Health insurance claims data can provide a wealth of knowledge—if you know where to look. Whether you review your program’s claims activity monthly, quarterly, or bi-annually, the process can allow you to see how the year is progressing and year-over-year performance. Think of it as an insurance plan barometer, helping identify any trouble areas that could arise. It can also be used to help you anticipate and prepare for any potential plan increases the following year.

Here are three data points to start making data-informed decisions that can help you optimize your cultural exchange accident/sickness medical insurance plan using the claims reports you already receive.

1. Are atypically large claims derailing your plan?

Large claims can and do happen, but they shouldn’t upset an otherwise stable insurance plan. However, they can affect your claims experience.  Large-dollar claims can be considered either a normal trend or an unusual occurrence. If the large-dollar claims are part of a normal trend, then they will be factored into your insurance rate going forward.

If they are considered atypical, nonrecurring large insurance charges—such as an acute condition resulting in a lengthy inpatient stay or a complex surgery—they should be separated and pooled with your carrier’s portfolio of other large claims. If you discover a large atypical claim, ask your broker if that charge is being removed from the completion factor or how it is being discounted from the experience. Familiarizing yourself with your claims trends through regular conversations with your broker will help you identify anomalies within your participant health plan as they occur, and potentially save you from a higher premium during renewal.

2. Are participants seeking care where you want them to?

Because network providers are typically more cost-effective for both the insured participant and the plan provider, in-network care, as opposed to out-of-network care, is the preferred option. A claims report can uncover behaviors that drive up plan costs such as the number of participant health care services being provided in-network.  Armed with this data, you can compare current participant activity to your program’s goals and evaluate whether or not there is a need to drive participant behavior.

Find the total allocation for in-network versus out-of-network services section of your claims reports.  Because large claims amounts can have an outsized effect, allocation data alone doesn’t tell the whole story. Examine allocation amounts in conjunction with the specific numbers of in-network and out-of-network claims to monitor out-of-network provider usage, and create program participant outreach strategies before those expensive out-of-network visits get out of hand.  If you find that 85 percent of payment allocations are in network, but only 50 percent of all total claims are filed in network it might be time to increase awareness of health care options.

3. Is there excessive emergency room use?

Your claims report can also reveal if your participants are making too many trips to the emergency room—a common problem, especially within international populations who are unfamiliar with alternative health care options. An average ER visit can often lead to claims exceeding $2,000, proving costly for both participants and health plans.

Use emergency room claims data from previous years or, if available, other programs, to provide a valuable frame of reference. Consult with your broker to determine how your program’s emergency room claim amounts compare to claims from other providers during the same period.

Check to make sure you understand what practices your plan’s claims administrator has in place to obtain proper discounts, adjudicate claims that may arise from non-emergency care, and remove unreasonable charges (whether or not they are emergency room claims).

 

Reviewing claims data before your annual policy renewal date can help pinpoint activities, utilization behaviors, or trends that will influence important decisions about your plan, such as the changing of a benefit offering or the incorporation of a different network.

If diving into data analysis seems daunting, there’s good news—you’re not alone. Your broker or health plan provider can be a valuable partner in the process by regularly reviewing claims data with you and conveying what that data means for your program.

Schedule a claims data review to more fully evaluate the intricacies of your cultural exchange program’s accident/sickness medical insurance plan and manage it more strategically and sustainably.

 

-Michael Babore

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To read more about Relation’s cultural exchange services, visit this page.

 

Hi, I’m Jesper Tejsen Lykke, the new Vice President, Global Markets for Relation’s Education Solutions practice group. I’ve been working in the international travel industry for more than 30 years and have always been passionate about the educational and cultural value of cultural exchange. I am delighted that my path has brought me to Relation and back to this world.

Cultural exchanges provide an opportunity to explore other countries’ traditions, customs, beliefs, societies, languages and much more and provide opportunities for participants to view the world with a different lens. Here in America, cultural exchange brings non-U.S. residents to the country on short-term visas to take up temporary positions as au pairs, camp counselors, interns and trainees, summer work/travel visitors, professors, and visiting scholars. United States-based companies and organizations act as the host, provide placement, and provide or coordinate the visa and insurance components.

