Most Health Plan Problems Begin With Plan Administrator: Report

September 6, 2001 ( - More often than not, consumers are not at fault for issues with their health plans, according to new data from Hewitt Associates.

Nearly three-fourths (71%) of reported escalated issues during an 18-month period originated with errors made by the plan administrator or care provider, according to the study. Those issues included disputes with access to care or billing.

More than half (54%) originated with the plan administrator, 17% with the care provider and the remaining 29% were attributable to the covered individual.

The study was based on tracking of nearly 2,500 plan issues by Hewitt’s advocacy participant services from January 2000 to June 2001.

Claim Counts

The vast majority of issues reported (86%) were related to claims, while 12% involved access to care, and 2% fell in the “other” category. More than half (51%) of the overall claim-related issues required reprocessing.

Just 8% were classified as “critical,” that is, requiring resolution in 24 to 48 hours. The remaining cases involved issues that generally arose after care was received.

The major causes of reprocessing included:

  • balance billing within network arrangements
  • all or part of the claim missing
  • denial based on medical necessity
  • denial based on plan provisions.

The most common reasons for denials were medical necessity determinations and plan provisions limitations across all plan administrators.

Hewitt currently provides advocacy services for 16 benefits outsourcing clients, representing more than 2 million employees, retirees and their dependents.