Retiree Health Plan General Questions
All questions received from the Retired Public Employees Association and National Educators Association retired members.
Please select a topic from the following list:
- Miscellaneous Questions
- Provider Info
- Usual and Customary Rates (UCR)
- Web sites & online information
What percent of claims appeals are resolved in favor of the retiree at each step of the appeals process?
HealthSmart (formerly Wells Fargo TPA) appeals data is not available as we are only in the sixth month of their contract.
Appeal information was not previously on HealthSmart (formerly Wells Fargo TPA) or DRB Web sites. Is it now? If not, will it soon be posted?
The Retiree Health Claim Appeal brochure is, and has been, located on the Division Web site under Quick Links – Forms/Brochures as well as under the retiree insurance pages. The brochure is being updated to include the current claims administrator appeal address for HealthSmart (formerly Wells Fargo TPA). Appeal information is also included on each EOB statement. Health appeal brochures and EOB appeal messaging has also been available in the same manner for the previous claims administrators.
Is there a cutoff date for appealing any Premera determination? We assume any such date would be tied to the date the claim was denied?
As stated in the brochure and on the EOBs, appeals must be received by the claims administrator within 180 days of the date of the EOB or of the date the precertification denial letter was issued.
What is the status of the purchase of Beech Street and its parent company? What are the implications for retirees?
This sale is under review and there are no implications expected for AlaskaCare members at this time.
What is the status of Viant’s merger/buy out by the other firm?
In mid-March Multiplan, Inc. announced that they had acquired Viant, Inc. however it will most likely be 2012 before we see a merge for their two PPO networks. Read the press release for additional information about the merger.
We have had a number of complaints from retirees that have had claims sent electronically to HealthSmart (formerly Wells Fargo TPA), or faxed to HealthSmart (formerly Wells Fargo TPA), or claims mailed to HealthSmart (formerly Wells Fargo TPA), that seem to get lost at a high rate. Some retirees report having to send claims in 2-3 times before anyone would acknowledge receiving them. How can we fix this?
The Division needs to know more specifics to get to the root of the problem. Remember that electronic claims from providers are submitted by the provider to a clearinghouse and then to the TPA. If they reject along the way, it is the providers’ responsibility to work their error reports. Member submitted claims should be mailed to the Anchorage office address on the claim form for best service – they will be imaged there and electronically transmitted to the claim office for processing.
We are still receiving calls from retirees that received written authorization for travel under Premera, and are still having trouble getting bills paid for the expenses that occurred shortly after the beginning of FY-10. What can be done to fix this?
Members should submit their travel claims with their Premera authorization for the most prompt service. If a member has an issue they are not able to resolve, they should contact HealthSmart (formerly Wells Fargo TPA) and then, if necessary, the Division.
What requirements does the contract with Premera and with HealthSmart (formerly Wells Fargo TPA) have about time lines for payment of claims? How frequently has HealthSmart (formerly Wells Fargo TPA) met those requirements in the last few months? How many claims a month are not meeting the time line requirements?
The contracts indicate a 12-day turnaround to process clean, complete claims. Although there were some initial delays in the first few months following the transition and over the recent holiday, HealthSmart (formerly Wells Fargo TPA) has been able to process claims faster. They are currently averaging a 9 to 10 day turnaround.
If a doctor deems sclerotherapy is medically necessary to correct a problem with varicose veins, will retiree insurance cover this procedure?
This is a medical claim review question and specifics should be provided to the claims office for review.
A retiree is frustrated with still not having claims paid correctly for services in April 2009. The retiree has dealt with numerous employees of the third party administrator (TPA) and with staff from DRB. They finally acknowledged the bill should have been paid, but as of November, the retiree still had not received reimbursement. She has spent countless hours for a simple bill. She has been involved with at least one conference call with DRB and the TPA. Who should she call that can resolve the problem?
Members can call the Benefits Section at (800) 821-2251 or 465-4460 in Juneau for assistance. If at anytime members are not receiving adequate assistance from the Benefits Section customer service representatives they may request a supervisor’s assistance.