Cultural exchange helps make our world more connected, and without the sponsorship of those host companies and organizations it wouldn’t be possible. Yet they are often time- and resource-strapped, especially when it comes to handling claims. I’m especially excited then, that Relation is now serving the in-bound international exchange market because we are both broker AND an experienced third-party claims administrator, which lets us support our partners every step of the way. Our team also brings valuable resources, technology solutions, and infrastructure to the table that can help reduce the administrative burden for sponsoring organizations and create more program sustainability.

Personally, I am looking forward to returning to an industry where I have decades-long ties and many great friends. I’m also excited to be developing deep partnerships, finding creative solutions, and helping create a safe, smooth experience for partners and participants alike. Our goal at Relation is to do everything we can to support the great opportunity that cultural exchange is, while helping improve program outcomes.

In the coming months I’ll be on the road at WSTC and ICEF Berlin and hope to see you out there. I’ll also be sharing insights and resources on Relation’s blog that can inform the work of time-pressed program administrators as they support participants. First up: Unlocking Claims Data: 3 Data Points to Help Optimize Your Cultural Exchange Insurance Plan.

If you’re interested in signing up to get notified when I post on the blog, click here…and in the meantime you can always find me on LinkedIn. If you’d like to read more about Relation’s cultural exchange services, visit this page. (My contact information is there, also.)

By Michael Babore, Executive Vice President, Ascension Collegiate Solutions

I have worked in the student insurance marketplace for over 15 years. With the implementation of the Affordable Care Act (ACA), the past three years have been the most challenging for our clients and the marketplace in general.

The first challenge was understanding how the ACA would affect student health insurance plans (SHIPS). SHIPs aren’t like employer plans, and also aren’t like other types of individual plans, so we worked hard with our underwriting partners to understand the new regulations and make the necessary policy adjustments.

But that was only the first step. Next came implementing plans with expanded benefits and higher premiums. For some colleges and universities that had historically offered low-cost, limited-benefit plans that suited a young and healthy population, the higher costs associated with ACA-compliant plans was shocking. At the same time, the state insurance Exchanges came online, offering an option previously unavailable to college-age students. There was also a strong push by the Exchanges to get younger people on these plans with targeted marketing campaigns.

However, now that we have a clearer view of the ACA in terms of the both its regulations as well as what kinds of plans are being offered through the Exchanges, we have a lot more information to help determine what is the best option for students at higher education institutions.

Let’s take a closer look at the Exchanges versus SHIPs.

Exchanges

1. Affordability

   – Plans are generally affordable and priced based on health history as well as income. This seems like an advantage for the “young and healthies” that typically make up college populations. However, students that access the Exchanges for an affordable option often just select the cheapest Bronze option, a High Deductible Health Plan. From the student’s perspective, they are covered and can forget about it. The reality is that the student will still have to satisfy a large deductible ($6,600 for most Bronze plans). Too many students do not understand this, and find themselves paying out-of-pocket for day-to-day accidents or illnesses. Many, if not most, students don’t have the money required to satisfy the first $6,600 of their medical expenses, which could result in students having to decide whether to pay for their education or pay for medical treatment. Since 98% of all medical claims are under $5,000[1], this puts the responsibility of paying for their healthcare squarely on the student’s shoulders.

2. Subsidies

   – The subsidies offered to people in certain income brackets may sound appealing to students, as they perceive that subsidized Exchange plans are more affordable than the student health plan offered by their school. However, a recent study by the Kaiser Family Foundation that focused on IRS penalties in 2014 found that over 50% of individuals who accepted a subsidy for health insurance were not eligible for the amount they received[2]. We hear frequently that students are going to the Exchanges and answering the income questions accurately from their perspective, only to find out that mom and dad are claiming the student as a dependent on their tax return. Since subsidies are based on the total household income, families will be required to pay back the subsidy a student received in error. In this instance, what originally seemed to be a great value to the student has turned into a tax burden for their family.

