Premium Saver Claims Process
Kim White interviews Wendy Thomas and Elizabeth Floyd about the claims process of the Premium Saver, our longest running plan.
Wendy Thomas
TPA Manager
MWG Administrators
Elizabeth Floyd
Claims Manager
MWG Administrators
This quarter's featured article will cover the claims process of our longest running plan, Premium Saver. Kim White, Project Manager for MWG Broker Services, interviewed our TPA Manager Wendy Thomas and Claims Manager Elizabeth Floyd.
Because Wendy and Elizabeth have been with Morgan White Group (MWG) for over a combined 33 years, they bring a wealth of experience and knowledge to the table. Given the benefits of this process, we wanted some of our key team members to help cover it in more depth.
Featured Article
Kim:
Wendy let’s start with you. I know the TPA provides Customer Service, Billing, Eligibility, Licensing and Commissions, Claims and so much more. Would you please tell us about the TPA and the claims department?
Wendy:
The TPA was founded in 1997 as the domestic third-party administrator of MWG. We are licensed or approved to do business in all 50 states, the US Virgin Islands and Puerto Rico. We support and promote electronic processing of claims for several insurance carriers: AmFirst, Standard Life & Accident, Monitor Life, and TPM.
We use two clearinghouses, Change Healthcare (formerly Emdeon) and Soft Care (formerly I-Plexus). A claims clearinghouse basically functions as an intermediary between healthcare providers and insurance companies/payers. The clearinghouse reviews the claims to make sure all the information necessary to pay the claim is submitted. Ultimately this means less back and forth and claims can be processed quickly.
Kim:
Elizabeth, how many claims does your department process during an average month? How many people does it take to assist in the processing of these claims?
Elizabeth:
It can vary depending on the time of year, but on average we can process around 20,000 claims a month. We now have 12 processers with several having been with MWG over 10 years. From my experience, it’s not just about how many people you have processing claims but the quality of people that are processing. We have over 60 years of combined experience currently in the claims department which adds a lot of value.
Kim:
With that many claims, what is the time frame that a provider can reasonably expect payment?
Elizabeth:
Our goal is to complete everything, from receiving the claim to processing and payment of the provider, within 3 to 5 business days. If any issues arise with the provider, we have a “provider relations” subsection of our department which works with the provider to get everything completed and any questions answered.
We also use electronic claims processing which can process the claims received electronically in 24 to 48 hours. Not only does this speed up the time it takes to process a claim, but when we receive claims electronically, all information from the provider, such as tax ID, claims codes, etc., is included. This results in no back and forth or missing information, which is the biggest value to electronic claims processing.
Kim:
What is the claims process from the time the provider submits the claim to MWG Administrators to when the claim has been adjudicated? When can the provider and member expect to receive EOB/Payment?
Elizabeth:
If the claim is filed electronically through one of our two clearinghouses, Softcare or Change Healthcare, the claims process is faster and more efficient, therefore claims can be paid to the provider rather quickly. When claims are submitted electronically the turnaround time is 3 to 4 business days from date received. The provider can also submit the claim manually by regular mail. This process can take a little longer. The turnaround time is usually 10 to 15 business days and the benefits will be paid directly to the provider.
We process checks twice per week. Payments and EOBs to providers are mailed out within two days of processing the checks. EOBs to the members are mailed out once a month.
Kim:
How does a member know if their claims have been filed? What should they do to find out?
Elizabeth:
If a member is unsure if a claim has been filed, it is always important to start with the provider to verify they have the correct filing information for the secondary insurance, located on the back of the ID card. Once verified with the provider that they have the correct filing information for secondary insurance, the member can follow up with MWG Administrators by calling our Customer Service number or emailing our Claims department with detailed information on the date of service.
If the member would like a copy of claims processed by MWG Administrators, they can call our Customer Service department or email the Claims department and request a copy of the EOB and/or a detailed claims summary.
Kim:
The only issue which comes up regarding the Premium Saver claims process is occasionally a member will say we did not pay. Why would this happen?
Elizabeth:
Premium Saver is composed of a two-card system. One card is the major medical plan and the second card is Premium Saver. The only way the provider will know that you have two insurance companies paying your claims is if you show them both cards.
If the member provides the card to their providers when services are rendered, once both the primary and secondary insurance companies have adjudicated the claims, the member can pay their final bill.
A lot of members think if their major medical processes the claim, MWG Administrators should have it too. Yes and No. The only way MWG Administrators is notified of a member having a claim is if the provider submits a claim to us. In order for the provider to submit a claim to us, they must have the secondary insurance on file!
Kim:
Wendy, what projects are in the works that will help streamline the claims process?
Wendy:
From a claims processing perspective, we are working on auto adjudication, which means the claim is processed by the system instead of staff. We will continue to use our staff to audit these claims, but the electronic processing will get the payment to the provider much quicker.
From a member/agent perspective, we have been asked for years to allow the member EOBs to be accessed online. This is something we want as well because a lot of our customer service calls are simply “Have you received our claim yet?” We are pleased to announce that by January 1, 2018 we will have EOBs available online for our members.
Kim:
From a technology standpoint, it sounds like you have automated, or are in the process of automating, much of what a claims processor will do. However, there is something that can’t be 100% automated and that is training. Tell me a little about the training that takes place for your employees?
Wendy:
First off, all our claims team is cross trained. This insures if someone is out sick or on vacation, another member can complete that person’s work and not fall behind. We feel that training is a vital part of an organization to make sure you can change with the times and take care of our customers to the best of our ability. We also have a “buddy system”. Team members are paired together to meet at various times during the week to work out issues and other questions regarding a claim and to make the team stronger.
Kim:
What advice would you give to agents/members to help make the claims process more efficient and streamlined?
Wendy:
First and foremost, always present both primary and secondary cards at the time of service. Secondly, follow up is key!
From time-to-time we get a call from an agent or member because a provider isn’t sure who we are or what we do. Instead of the provider calling MWG Administrators to see how our process works, they tell the member they will not file. The final piece of advice I would give is, when a member comes across this issue, it is best to notify MWG Administrators either the day of service or within a few days of when services are rendered. MWG Administrators has a dedicated Provider Relations team who primarily works on these “issues”. If we are provided the facility name & billing contact information, we can reach out to that provider by phone and letter, and can provide understanding on how the Premium Saver claims process works. Usually, the provider will move forward on filing the members claims with MWG Administrators.
Kim:
If any of our agents have questions regarding our TPA and/or the claims process, who should they call?
Wendy:
We are available to talk with any agent or group with questions or concerns. We understand changing TPA’s can be a challenging time, but we want to assure you that we will work with you and make this transition as smooth as possible. Please speak with your Broker Services Product Specialist and they will set up a time for a call with us to discuss any questions or concerns.