How many claims were denied by Wells Fargo since July 1, 2009? How many denied claims were approved after a follow-up phone call from AlaskaCare members to Wells Fargo? How many denied claims were approved by Wells Fargo through a written appeals process initiated by AlaskaCare members? How many claims were denied by Wells Fargo following the initial written appeal? How many denied claims were appealed to Retirement and Benefits? How many of the denied claims appealed to Retirement and Benefits were eventually approved?
We have only recently starting to compile appeal statistics from HealthSmart (formerly Wells Fargo TPA), but at this time do not have information for the above questions in a format available to share.
Some members claim that the provider submitted procedure code has been changed by Wells Fargo and the change negatively impacts coverage. Why does this occur?
This is what is referred to as the bundling and unbundling of charges. Unbundling is defined as reporting CPT codes when one CPT code is sufficient. For example, it is considered unbundling if related or incidental surgical procedures are coded separately, or office visits for uncomplicated follow-up care are separately coded. This practice often happens unintentionally. However, most third-party payers, currently have software in place to catch unbundling when it occurs. An example:
80050 General Health Panel (blood lab work)
This panel includes the following: Comp metabolic panel 80053, CBC, automated and automated differential WBC count 85025 or 85027 and 85004 or CBC, automated 85027 and appropriate manual differential WBC count 85007 or 85009 Thyroid stimulating hormone 84443. If billed separately, the cost is higher so providers often unbundle charges in order to maximize reimbursement when in fact there may be more appropriate ways to code a service.
I was pleased that HealthSmart (formerly Wells Fargo TPA) has Alaska offices in Anchorage and Juneau to assist members in person and on the toll free number. How do callers get connected to the Anchorage or Juneau office if the call is answered in W. Virginia?
The Anchorage, Juneau and Charleston offices are linked together in a common phone system. The calls are handled by the first Customer Service Representative (CSR) available regardless of office. In order to ensure we meet the requirements regarding hold times and abandonment rate we are unable to route specific calls to Alaska CSRs. Our Charleston CSRs are some of our most qualified people (many have been with us 10 years or more) and they work exclusively on AlaskaCare. While we are still in the beginning stages of evaluating our performance, our call centers have received very high ratings from AlaskaCare members that we’ve randomly surveyed.
At what point should a plan member contact DRB with their problem or questions if they have not received an appropriate explanation or response from HealthSmart (formerly Wells Fargo TPA)?
Members who are not able to resolve issues with any DRB contractor are welcome to contact the Benefits Section at (800) 821-2251 or 465-4460 in Juneau.
If a retiree has a diagnostic code for a procedure, is HealthSmart (formerly Wells Fargo TPA) able to tell the retiree whether or not this procedure is a covered expense? Will they?
HealthSmart (formerly Wells Fargo TPA) determines whether or not a claim is covered at the time the claim is adjudicated. There are a number of factors that are considered when doing this which makes a predetermination without all of the information problematic. However, HealthSmart (formerly Wells Fargo TPA) does their best to answer member questions when they call. They can quote the plan benefits, determine medical necessity, verify provider network status, and research UCR assuming the member has the procedure codes.
Some members are reporting that the amount paid for dental coverage through Wells Fargo is less than what was paid by Premera. Why?
We would need additional information about specific claims in order to research the issue. We are not aware of any large scale issues with dental charges.
How did the dependent information transfer to Wells Fargo so that children attending college are still covered? AlaskaCare members have reported claims being denied and then have to call a Wells Fargo service representative.
All dependent information is maintained by the Division and was provided to HealthSmart (formerly Wells Fargo TPA) in advance of the transition. Student status information was held by Premera and a data file of that information was provided to HealthSmart (formerly Wells Fargo TPA) at transition. We are now over a year past the transition to Wells Fargo and any issues or concerns for dependent information transfers should have been addressed on an individual basis.
What is the State doing to help alleviate the problem of retirees’ lack of access to medical services because so few providers accept Medicare patients?
While there are a few providers who have opted out of Medicare completely, most providers have not done so. However, many physicians limit the number of Medicare-eligible patients they see because of the substantially lower reimbursement Medicare provides. As the difference between what Medicare will pay and what physicians charge grows, it is possible more physicians will choose to opt-out of the Medicare system. These are serious issues, but at their core, they are Federal issues and require a Federal solution. The Department of Administration and its contractors continually monitor the medical community in Alaska and elsewhere. Our hope is to learn from other jurisdictions how to keep providers from exiting Medicare, and making sure we do not incentivize “opt-out” decisions in any way.
