How can Plan Member Advocacy help individual members?

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The process of submitting an out of country claim can be incredibly time consuming, complicated and stressful for the claimant.  Many of the parties involved in the claims process are open during standard business hours, leaving the members to use valuable work time to make calls, sort documents and follow up on their claim.  Plan Member Advocacy teams help to reduce the work time-loss for employees and alleviate the stress felt by employees and dependents by fully managing the member’s claim on their behalf.

A formal Plan Member Advocacy offering provides employees and their dependents personal access to a dedicated Plan Member Advocate, whose objective is to manage all aspects of the employee’s claim; from initial contact to claim closure (payment to all medical facilities and repayment to the member of any out of pocket expenses).

The Plan Member Advocates (PMAs) assist with the completion of out of country claim forms, follow up with insurers, contact collection companies on the member’s behalf, and facilitate the retrieval of invoices and receipts from the medical facilities involved if the initial documents provided were insufficient.  Phone calls records, written correspondence, and claim status updates are all tracked and the member is kept up to date as their claim progresses.  When an insurer is unable to coordinate with the applicable Provincial Health Plan, the member then becomes responsible for claiming through their Province and remitting to their insurer.  PMAs are knowledgeable about the claiming requirements of each Province’s Provincial Health Program, and know which insurers coordinate directly with the Provincial plan.

Recently, we worked with Burt, a member who was travelling in the United States on holidays.  Burt suffered a heart attack and was admitted to the hospital for 5 days for treatment and released.  During that time, the medical bill, not including emergency transportation, accumulated to over $65,000.  Although the member had comprehensive Out of Country Emergency coverage through his Employer Sponsored Benefit Program, the medical facilities required him to sign for responsibility of the charges and coordinate repayment through his insurer himself.

This is a common situation our Plan Member Advocacy team sees when working with members and their families.  Many medical facilities outside of Canada refuse to bill to a third party insurer, leaving the member to navigate through the claims process themselves.

The average out of country claim can take 2-6 months to resolve based on coordinating coverage through your Provincial Health program and then through your group benefits insurer.  This time-frame can lengthen drastically if receipts are not itemized properly, documents are missing, or if claims are sent to providers in the wrong coordination order.  During this time, it is not uncommon for the member to receive collection letters and calls on a regular basis from the medical facilities where they were treated.  This can cause a lot of anxiety for the member and their family, often at a time when they are still dealing with the medical issue that required them to seek medical attention while out of the country.

In Burt’s case, we were contacted by Burt’s spouse 6 months after the incident, as they had been jumping through hoops to have their expenses initially adjudicated through their Provincial plan and had only just become aware of the Plan Member Advocacy team through their employer.  Our Plan Member Advocate was able to have the out of pocket expenses reimbursed to the member by their group insurer within 2 weeks of being contacted, retrieved the required medical receipts and documents from the medical facilities needed by the Provincial Plan for adjudication, and coordinated the reimbursement balances with the members insurer in under 2 months from initial contact.  The medical facilities were reimbursed, collection calls ceased and Burt was able to put the incident behind him.