Do you have experience dealing with your health ins "Care team"?

April 7, 2021 9:14 AM

My job's health insurance has one of these "Care teams" who purport to provide you with a personal contact & concierge support with claim issues, etc. Given that the concept of health insurance is pure theft, what kind of horrible trick are they trying to play here? Would I actually get anything out of this arrangement or is a trap?

I am considering it because my husband has some chronic health conditions and I have a lot of experience with fighting with whoever our current ins company is to get them to hold up their end of the bargain they made without anyone really consenting to it. So perhaps having just one person to fight with will be easier than the faceless, inhuman Kafka-esque nightmare I'm used to. So will it be easier with this "care team" or is it a trap to collect information they can sell or some shit?

posted by bleep to Work & Money (17 answers total)

I haven't experienced Care Teams, but I share your recognition of the reality of health insurance. My experience with similar things (like, "concierges" for specific high-profile drugs) is that it's not about selling and it's not about theft, it's about that if they can more reliably ensure you're taking the drugs you're supposed to you're less likely to need massive surgery. I think insurance companies are wising up that preventative medicine is cost-effective. But of course, I bet when you need a exception, that Care Team won't do nuthin'.
posted by Pacrand at 9:23 AM on April 7, 2021

I actually had cause to use my own insurance company's "care team" when I broke my knee this fall; there was a one-week gap between the day I broke my knee and the day I had the surgery to repair it, and during that week, my insurance plan number changed, and the surgery was mistakenly billed to the old number. The care team took on the task of calling the billing department and sorting them out so I wouldn't have to sit forever on the phone doing it myself at a time when I was recuperating from knee surgery.

They're not a trick - they are legit there to help you with that kind of annoying shit at a time when you least need to be worrying about annoying shit.
posted by EmpressCallipygos at 9:28 AM on April 7, 2021

I do not have experience with a "care team", but the first question I would ask is, "Who is the care team accountable to?" Is it you or the insurance company or the company for which you work? Look at everyone's incentive. Insurance company wants to pay out as little as possible (natch). Company, assuming it pays some or all of the insurance cost wants to keep payouts down to keep premiums low(er). You, rightfully, want what you are entitled to. Who is the care team reporting to? What is their incentive?

Why not try it? If it turns out to be a boondoggle, or worse, abandon them. I assume they have to abide by HPPA so I doubt they are information gathering. I just don't know how hard they will fight for you. If they have a larger overall relationship with some insurance company manager, they may be in a position to help, but also may not want to rock the boat on your claim because they are fighting for another person's larger claim. They may be willing to "settle" much sooner than you would stop fighting.

I would use them for the administrative red tape stuff and keep fighting yourself for the money stuff.
posted by AugustWest at 9:30 AM on April 7, 2021

These teams tend to be designed for dealing with the bureaucracy of the health insurance company for people who need extra help (complicated claims, large claims that will need lots of follow-ups, etc.)

So yes, they work for the insurance company but it means your employer paid extra money to get you better customer service when you need it. It usually means you talk to one person who knows your history and what's upcoming, can help get pre-authorizations done, can help work with claims that may be denied.

Yes, you should absolutely take advantage of it.
posted by magnetsphere at 9:41 AM on April 7, 2021

I think there are two possible services. One is your employer has arranged for their employees to get better customer service (better trained, more available, willing to step in a fix problems). The deal here is that the insurance company sees value in providing better customer service. These folks still work for the insurance company but they incentivized to be helpful.

Second service is more about actual medical care than billing - some plans offer nursing staff to help make sure you are getting the care that you need. This usually targets people with chronic medical condition where proper on-going care will reduce total medical needs in the long run. I have a family member who gets contacted with this offer a couple times a year and we refused just because her care team is already on top of things.
posted by metahawk at 9:44 AM on April 7, 2021

When I medically transitioned, my insurance company offered such a service (they were called 'nurse navigators'). I did call and speak to one and didn't bother asking them for help because they couldn't do much beyond tell me what I had succeeded in finding on the website. However, I did know trans people who found them useful for navigating what is many people's first significant interaction with health insurance (what's a prior authorization, what the heck do I need to send to get said prior auth, etc, etc)--basically, it gave them one person to telephone who had some idea who they were and they found talking to a person easier than digging through the website.