Members should ask their provider if he/she accepts assignment and will accept them as a Medicare patient – most will be willing to continue to provide service to an existing patient even after they become Medicare eligible. If necessary, to find a provider who does accept assignment, they may go to www.medicare.gov for a directory of participating Medicare providers.
Is it correct that Medicare does not pay for dental, audio or visual [non-surgery] services for those on Medicare, so if a retiree has DVA through the State, claims would be paid according to the current plan book?
Specific Medicare coverage questions should be directed to Medicare but it is our understanding that non-medical dental, vision and audio services are not covered by Medicare. They would be paid according to the current plan book.
Some retirees have had to be hospitalized for surgery. Some do ask about the costs from their surgeon and the hospital when making arrangements. Try as hard as they might, they couldn’t find out what other non-hospital staff [such as radiologists, anesthesiologists, etc. might be providing them services and then billing them. Retirees have found after the fact many of these medical practitioners are not taking Medicare, therefore HealthSmart (formerly Wells Fargo TPA) won’t pay, so the retiree is stuck with hundreds to many thousands of dollars in medical expenses. The retiree has no idea in advance of who will be providing these ancillary services. How can the State/HealthSmart (formerly Wells Fargo TPA) help retirees not get stuck with these huge out of pocket expenses?
The DRB has not received complaints regarding these types of issues in the past and would need to see information on specific claims, however, members should continue to press for information about their providers. Patients have the right to know who their health care providers are to make informed healthcare decisions.
Is it correct that retirees that haven’t worked the minimum number of quarters under Social Security to be eligible for Medicare Part A, will have their hospitalization claims after age 65 paid at the regular 80% rate under the State retiree plan?
This information is located in the Medicare brochure available on DRB’s Web site. Members who are not eligible for Part A may obtain a letter from Medicare stating that and provide it to HealthSmart (formerly Wells Fargo TPA). At that time, AlaskaCare will continue to pay for Part A (facility) expenses as primary. It should be noted that these members will not benefit from having two health plans to coordinate and pay up to 100% of items which both plans cover. In addition, lowering the cost to the AlaskaCare plan helps stretch the retiree’s lifetime maximum.
Looking at the monthly call centers and correspondence statistics, what have been the Top 5 “issues, concerns, complaints” in recent months versus July 2009?
The majority of complaints HealthSmart (formerly Wells Fargo TPA) fields from members have to do with claims payment. The provider network and UCR are the most prevalent issues discussed.
What are the current “wait times” and volumes at the call centers in recent months versus July 2009? What are response times when HealthSmart (formerly Wells Fargo TPA) has to “get back” to a retiree on an issue? What are response times to emails or letters?
The State’s contract with HealthSmart (formerly Wells Fargo TPA) requires certain performance standards for answering calls and processing claims and failure to meet those standards will result in penalties to HealthSmart (formerly Wells Fargo TPA). HealthSmart (formerly Wells Fargo TPA) reports this information to the DRB each week. The current call wait times are under 60 seconds and the call abandonment rates, people who hang up without talking to a customer service agent, are very low - around 2%. The current turnaround time on all mail is 13 days. New mail is being processed within 9 to 10 days.
Regarding coordination of benefits for RX’s when both spouses are covered, can you provide the instructions we can give to local pharmacies so they can do the billing electronically without retirees having to fill out paperwork after the fact?
When both spouses are enrolled in and covered under each other’s plans, the pharmacy may file a claim under both accounts to have the benefits coordinated. The member must provide the pharmacy with both health ID cards. Any pharmacy having problems with filing for the COB should be referred to the pharmacy help desk at the number on the ID card – this help desk is available 24 hours per day, 7 days per week.
What is the status of plans to possibly change names/member ID numbers of AlaskaCare cards?
Upon review, it was found that the current ID cards are in the same format used and preferred by health plans nationwide as they disclose only a minimum amount of personal information about the member. Based on this, there are no plans to change the ID card at this time.
Are customer satisfaction forms sent out every time a customer service representative interacts with a retiree? If not, what % gets them? How does HealthSmart (formerly Wells Fargo TPA) use this information? What is HealthSmart (formerly Wells Fargo TPA) practice about providing personal information on the retiree to the customer service representative?