3. International Students

   – Not only can the Exchanges be confusing for international students, but this population is not eligible for subsidies or Medicaid, since those are for U.S. Citizens or permanent residents only. Without guidance from foreign student advisors or insurance professionals, these students are unassumingly accepting subsidies without fully understanding the ramifications for doing so. In the past year our firm has seen a large increase of international students being deported for violating the terms of their visa.

4. PPO Networks

   – While Exchange plans have access to national PPO networks, the networks affiliated with Exchange plans are often limited networks, especially in non-metro areas. What’s happening is that national PPO networks will offer a much smaller network carve-out to Exchange plans. We’ve heard reports (and seen first-hand) of signs in doctor’s waiting rooms saying they don’t participate in the Exchange PPO network. The result is that students are left with few choices of in-network providers near campus, and end up paying the higher out-of-network prices – including coinsurance, deductible, and out-of-pocket max – for services they need.

SHIPs

1. SHIPs help the school’s bottom line.

   Our consultants have reported that many colleges and universities no longer see the value of providing a comprehensive health insurance plan to their students. The simple truth is that requiring students to have a health insurance plan is in the best interest of the college or university; keeping students healthy and enrolled has a significant impact on the school’s bottom line.

2. SHIPs are usually the best deal for students.

   Many think the Exchanges are good enough for their students. However, as I pointed out earlier, Exchange plans often include really high deductibles which may be financially overwhelming to a student trying to pay for college. SHIPs, on the other hand, generally have low deductibles, coinsurance, and copays. That means a student enrolled in a SHIP can get the care they need right away, without the need to pay for all expenses out-of-pocket until they meet a (generally unattainable) deductible.

3. Health Center Tie-In (and Buy-In).

   A lot of students are going off-campus to seek medical care, rather than utilizing the on-campus health center. SHIPs can coordinate with student health centers, which can help bring more students in and increase revenue for the campus, as well as keeps insurance costs down for students. It’s a win-win.

4. SHIP premiums are competitive

   Sometimes we hear that SHIP premiums are high compared with Exchange premiums. However, a lot of the low-priced plans on the Exchanges have high deductibles and limited networks (therefore a lot of the charges are being paid at the out-of-network prices). The reality is that, if you are making an apples-to-apples comparison, SHIPs are often less expensive than Exchange plans or than students being insured as dependent on a parent’s plan. Since SHIPs now offer full coverage (rather than limited benefits with low benefit maximums that they did in the past), SHIPs are more expensive than they used to be; however, the value of SHIPs has increased as well.

The bottom line is that a quality insurance plan can cover the costs of high medical expenses that could otherwise prevent a student from continuing his or her education. It’s important to consider all the ramifications to students of sending them off to the Exchanges. For many students, the Exchange reality is very high out-of-pocket expenses, few in-network doctors, and not much coverage in the absence of extreme illness or injury. SHIPs might not be the answer for every campus, but I truly believe that in most cases, they can offer students and schools a much better option.

 

Michael Babore has worked with colleges and universities since 2000, developing roadmaps for successful student health insurance programs. His goal is to deliver the service each and every client requires. Prior to joining the Ascension team, he worked as the Head of Sales for HTH Worldwide in their international student insurance division. Michael is a member of NAFSA,ACHA, URMIA, NAICU and the FORUM. He is a regular presenter at many industry-related events and has traveled to 22 countries in his career. For more information, contact Michael at 310-255-2061 or [email protected].

[1] Claims data based on breakdown of claims for students insured through Ascension for the 2013-2014 and 2014-2015 academic years.

[2] Cox, Cynthia, et al. “Repayments and Refunds: Estimating the Effects of 2014 Premium Tax Credit Reconciliation,” March 24, 2015. Kaiser Family Foundation. Web. <http://kff.org/health-reform/issue-brief/repayments-and-refunds-estimating-the-effects-of-2014-premium-tax-credit-reconciliation/>