SPEAKER_00 0:00

How can you be sure the consumers aren't being overcharged? A TPA tells all. Will you be surprised by what she has to say? We'll find out on this episode of Shift Shapers.

Announcer 0:13

Change either paralyzes or energizes. The choice is yours. You're listening to the Shift Shapers podcast. You're about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change you want to see. This episode is brought to you by Shift Shaper Strategies. In sales, if you confuse, you lose. Clarify your message so you win more clients, crush your sales goals, and build your practice. Learn more at ShiftShaperStrategies.com. And now, here's your host, Storybrand Certified Guide and Chief Transformation Strategist at Shift Shaper Strategies, David Saltzman.

SPEAKER_00 1:05

I've mentioned once or twice or three times on the podcast in eight years, it's hard to remember how many times that once upon a time I spent seven and a half years as president of a third-party administrator. And so I think I've seen enough claim shenanigans that would probably make most white-collar criminals blush. Certainly ought to, even if it doesn't. So how can consumers make sure that they aren't being overcharged and make sure that they're not being gouged, for lack of a better word? And there are loads of tricks that folks play. So we invited Holly Monger, who's president of HSM Computing, and Holly is somebody who does this for a living and does it for clients. And so with that, welcome, Holly. Thanks for joining us.

SPEAKER_01 1:49

Thank you for having me.

SPEAKER_00 1:50

So talk a little bit about your journey because people don't, the same way I didn't end up, I didn't grow up and go to high school and go, damn, I want to be president of the TPA someday. You know, this doesn't exactly happen. What's your journey been like?

SPEAKER_01 2:01

I actually started out thinking I wanted to be a nurse when I grew up. So when I was in high school, I had a work program where I worked in a local hospital, spent four and a half years there, and at the end of four and a half years, I said, I don't like the way the direction that nursing is going. So I left nursing and I started at Allstate Insurance Company when they had large group insurance. Started from the bottom, paid claims, worked my way up when I left there after 13 years. I was a regional group claim manager, and I was a manager over what was called user acceptance testing. And in my journey at Allstate, I paid claims, I worked in benefits, I dealt with user acceptance testing, which is it was a unit that tested all software for claim payment systems. I helped build a brand new claim payment system. I became so adept at it, so involved with the actual coding, that I worked very well with the programmers in determining where to put in changes. So we basically tested every single new addition to that claim payment system, made sure that it was installed in production efficiently and quickly with no problems, because the last thing you want to do is blow up a claim payment system and nobody can use it that day of work. From there, they sold the block of business after 13 years. And I moved on. I went to Kemper and worked in a user acceptance testing area. I stepped down from management because it was a part-time position. And I learned property casually, which I didn't like at all. I had several part-time jobs in between there, trying to figure things out. And family and friends said, Why don't you start your own business? You help people all the time understand their health insurance benefits. So I did. The journey was long and rocky. At that time, I ran into a lot of roadblocks because people didn't understand what I could do for them. They thought, well, my agent can do that. Well, not every agent is going to do that, and they could not. Some agents saw me as a threat because in the state of Illinois, I have to be licensed in order to do what I do. And I audit claims, which is the biggest piece. And because of that auditing, I had to have a license to as if I could sell. I've never sold any insurance whatsoever. But I figured out that it's difficult to try and get into so many different aspects of health insurance. You have individual insurance, you have group insurance, large and small, and you also have Medicare and Medicaid. Now, I don't deal at all with Medicaid, but I do deal with every other kind of health insurance.

SPEAKER_00 4:55

So let's level set for the audience. How big a problem is this? And how does it generally manifest itself?

SPEAKER_01 5:03

It is a very big problem. Now, people have learned to get more involved with their health insurance benefits because it's a need to do. So it's it's come a long way in many respects, but in others it hasn't at all because people don't understand health insurance. They don't understand how to figure out if they should pay a bill or shouldn't. I meet clients all the time. Some say, well, I just pay the bill because the doctor or the hospital says I owe it. And I try and educate them that that's not always true. And you should actually make sure that you you do owe that. I have people that say, I just don't want to deal with it. It's like looking at taxes. I'm done. Here, you figure it out and you tell me what I need to do.

SPEAKER_00 5:48

What are the most frequent problems that you see?

SPEAKER_01 5:51

Probably people do not track their deductibles. They don't pay attention when they go to an out-of-network provider, which is critical these days because that's when they really get zapped. They don't pay attention to how they can appeal a claim and understand that you can't wait a year or two to go back and appeal. I also have a lot of people that come to me that collections has come after them because they just didn't pay the bill, because they didn't understand what they were paying, or it's too large. Those are some of the bigger pieces that I see. I do have some long-term care claims that people come to me about also.

SPEAKER_00 6:31

Do you find more of a challenge with the facilities claims rather than the provider, the individual provider claims? Obviously, facilities claims is are the bills are almost always larger.