The State’s contract with HealthSmart (formerly Wells Fargo TPA) includes performance guarantees based on customer satisfaction and the survey is used to measure that. One survey per customer service agent is sent out daily to a member that they have spoken to. HealthSmart (formerly Wells Fargo TPA) averages approximately 50 calls per day per customer service representative (CSR) and there are usually at least 20 CSR’s on the phone each day. Survey information is compiled and provided to the State quarterly to report on the performance guarantee.
If there are negative comments on the survey, a Team Leader will research the issue and respond to the member by phone or in writing and address any service issue with the CSR.
CSRs have access to member’s personal information that has been provided by the State, a provider or the member as required to perform the job. All CSR’s have been trained regarding HIPAA privacy and have signed confidentiality agreements.
Retirees were told years ago the 2003 Medical Benefits Booklet was being revised and would be out NLT 2007. What is the completion date? How much consultant time and money has been spent on the effort so far?
The State plans to revise all booklets to update their format and incorporate changes in addresses, etc. A firm deadline for completion has not been set. At this time, no consultant time or money has been spent on the retiree booklet as the employee booklet, which they assisted with, will be used as a model.
Is DRB considering opening enrollment to the Long Term Care Plans for older retirees who have not elected this coverage?
The last open enrollment was provided to all retirees in 2000 due to the creation of new Long Term Care options. The DRB has no plans to provide another open enrollment at this time.
When HealthSmart (formerly Wells Fargo TPA) sends out benefits checks to retirees, it is clear from a glance at the envelope it contains a check. In the left part of the window, you can read “PAY TO THE ORDER OF” and then the name and address of the retiree. Also, at the bottom of the check, viewable through the window, the words “THE BACK OF THIS DOCUMENT CONTAINS AN ARTIFIC……..” are seen. Having this information visible in the envelop window is an invitation for theft and fraud. Can HealthSmart (formerly Wells Fargo TPA) change their process so the check information noted above is not in the window?
This request will require significant reformatting to the HealthSmart (formerly Wells Fargo TPA) system and is something they will work on in the future.
In previous years, retirees were invited to fully participate in the quarterly TPA meetings, including getting a copy of the data book provided to participants. We think it would be more productive if we were allowed to at least sit through and monitor the progress at these meetings. We are also requesting that we be provided the retiree information/data presented at the quarterly meetings.
The quarterly meetings are working meetings where the Division of Retirement and Benefits staff is able to sit down in the same room with the staff from the TPA to discuss a variety of topics in a very tight timeframe. Much of the information is confidential and not appropriate for sharing with outside parties. It would be disruptive to the flow of the meetings if we are not able to share information freely or if we needed to table discussions for closed door discussions at a later time. Based on our records retirees have not been given open access to the quarterly meetings.
Many thanks to the Division of Retirement and Benefits for instituting a new series of DRB Fairs to be held around the state on a regular basis. I would have attended the one held in Fairbanks had it been better advertised and look forward to the next one. The topics listed are very relevant to retirees. Plus, it would be great to be able to meet Division staff that might attend since we in Fairbanks rarely have that opportunity.
The Division is making an effort to reach out to both our active and retiree members statewide thru Benefits Fairs and Open Enrollment Fairs. Just recently we have included topics such as the Health and Optional Benefits, but have not yet created a curriculum that addresses the specific topics of interest to our retiree members. Thus, the advertising has been directed to the audience we wished to reach, our active members. In the future, we will expand the offerings to include topics of interest to retirees and we will be including the dates in the newsletters sent to our members and on our Web site.
The current EOB does not list the amount of out-of-pocket paid during the calendar year, and the amount remaining before the out-of pocket requirements are met. This has been a practice with previous plan administrators. Why is it not happening now?
At the beginning of the transition HealthSmart (formerly Wells Fargo TPA) did not have this capability. However, HealthSmart (formerly Wells Fargo TPA) has updated their system and this information began to show on the EOBs in June 2010.
What was the basis for increasing retiree insurance premiums in January 2009 for Dental Audio and Visual coverage? Has the DVA fund, paid by retirees, been audited in the last 5 years? If so, by whom?
