Lack of Handoff Integrity and Empowerment

A couple of weeks ago, my wife was dealing with a mess between our health insurance provider and our flex plan provider.  This is our first year of using a Flex Plan that pulls money directly from my paycheck (before taxes) into an account to be used on medical visits, prescriptions, etc…  Everyone mentioned how wonderful this is.  It is kind of like level loading the payment for doctor visits and prescriptions we would need during the year.  This is suppose to be a seamless process for us.  The insurance company is suppose to automatically send processed claims through to the flex account provider.  At that time, the flex account provider is suppose directly deposit the money into our checking account for us to pay the bills.

If you noticed, I used the word ‘suppose’ a lot above.  There is a good reason for that.  The process is not working like that at all.

After a few months, my wife had noticed that we hadn’t received our reimbursement from our flex plan for several doctor visits.  She keeps meticulous records, so she knew exactly what the amounts were, what doctor, and for what.  My wife called our flex plan provider.  It didn’t take long before the flex plan provider pointed the finger at the insurance provider.  I think it was put this way, “We can’t reimburse you if we haven’t received any notice so it is their fault.”

That led to a call to our insurance provider.  My wife spent almost an hour on the phone with them.  The insurance provider said they sent it.  Their system showed it was sent on a specific date.  My wife asked how often do they send claims to the flex plan provider and do they get a confirmation of receipt back?  It was explained to her that all claims are sent out electronically to the flex plan provider on Wednesday (weekly batch and queue method) and they do not get any confirmation back of what was received.  The woman that my wife spoke with was very nice.  She very politically said they know there is a problem and there was nothing she could do about it.  Basically, we have to now re-submit for reimbursement the manual way.  Send a fax to the flex plan provider with the Explanation of Benefits.

How much of this sounds like the place you work at?  A very common failure point is at the handoff point.  Passing information and work from one person to another.  This is exactly where the failure is happening in this case.  Could the handoff errors be caused by the batch and queue method of sending claims all over at the same time on Wednesday?  Could this overload the computer system and cause claims to disappear?

Does the insurance and flex plan providers really have the consumer in mind?  If they did, I would think they would be more willing to work together to solve the problem and help consumers.  Instead, they point the finger at each other and the problem continues, causing headaches for the consumer.

Finally, the woman working for the insurance provider is the closest to the problem because she hears from the consumers directly.  She told my wife they know it is a problem but they aren’t going to do anything about it.  The insurance provider does not even have a stop gap or rework loop.  They put it all on the consumer to manually refile directly with the flex plan provider.  Would you agree that she is not empowered to make change or even suggestions?  If the woman was empowered to make change she would have mentioned what action was being taken.  Instead, she made it sound like she can’t take action because the company won’t let her.

Wouldn’t the insurance provider’s cost be less if this problem was fixed?  Wouldn’t they need less call center people answering phones?  Maybe they could be working on other improvements to the system?  Maybe the benefit pre-approval area is swamped and could use the resources to help out?

The biggest thing that irritated me wasn’t the existence of a problem, but rather they knew it was a problem and sounded helpless to do anything about it.  That sounded like the sentiments I hear every time I go to a new area to conduct a kaizen event and try to engage a new set of employees.  They can say the industries are different but the problems look the same to me.

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Posted on June 25, 2010, in Customer Focus, Engagment, Health Care, Problem Solving and tagged , , , , , , , . Bookmark the permalink. Leave a comment.

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