I was speaking with an experienced assistance company executive and we started chatting about the Guarantee of Payment (GOP) process, as one does in our industry. His eyes lit up and he looked in both directions, as if to make sure no one was listening. Then, in a hushed voice, he revealed: “We do it the easy way – we just send ‘faux guarantees’.”
While I love my ‘faux fur’ and try my best to avoid ‘faux pas’, a ‘faux guarantee’ was not something I had heard of. He continued, still sotto voce, but now rather proudly, as if he was letting me in on a great hidden secret. He explained that when they admit a patient to a hospital, they send a document that looks and feels and even smells like a GOP, but in the teeny, tiny, small print, it reveals that it is actually nothing more than a verification that the member has an insurance policy.
So, there might be full coverage for the services the hospital is providing in good faith. Or there might be an exclusion for pre-existing conditions ... or there might be a large deductible ... or any myriad of other limitations. With a certain sense of glee, he explained that the hospitals can’t tell the difference and by the time they realise they’re not getting paid, the patient is discharged and back in their home country!
Incredulous that this approach had worked on a long-term basis, I asked him what happened when they later went back to admit the next patient to the hospital. “Ah, well, of course, that can make things a bit more complicated,” he stammered.
Actions have consequences
The conversation then turned to pricey claims from providers in Mexico, submitted to North American insurers via US billing agencies. He was outraged by this practice, but clearly had never considered that medical facilities that were frustrated by ‘faux guarantees’ and unpaid claims were probably the perfect candidates for US billing agencies’ services!
Once there is distrust between a provider and an assistance company or insurer, the relationship can easily develop into a cold war of suspicion, doubt, and retaliation for real or imagined slights. It is possible, however, to rescue these situations with a few best practices.
lack of communication is the root of many issues between providers and payors
Top 10 tips for better relationships between assistance companies/insurers and providers
1. Say no to ‘faux’
If you or your assistance company are using ‘faux’ guarantees, please stop. They are shady and damage relationships with providers that one of your members may need in the future.
2. Put formal written agreements in place
It sounds obvious, but a surprising number of players in our industry see this step as optional.
Again, this sounds obvious, but lack of communication is the root of many issues between providers and payors. Insurers, make sure your providers have an effective way to communicate with you to discuss both routine claims inquiries and more significant contract issues.
If your hospital is frustrated with an assistance company or insurer, open a channel of communication and give them a chance to solve the problem.
4. Be candid about your capabilities
Everyone likes to put their best foot forward, but make sure you are not exaggerating your abilities or services. For medical facilities, please don't say ‘we have a T3 MRI’ if you mean, ‘there is a T3 MRI at a public hospital about 30 minutes away’. For payors, if you know it will take you 42 days to pay a claim, don't promise payment in 30 days.
5. Consider new solutions
The insurance industry is not always known for its innovative spirit, but don't let that stop you from looking for ways to improve relationships with providers. Look into new payment platforms that make it faster and cheaper to move funds internationally. Consider whether you need a formal claim form or medical reports for every outpatient consultation.
6. Keep it simple
For insurers, especially those in the US, keep in mind that the more complex your benefit design, the trickier they are to administer, and the more you risk misunderstandings with providers.
Sadly, I have seen small co-pays jeopardize otherwise happy provider/payor relationships!
7. Keep expectations reasonable
Many large hospital groups have superb international departments with experienced staff, but don’t expect this level of expertise at every medical facility worldwide. Be aware that staff at smaller facilities with fewer international patients may have difficulty interpreting complex policy wordings in foreign language. I know I do.
8. Stay open minded
I do love a challenge, but I can't tell you how many times providers have started discussions with, ‘we don't work with international insurers’. I recognize many providers have been burned in the past, but please stay open-minded. Not all payors use faux guarantees!
Stay open-minded. Not all payors use faux guarantees!
9. Be puzzled, not paranoid
Standards of care and lengths of hospitalizations can differ around the world. In some countries, certain services may not be available over the weekend. There are still places where certain surgical patients are routinely admitted the night before their procedures. Some private hospitals don’t have the ‘semi-private’ rooms that a policy might cover. Managing healthcare on an international basis is simply more complex and varied than domestic health insurance, and this can be unsettling for claims staff and medical case managers who are accustomed to a strict and unwavering set of rules. Insurers can help staff anticipate these variations by developing robust internal databases that describe the standards of care by country. Now, this is not to say that it is never necessary to raise an eyebrow at an international claim ... especially if the provider is telling you they need five assistance surgeons in the operating room for a simple procedure.
10. Talk to others in the industry
Others may be having the same issues as you or, if you are in luck, they may have already solved the problem! Join the conversation and collaborate with like-minded colleagues at the ITIC Global Provider Network Forum.