Insurance premiums are reviewed annually and are impacted by claims experience – the cost of claims being paid by the fund. The actuarial consultant for the DRB annually reviews the retiree premium rates and calculates the need for rate increases based on the claim experience. All of the AlaskaCare funds are audited annually by KPMG.
It should be noted that the January 2009 increase of approximately 5% was the first increase in premium since January 2005.
If a HealthSmart (formerly Wells Fargo TPA) employee questions the legitimacy of a RX, what is the protocol about who is contacted, the pharmacist, the prescribing physician, the patient, someone else? Or is protocol to deny the claim and let the patient appeal
As has been the case in the past, certain drugs require prior authorization and will be rejected if authorization is not obtained. When this occurs, Envision works directly with the physician to obtain the information required to issue the authorization.
A retiree received medications while hospitalized this summer, and the claim for reimbursement was denied. What basis would HealthSmart (formerly Wells Fargo TPA) have to deny a claim for a RX that was medically necessary and physician prescribed?
Specific information would be required in order to check this issue.
What provision in the contract allows HealthSmart (formerly Wells Fargo TPA) [or subcontractors] to deny the payment of RX drugs if the drug prescribed is “atypical” in the eyes of HealthSmart (formerly Wells Fargo TPA), if the drug is medically necessary [not Viagra, etc.]? These are drugs that have been paid for by AlaskaCare TPA’s for years.
More information is needed to determine what is meant by an atypical drug. A specific example would be of help here.
What concessions does HealthSmart (formerly Wells Fargo TPA)/Beech Street ask of providers to become part of the provider network?
Beech Street asks providers to discount their billed charges and agree not to bill the member for the amount over the contracted rate.
What are the benefits for a provider to become a member of the HealthSmart (formerly Wells Fargo TPA)/Beech Street network?
Providers benefit from increased member business at their practice. They also receive contractual guarantees with respect to payment amount and speed of payment.
How many providers were in the Premera network in the spring of 2009 versus the number in the Beech Street/Viant network now? How many new providers have been added in the last 3 months? How do you track which providers have rates that are within UCR? Will you make that information available to retirees?
At the end of 2008, Beech Street’s Alaska network had 557 providers. During contract negotiations, the State requested and HealthSmart (formerly Wells Fargo TPA)/Beech agreed to a focused campaign to increase the network size. In 2009, Beech Street’s Alaska network added 253 providers – 219 were added after July 2009. Two additional campaigns were launched after July 1 to increase the number of specialists and mental health providers. Currently, the Beech Street Alaska network has 889 providers while their lower 48 network is over 600,000 providers.
All network providers have rates that are within UCR. Most other provider’s rates are within UCR as well. In fact, less than 3% of claims have any amount of UCR reductions.
Providers cannot be tracked based on whether or not they are within UCR because provider information is not associated with UCR data. In addition, UCR looks at individual claim codes and a provider might only have one code that exceeds UCR but is otherwise within the limits for all other claims.
The Division estimates that there may have been more Alaska providers in the Premera network in the spring of 2009, but we do not have specific numbers readily available. The number of network providers was included in the Premera RFP in 2005, but providers have left or been added since that time. Not all providers in the Premera network offered discounts. Since the current network requires providers to help us achieve savings, some have declined membership. However, many have chosen to help us – including Alaska Regional Hospital, whose significant discounts can help members and the plan save millions of dollars a year, while still providing excellent services.
Many retirees have complained that the State and HealthSmart (formerly Wells Fargo TPA) are not doing a good enough job getting providers in network, at least the same level as under the Premera administration. They have provided examples of how they are now paying much more out of pocket than previously. They are saying it is a much bigger concern than what they were led to believe in June and July of this year. How can you fix this?
Beech Street has contacted over 1400 providers in Alaska by phone and mail and, as noted above, has substantially increased the size of the network. AlaskaCare members nationwide can request Beech to contact their providers regarding participation in the network by completing a nomination form from the AlaskaCare Web site. Members may also ask their doctors to consider participation.
Does DRB/HealthSmart (formerly Wells Fargo TPA) track the number of claims in which the provider is NOT in network, and what % of those claims are costing retirees more money than if the provider was in network?
HealthSmart (formerly Wells Fargo TPA) tracks the number of network claims vs. non network claims and reports this information to the State quarterly. There is no way to quantify the value of what more network providers would mean in terms of dollars. Provider contracts are done on an individual basis and vary by provider type and geographic region.