SPEAKER_01 6:41

Actually, the facility now, and I'm guessing it's because of COVID, because of all the lockdowns and the people leaving and working from their homes, there are a lot of problems, even with my everyday phone calls and interactions. It's trying to find a person that knows what they're talking about. So that's more and more difficult. You know, people say to me, Well, how did you get through? Well, it it's all about terminology and knowing what questions to ask. And that's the most frustrating for most everyday people. They just they'll call up and say, Well, I don't understand. Why am I doing this? And that person at the facility isn't explaining it at a level that they can understand. So that's where I come in and try and help them out.

SPEAKER_00 7:27

Yeah, unfortunately, they don't give out secret decoder rings very freely. And no. Is back back when I was TPA, which was a number of years ago, one of the big problems that we look for, again, especially on facilities claims and complicated surgeries, was bundling and unbundling. Is that still as big a problem as it used to be?

SPEAKER_01 7:45

Not as much, no. Because when they the PPOs negotiate or the HMOs, they already take that into effect. And your providers already know that if they bill it as a bundled charge, that it's not going to get paid. Same with Medicare. So that aspect of it is is pretty good for the most part. Every once in a while you get into it, but it's not that often.

SPEAKER_00 8:08

There's also uh thinner resurgence, I guess, because there's just no place else to go in partially self-funded plans. Do you see because there's so much more data that's provided to the plan sponsor, do you see more of your work coming from self-funded plans?

SPEAKER_01 8:25

No. I see a little bit of self-funded. Most of the people that I talk to, they go to self-funded because it's going to save them some money. So they're betting that the employee base is young enough and healthy enough that they're not going to see many claims.

SPEAKER_00 8:39

Interesting. So you can you give us a couple of examples of clients that you've helped and what the financial outcome and the difference was?

SPEAKER_01 8:47

You mean uh an example such as a $200,000 claim on a person that didn't understand how horrible his health insurance was, had a horrible accident, and policy maybe paid out $2,000 out of that. That was negotiating a lot with the different providers. It was negotiating a lot with the health insurance carrier, although that didn't get me too far. I have other large claims. Let me see, recent one from last year, it was $171,000. The provider insisted for nine months that the balance was due because they were an out-of-network provider. The insurance carrier kept telling this poor person that no, they have to write off that balance. It took me, because of the poor communications with the facility, probably six months to get that straightened out. They reprocessed the claim and wrote off basically they accepted the liability of $115,000, and all he had to pay in the end was $400.

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SPEAKER_00 11:01

Why do you I mean we talked a few months ago when the Kaiser, the annual Kaiser study came out on healthcare literacy or biannual whatever, uh semi-annual rather? Um we talked about the fact that year over year after year. I mean, I've been in this business since 81. Year after year after year after year, the number on healthcare literacy doesn't change. What do you attribute that to? Do people just think it's just way too damn confusing? Or is it because insurance carriers and providers and whatnot speak a foreign language?

SPEAKER_01 11:29

I think it's a combination of all three. So what can we do about it? You know, that's hard because first you have to get the people to want to learn about their health insurance. Most of them don't. So that's hard to do. So the next thing in my mind is to push an agent. Unfortunately, our government has pushed agents back to such an extent that they can't afford to not charge at least a flat fee to do more than just sell a person a policy. And that's really sad. They've taken away a lot of the benefits of agents. Commissions are way down because your carriers want to sell it by themselves. And I think that's where the danger is. The danger is that insurance carriers want to do it themselves so they don't have to pay agents. But when this poor person gets it that way and they try and ask questions, they aren't talking to anybody that makes any sense. They don't understand it. There is nobody educating them there.

SPEAKER_00 12:27

Now you said that when you started, agents saw you or some agents saw you as a threat. But you work with agents and brokers, don't you? Yes, very closely. What's that process like? If somebody does an agent or broker just say, you know, I I I'm being asked to do more with less. I can't offer this service, but I know somebody who does. Here's a number.

SPEAKER_01 12:48

That's what's happening. Well, I'm very selective in the agents that I refer because I do get many people asking me, Do you have an agent? And I will refer them to certain people that I know are good and are going to take care of them. In the reverse situation, when they have situations that they can't answer the questions or can't charge for it, they do just give out my name and tell them that you're going to have to pay for this. Now, some people don't want to pay, others don't have a problem paying. I do also provide some services, especially to senior citizens, I guide them. So there are some free services that they could use so they don't have to pay me. If it's something that's simple and it's a two-sentence answer, I just answer it without a charge.

SPEAKER_00 13:29

Without getting too much into the details of your business, if if I were an agent and I wanted to have you on tap as part of my team, so that when I had a client who had this kind of a problem, I could just say, okay, you know, call Holly, she'll handle it. How do those arrangements work? Do you do you work on a flat fee basis with an agent over a period of time to have you on on tap? Do you charge per claim? How does that work?

SPEAKER_01 13:54

The only way it works for me is to charge by the hour. And some of the agents don't necessarily want to pay me if they take me under their wing because that takes out of their profits. So they find it easier just to refer me and say, you deal directly with my client, you create a contract between the two of you and leave me out of it.

SPEAKER_00 14:13

Did you ever get into a percentage of savings payment model, or is that not comfortable for you?

