actually being more obtuse than ever, according to J.D. Power and Associates, which conducts a study every year to measure member satisfaction among the nation’s largest health plans.

The study annually examines seven key factors that determine member satisfaction — coverage and benefits; provider choice; information and communication; claims processing; statements; customer service; and approval processes. Recent results aren’t promising. In fact the 2011 study, released in March, showed that overall member satisfaction not only isn’t improving, it is at the lowest point since the company began conducting its annual survey of health plan members in 2007.

The 2011 study also found that more than one-half (57%) of health plan members surveyed said that they were either required or had chosen to make changes involving cost or coverage during the past year — “continuing a trend where more members say they are powerless in being able to control costs on their own.”

J.D. Power and Associations, as you may know, surveys customers in a host of industries. Sadly, you probably won’t be surprised to learn that the satisfaction of health insurance plan members is among the lowest across the industries in which J.D. Power conducts research. Lower, even, than satisfaction levels with mortgage companies and banks.

J.D. Power also found last year that only 40% of the 34,000 respondents to its survey of health plan members said they fully understand what is included in their benefits packages.

Another firm that monitors and evaluates health insurers’ interactions with their customers, Boston-based DALBAR, gave big fat “F’s” to most insurers in the way they present information on their Explanation of Benefits (EOB) statements. In a recent national sampling of 34 insurers’ EOBs by DALBAR, which bills itself as a “third-party communications evaluation firm,” 68% of the EOB statements it analyzed got a failing grade.

In a Managed Healthcare Executive story about DALBAR’s survey last year, Kathleen Whalen, the company’s managing director, was quoted as saying, “The majority of them really fail to answer the basic questions for members: ‘How much, if anything, do I owe?’ ‘What action should I take?’ and ‘What is my financial obligation?’”

She added that while all of the EOBs contain the “basic requirements,” most health plans seem to consider the statements a “necessary evil.”

“The language that is typically used in the EOBs that are not performing well is so obfuscating that it’s very confusing,” she said.

Hardly a week goes by that I don’t get an email from someone asking if I can help untangle a problem they’re having with a health insurer. That’s why I decided to include a resource guide in the about-to-be-released paperback edition of my book, Deadly Spin, An Insurance Company Insider Speaks Out On How Corporate PR Is Killing Health Care and Deceiving Americans. The guide is a compilation of federal and state government agencies and nonprofit organizations that exist to help people find their way through the maze and haze that characterize the U.S. health insurance industry.

But now — with a bit of nudging from my colleagues at the Center for Public Integrity — I’d like to attempt to assist in another way. If you have a health insurance related question — or are in the midst of a fight (or nightmare) with your insurer — and think I might be able to help, just “Ask Wendell.”

Have you been denied coverage for a doctor-ordered procedure? Let me know about it. Is your insurer telling you that an important benefit, which you thought was included in your policy, is not available after all or has been eliminated? Let me know and I’ll see if I can find out why. Has your insurer cancelled or rescinded your coverage without justification? I want to hear from you.

Those are just a few of what I’m confident is a very broad range of issues that Americans are attempting to deal with, without much success or even hope of resolving, every single day. I won’t be able to help everyone who contacts me, and I cannot address every inquiry. But I’ll do my best to answer questions, provide guidance and even do some troubleshooting. You can contact me by emailing askwendell@iwatchnews.org or by posting your queries as comments at the bottom of my columns. I’m also on Twitter, so feel free to tweet your questions to @wendellpotter using the hashtag #AskWendell.

We’re launching “Ask Wendell” because there is little evidence that insurers are behaving in any more consumer-friendly way now than they were two years ago when I testified before Congress about how health insurance companies “confuse their customers and dump the sick—all so they can satisfy their Wall Street investors.”

I’ll be away until Sept. 15, but go ahead and start sending your questions. I’m not sure how much I can do to help, but I’m willing to give it the old college try. So don’t be shy. Ask Wendell.