Is there an ongoing effort to increase the number of network providers? After being contacted by an out-of-state RPEA member, I searched online for dentists in the Las Vegas area and found only one listed as a member of the network.
Please see the network information provided in the questions above. In addition, there is currently no dental network.
Members continue to complain that many providers are not in network, thereby costing member considerable additional dollars over what was paid under the previous TPA. You have suggested members ask their providers to join the network. Please provide us with the stipulations/conditions providers must agree to if they want to join the network, so we may know what we are asking our providers to agree to before we try to encourage them to apply.
Beechstreet/Viant negotiates contracts directly with the providers and the Division of Retirement and Benefits is not party or have access to the stipulations or conditions of those contracts. However, we do know that, in keeping with a true preferred provider network, providers are required to provide a discount to our members.
Some AlaskaCare members report that their medical provider has never been approached by Wells Fargo to become a preferred provider. How does the preferred provider recruitment process occur and how frequently are providers encouraged to become a preferred provider?
It's true that Wells Fargo has approached only a few providers. However, Beechstreet, the PPO contractor has approached many if not all of the providers in the State in one form or another, and probably multiple times since the Spring of 2009.
Beechstreet has done several mass mailings and made many targeted phone calls and meetings with various providers statewide. A campaign targeted at about 100 specialists met with some success including adding a couple of oncology providers. Beechstreet has attended all of the major provider conferences in the Anchorage area.
It has been our experience thus far one of the most effective ways to encourage a provider to join the network is when the patient encourages the provider to do so. If you have a particular provider you would like Beechstreet to contact please contact Wells Fargo so they may provide this information to Beech Street and allow us to track the outcome of that request.
Usual and Customary Rates (UCR)
Why is HealthSmart (formerly Wells Fargo TPA) sometimes basing UCR calculations on Seattle prices, when respected research [Commonwealth North] shows that medical costs in Alaska are 40% higher than Seattle? In one case, a retiree was billed for $54,000 more using the Seattle UCR. Retirees have told us this was not a problem with Premera.
The recognized charge, frequently referred to as Usual, Customary, and Reasonable (UCR) is calculated as described on pages 13 and 14 of the Retiree booklet using claims paid data for the area where the service was received. Most services are paid using data from their Alaska region; for example, claims for Juneau are paid using Southeast Alaska data. Some services such as surgery are paid using data from the entire State. If a service is uncommon in the State and insufficient data exists, calculations may be made using national data plus a conversion factor or using a percentage over Medicare.
You have indicated when there is not enough Alaska data on which to base a UCR calculation “national data plus a conversion factor or using a percentage over Medicare” is used. Is it total US data, regional US data, or some other configuration? What conversion factor is used? If “percentage over Medicare” is the basis for a payment calculation, which Medicare rate is being used on which to apply the “percentage over”?
We are using only the Ingenix database. We are not modifying it in any instance or applying a formula based on Medicare. When there are not enough codes in a particular area to calculate a UCR amount, Ingenix derives one using a formula that looks at related codes in the geographical area and calculates UCR amounts by applying relative values and conversion factors to the procedures for which sufficient charge data does not allow for calculated values.
How are Usual and Customary Rates determined and how does a Plan member access information about UCRs? For example, if a member is going to have an expensive medical procedure and cannot find a network provider, the member would like to know what to expect in insurance plan reimbursement.
Please see the UCR information provided in the questions above.
We would like to know more about the geographical area used to determine UCR. We would like to have easy access to that information as well as reasonable access to information about UCR for common medical procedures or office visits.
The State and its TPAs continue to explore options to make this information available to the members. In the meantime, members may be assured that their providers are not charging over the recognized charge by choosing a preferred provider. In addition, a member may contact HealthSmart (formerly Wells Fargo TPA) Customer Service to request a benefit advisory. The member should be prepared to provide the provider’s name and contact information, the diagnosis code(s), the CPT (billing) code(s) and the dollar amounts for the code(s). HealthSmart (formerly Wells Fargo TPA) should be able to provide the member with information whether the charges are within UCR at that time.
