Health insurance plan administrators — not consumers — are at fault for the majority of problems with billing and access to care that consumers have with their health plans, according to a recent Hewitt Associates survey.

Findings show that 54 percent of health plan problems start with the plan administrator, and 17 percent start with doctors or other providers of health care, while only 29 percent originate with health plan members. Nearly 2,500 health plan problems were tracked by Hewitt over an 18-month period, from January 2000 through June 2001.

"The results are surprising because many people, including health care experts, would guess that the exact opposite would be true," says Marie Kobos, a Hewitt spokesperson. "This shows that many employees are taking the correct steps to resolve benefit plan issues, but still need assistance with an escalated issue in navigating the health care system, which can sometimes be both frustrating and complex."

Claim problems top the list

The majority (86 percent) of health insurance problems are related to claims, according to the study. Other key findings include:

• Access to care issues account for 12 percent of health insurance problems.

• Only 8 percent of all problems were "critical," requiring resolution in 24 to 48 hours. Most of the critical issues were because plan members were denied access to care.
  
• Of all problems, 90 percent were medical, 9 percent dental, and 1 percent were for other types of coverage.
  
• More than half (51 percent) of the claim-related problems required reprocessing by the insurance company. The major causes included balance billing, all or part of the claim missing, claim denial based on medical necessity, or denial based on plan provisions.

According to Kobos, an employer can expect that approximately 2 to 4 percent of its health plan members will experience a health benefit problem that will require assistance. "The good news is that the percentage is relatively small compared to the number of benefit plans that a large employer typically offers," she says. "But, the bad news is that these types of issues are very time consuming, emotional and complicated for the employees, which can lead to decreased productivity, morale, as well as overall dissatisfaction with benefits."