SPEAKER_01 14:18

That's not comfortable because in some situations I put in more time than I would ever get back. So it's not cost effective for me. My husband asks that question all the time. You just save that person $115,000. Why didn't you ask a percentage?

SPEAKER_00 14:35

Wait, so let's circle back a little bit. If the cause is illiteracy, healthcare illiteracy, again, what are the sources that you're seeing? Is it is it are you seeing problems with beyond the network? If somebody goes out of network with balance billing, are you still seeing those old old chestnuts or have the laws finally caught up with that?

SPEAKER_01 14:55

Well, the new balance billing laws are just coming into effect. So I haven't seen a whole lot with that. Balance billing does still occur. Sometimes it's because of the billing agency that a provider, especially a physician, might hire. So they don't necessarily pay any attention and they will balance bill, or you'll find out they will tell you that, well, you need to send me proof that that was paid by the insurance carrier or the provider.

SPEAKER_00 15:24

Interesting. What advice do you give when somebody calls and says, you know, what can I do so that this stops happening in here, so that I'm more aware? What kind of advice do you give them?

SPEAKER_01 15:36

I do teach people when they have medical bills how to match up the bill with the explanation of benefit statement. I teach them how to track their deductibles and they're out of pockets. And if they're interested and they're proficient in Excel spreadsheets and that kind of platform, then it's relatively easy for them once you start matching up. The more difficult ones are the ones on Medicare because you have two different statements typically, unless they're on Medicare Advantage. But it's an education process for some. Others, they just don't want to learn.

SPEAKER_00 16:11

Are the problems that you're solving similar in the Medicare population and the commercially insured population, or are they different? They are different. How so?

SPEAKER_01 16:20

Medicare is more complicated for so many people. Medicare summary notices are like reading Greek. They don't understand how to read the form, they don't understand what it means, they don't understand how to put it together with their secondary plan. If it's a Medicare Advantage situation, I'm seeing more and more problems with people that have to have skilled nursing care, which is really pretty scary because Medicare Advantage plans are starting to cut approving skilled nursing days, which is detrimental to some of these people. They don't understand why they're being cut off, they don't understand why benefits ceased, how are they supposed to take care of themselves? So I'm seeing that from some of your bigger carriers. And I'm hearing locally that some of the skilled nursing facilities are not accepting Medicare Advantage patients because they're tired of fighting with Medicare Advantage.

SPEAKER_00 17:17

It's a tough place to be. Yeah. I understand that. You mentioned also that you're seeing some long-term care claims. What kind of things are you seeing there?

SPEAKER_01 17:23

I have people that don't call me because they need to understand their plan, so I analyze their plan and educate them on what the plan means. I have people that contact me because benefits were stopped and I might have to write an appeal. I have people that call me that say, I don't want anything to do with filing this. Can you file it on my behalf? So those are the types of things that I deal with for long-term care.

SPEAKER_00 17:48

Do the long-term care clients that you meet understand their plans any better than the commercial medical insurance?

SPEAKER_01 17:54

No, not at all.

SPEAKER_00 17:56

How do you suppose that is? I mean, it's again, is it just the same thing? It seems way too daunting and too complex for them to deal with.

SPEAKER_01 18:03

Well, I think part of it also comes back to both health and long-term care. It's terminology. So you're talking about health. So you're talking about diseases and body parts and and how it relates to the policies, and most people don't understand that. It's no different than nowadays. It used to be that you could leave your loved one in a hospital room and you knew they were taken care of. I tell everybody that I meet, even my own husband, I say, you never leave anybody in a hospital by themselves. They need somebody there. I always have told my husband for years, anytime you go to a doctor's office and you're getting some scary information, always have somebody there with you because you get told the word cancer, which I had back in the 80s, a little bit of cancer, which was pretty scary. And when you hear it over a telephone and you're by yourself, you don't hear everything because all you hear is cancer.

SPEAKER_00 18:55

So we've got a couple of minutes left. Where do you see this going in the next five, ten years? Do you think it's going to get any better or are you full-time employee for life doing what you do?

SPEAKER_01 19:07

Well, it appears I'm employed for life because even though I try and back down, I'm getting more and more phone calls. So, but that's why I'm doing this. I I enjoy helping people. I'm trying to educate people. Some people come back to me five years later and say, Are you still doing this? I need your help. So it's rewarding. The cards, the thank you cards that I get from people and the acknowledgement. Make my day.

SPEAKER_00 19:32

Well, God bless you for doing it. And if any advisors want to reach out to Holly, her contact information will be in the show notes. Or you can click on her logo up in the upper right-hand corner of the Shift Chapers online page. You can reach her that way, and she can maybe help some of your clients. Again, from an old TPA, I know how daunting this can be, and I know how hard it can be to explain it to let's call them mere mortals, other than those of us who are crazy enough to spend time in business at a technical level. Holly Monger, president of HSM, thanks so much for joining us today.

Announcer 20:04

Thank you. The Shift Shapers Podcast is a production of Shift Shaper strategies and may not be reproduced or quoted in whole or in part without our express written permission. Copyright 2020, all rights reserved.