There are three geographical areas used for the State of Alaska as defined by Ingenix: 995 and 997 995 includes Anchorage and its outlying areas, (although not Mat-su). Also included are some of western AK like Bethel and Dillingham. 997 includes Fairbanks and its outlying areas, plus rural areas up to Barrow and down to Tok/Chicken/Eagle 996 and 998 996 includes the Kenai Peninsula, Kodiak Island, Mat-su and towards Fairbanks. Also, some of western AK like Dutch Harbor 998 includes Juneau and Southeast above Ketchikan 999 includes Ketchikan south and Prince of Wales Island
Recently, another Fairbanks member had a scheduled surgery in Anchorage. This member did much personal research ahead of time—asking the medical provider for CPT codes, calling Wells Fargo to see if the charges were within UCR, and checking the list of network providers in Anchorage, etc. Even so, the anesthesiologist assigned was not a network provider. The anesthesiologist’s charges may have been within UCR, but the member had no way of knowing this ahead of time. I hope you can appreciate the confusion this system creates for members that want certainty ahead of time as to what their financial responsibility will be for a medical procedure or office visit OR for members that get an unpleasant surprise when their EOB arrives. Please help us understand how to navigate through this system.
The Fairbanks area does have some in-network anesthesiologists and this information can be found at www.AlaskaCare.gov. It is important to note that you do have the right to request who your providers are – including your anesthesiologist.
Web sites & Online Information
What enhancements have been made to DRB and HealthSmart (formerly Wells Fargo TPA) Web sites since July 2009?
Wells Fargo designed and managed the AlaskaCare.gov Web site until Spring 2011 at which time the DRB assumed management and began an extensive redesign of the site to bring it into State of Alaska look and feel compliance. At the same time, content was added and restructured to make the site more usable, friendly, and aesthically appealing. This new site went live in December of 2011.
We understand many insurance companies/TPA’s have begun posting provider prices on the Web sites so patients can access cost information. This allows patients to compare prices among network and non-network providers, check on the price of diagnostic tests and other treatments. Would HealthSmart (formerly Wells Fargo TPA) be willing to provide this type of information on their Web site?
AlaskaCare and HealthSmart (formerly Wells Fargo TPA) are supportive of any initiative to put more information in the hands of members so that they may make better informed healthcare decisions. This was a major focus in 2010. There are certain federal laws that prevent hospitals from comparing their charges to other hospitals within a geographic area. These laws are intended as a consumer protection to prevent hospital collusion on price within a certain geographic region. However they do create unintended challenges in the area of provider cost transparency. We are working on ways to share as much information as possible within the confines of the law.
What is the status our RPEA’s request last December that the TPA post provider prices on the Web site so patients can access cost information? We were told it would be a major focus in 2010.
We are still looking for opportunities to provide members a meaningful and convenient way to “comparison shop” prices for physician services and other medical related costs. Until something like an internet “best-buy” tool is available, the single best approach members can pursue is to find an in-network provider whenever possible. In-network providers have already agreed to discounted fees and guarantee no balance billing in most cases. Preferred hospitals and similar facilities also offer deep discounts to AlaskaCare members.
If providers in your area are not in the network – ask them to join and alert them you will be making your provider selection decisions on that basis. Also, ask providers “what can I expect to pay for (this visit, this procedure) and how does it compare to others in this area?”
The State of Alaska has provided oral and written testimony on the recent national health care law that is likely to impact Alaskans. Does Retirement and Benefits plan to put this information on its Web site for the benefit of current and retired employees? Or does it plan to provide a link to another State of Alaska site? Will this information be updated as additional information is known/made available?
The Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act were signed in to law in late March 2010. On June 14, 2010 the US Departments of Health and Human Services, Labor, and Treasury issued joint regulations on Grandfathered Health Plans under the Patient Protection Affordable Care Act (PPACA). In the preamble of the Interim Final Rule, the Secretaries clarify it is not their intent to apply the PPACA coverage provisions to retiree-only health plans. This means the State of Alaska’s Retiree Health Plan is not subject to the provisions in PPACA. Read the full regulation »
Additionally, the US Department of Labor offers questions and answers regarding these regulations »
This Q&A clearly states that retiree only plans are not subject to the provisions within PPACA:
- Q: Will the Act and the new rule mean more red tape for employers who provide their employees with health coverage?
- A: …It exempts retiree-only and “excepted benefit plans” like dental insurance.