Cutting Through Health Care's Red Tape
Facilitator Walks Employees Through Insurance Company Woes
By Kathleen Phillips Satz, Human Resources
When a Berkeley faculty member needed a doctor while working out of town, he was frustrated by contradictory answers from his health plan.
And when a retiree was told by her pharmacy that her prescription coverage had been terminated, she needed help quickly, but got lost in her health plan's voicemail system.
In stepped Deborah Lloyd.
A health care facilitator in a pilot program through the Campus Benefits Office, Lloyd is available to employees and retirees who need help in cutting through the red tape of health care plans.
Lloyd is there to help employees understand their health plans and can intervene with the insurance companies if a case becomes too much for the insured to handle.
"Having a position dedicated to helping plan members is a big step forward," said acting Benefits Manager Mary DeShaw. "We've always provided this service to current employees, but we had to fit it in with our other responsibilities. Now we can do outreach and let people know that help is available to both active and retired faculty and staff.
"Deborah can concentrate on learning all the in's and out's of each plan, as well as Medicare issues and outside resources, and she can devote more time to resolving each case."
The program, funded by Office of the President, is running concurrently at UC Irvine.
Since she began taking calls Sept. 1, Lloyd has resolved cases both simple and complex. Most have required information rather than intervention.
In the case of the faculty member who was out of town, Lloyd worked with the health plan to clarify the procedure for choosing a doctor. For the retiree who needed a prescription, Lloyd determined that an administrative error had caused the retiree's name to be dropped from the database. As a result of Lloyd's intervention, the pharmacy filled the prescription immediately.
In another case, a retiree was moving out of California and could no longer use Kaiser as her health plan. She needed help to understand her options for choosing a new plan, and with assistance from an outside health care advocate, Lloyd helped clear up the confusion.
"Sometimes, unfortunately, a physician recommends a treatment or procedure that simply isn't covered under the health plan," Lloyd said. "In those cases, we help the plan member explore alternatives. In other cases, when a treatment is refused, we might advise them on the next steps in working with the carrier. Patients have to be much more active in their own care than in the past."
Health plan carriers have seen the benefits of Lloyd's service as well, she said. Several account reps acknowledged that they were a little worried at first, she said, but realized the benefits of having someone who was knowledgeable about the plans and could help resolve problems.