In fact, the EOB itself — Explanation of Benefit — often can be a fury-producing problem. An EOB is a computer-generated form of one or more pages with which insurers signal approval or denial of claims by doctors, hospitals, patients, pharmacies, clinics … and patients.
For those who work regularly with the cryptic forms, EOBs are simple. But for patients who rarely encounter them, the forms’ explanations are anything but clear … and can be both maddening and depressing, often leading to furious calls to human resources offices whose own staffs dread such contacts.
David Cuneo says his office tries to keep far away from that sort of thing.
Cuneo, a 20-year veteran of the health insurance industry who has worked for 15 years in managed health, is the president and founder of Health Plan Advocate (HPA).
The Ada-based health care utilization management firm works primarily with self-insured companies in this area. Currently, HPA serves employers of about 15,000 people.
And, as Cuneo explains it, HPA is not only managing health care, but also trying to turn around negative attitudes toward managed health care.
“What we try to do,” he told the Business Journal, “is gain the confidence of the patient.” And the way HPA does that, he said, is by contacting the employee whenever possible prior to hospitalization.
Impending hospitalization is signaled to HPA when hospital insurance clerks call to verify coverage.
“I started this firm as an alternative to existing punitive forms of managed care which seem to take the ‘benefit’ out of ‘employer benefit plans.’”
He said that as a routine part of its utilization reviews, HPA tries to be a supportive voice on the phone. He said the voice usually is that of a local registered nurse. And his or her job not only is to determine whether treatment the patient is receiving is appropriate to the diagnosis, but also to help the patients understand what they face, what their benefits will be, and to help them understand coverage and billing.
But as far as the patient is concerned, Cuneo indicates, HPA tries to sound like a sympathetic employer representative rather than some brusque claims processor at the other end of a 1-800 line in Cleveland or L.A.
“The public has negative perceptions about managed health care,” Cuneo says. “We even see it in recent Hollywood productions.”
Cuneo notes that, in the feature film “As Good As It Gets,” actress Helen Hunt used profanity when referring to HMOs.
“Some movie audiences have openly cheered those lines with anti-HMO sentiment,” Cuneo says. “Clearly, it was time to change those perceptions.”
He said that what HPA does is to work with patients rather than trying to control physician behavior.
“Our premise is that positive patient outcomes and good relationships with patients translates into cost containment.”
He explains that most health plans penalize doctors or patients who don’t get permission before undertaking medical procedures. But, he said, HPA dispensed with the cumbersome pre-certification process and annoying penalties that irritate patients and make doctors feel as if laymen are second-guessing them.
“HPA’s innovation is to place a registered nurse and a medical assistant in active roles for the administration of an employer’s health care claims,” Cuneo said.
Cuneo says the approach has been validated by a recent major study. The study — by URAC, a national accreditation organization — confirmed the trend away from programs that require blanket management of a plan’s total utilization.
Instead, says Garry Carneal, URAC president and CEO, “Companies are reviewing fewer procedures.
“But they’re looking more closely at each encounter to identify opportunities to improve and coordinate care more effectively. They’re hoping more targeted utilization management will improve patient outcomes and will also help restore relationships with physicians and other providers.”