My current insurance has offered me such a care team (I'm assuming having flagged me as someone taking an expensive prescription). I've turned them down because I'm actually straightforward medically, albeit expensive. But in general, I understand that it's the insurance company trying to make sure care is coordinated across providers because that's cheaper for them in the long run. (Of course, it would be cheaper still to nationalize healthcare, but...)
posted by hoyland at 10:09 AM on April 7, 2021

I worked with someone, I forget the folksy term, who worked for the insurance company, was not an extra for my employer, but dealt with complex multiple claims. Their deal seemed to be: for the claims that the company is going to pay in the end, the person can navigate the process, and ultimately cost the company less than the aggregate time of all the first-tier claims handlers leaving voicemail bickering with hospital billing people over code choice without any view of the whole picture.
posted by away for regrooving at 10:13 AM on April 7, 2021

We've had very good experience with the insurance concierge team at our companies. In one example, we had something not be covered that we thought should have been. We just handed the details to them, and they took care of it. In another, there were several different places to get a particular medication, but with dramatically varying costs, restrictions, and reliability. We just told them what we needed, and they sorted it out and recommended the best way to get it.

I don't know if all of them are this way, but it has always felt like they were on our side, and helped us deal with messy stuff we otherwise wouldn't have known how to handle.
posted by primethyme at 10:21 AM on April 7, 2021

I work for a health-insurance company (and I have real problems with the current state of health insurance).

I am genuinely in awe of the teams who advise members and help get them what they need. (In particular, these are members who are in really hard spots, with multiple medications, health problems, and procedures.) The team members are licensed nurses and really know their stuff. And they provide a real benefit to the business: keeping people out of the hospital, away from expensive procedures. So they're allowed to be caring, knowledgable, and actually beneficial.

(We also employ teams of people whose job it is to evaluate claims, but they're not the care team.)
posted by booth at 10:34 AM on April 7, 2021

I am a healthcare advocate. I have never worked for a health insurance company but have worked with several different complex care teams or concierge services within insurance carriers. I generally find that these folks are able to cut through some of the bureaucracy and speed up inevitable outcomes so that the things that would happen anyway can happen sooner and with less of a headache for you. Sometimes, they also assist producing outcomes that might not have been inevitable.

They do work for the carriers, but I actually find they are more clear-headed about the carrier having to pay for what it has agreed, by the terms of your policy, to pay for, than the first-level claims adjusters who are more likely to just deny something out of turn and cause you a big headache.
posted by gauche at 10:51 AM on April 7, 2021

There are lots of different ways this can be set up. My last job had advocates through our insurance broker, not the insurance company. My husband is in the public sector and his insurance is through the largest insurance company in the state - which also happens to be a nonprofit. They are notoriously excellent and making sure that things get handled - I have many times been on the phone with someone on the customer care team and a doctor's office getting things straightened out.

I have also worked with a "care navigator" from my insurance company who does things like check in on chronic conditions and make sure that perscrptions are not in conflict, etc. They call and say "DR X prescribed you blood pressure medicine, but you are also still getting Y blood pressure medicine filled. Is that intentional?" I have never felt like they were pressuring me, it really did seem like a useful service for people who need it.
posted by dpx.mfx at 11:20 AM on April 7, 2021

I work for a company that, among its other offerings, provides a care team to members of different health insurance plans (Mostly in the Latinx community). Our teams don't specifically deal with billing issues (though we can assist) but our nurses, pharmacist (and chaplain!) do make sure that our members: Understand any discharge instructions they might have received when being released from the ER, understand how medications they are prescribed might interact with any folk medicines/other prescriptions they are taking, remind them of required annual screenings and make sure that any family members who they ask to be involved in their care are informed of medical updates. Health care in this country sucks but there are people/orgs who are trying to work within the system to change things a bit.
posted by simonelikenina at 1:25 PM on April 7, 2021

The cost of care provided in a hospital is truly shocking. Even if the insurance company doesn't pay $80 for an aspirin, they are paying thousands in room charges. If they can help you manage your care so that you are seeing in-plan primary care and specialist doctors, instead of being hospitalized, they will save a ton of money. That goes double for going to the emergency room, where the costs go way up and the likelihood of the doctors being in-plan goes down.
posted by wnissen at 1:58 PM on April 7, 2021

My insurance coordinator is a free benefit of working for my employer. I think (but can't prove) that the idea is to take these kind of headaches off our plates so we won't go phoning or receiving phone calls to/from doctor's offices and insurance companies during our work days. My experience is that they may not get results or answers a whole lot faster, but they know who to call for what, and know the employee plans and so won't accept a totally wrong answer.

Example 1: my wife's coverage for cataract surgery on one eye cost a lot more out of pocket than the other, at the same facility with the same doctor. Yeah, it took them a while but they got it fixed. Note that cataract surgery is never done on two eyes at the same time anyway.

Example 2: my Vision/Eyeglass plan kept saying I wasn't covered at the doctor's office, but if I phoned their customer service number they said I was. Yeah, that never exactly got solved, but when I sent all the research that the insurance coordinator had dug up to the practice they worked it out. We'll see what happens next time I go.
posted by forthright at 4:30 PM on April 7, 2021

Yeah in my experience it is a benefit provided by the company, not a trap. Usually they're great, but sometimes either the person isn't as competent or the specific policy is bad/inflexible and there's nothing they can do. But under good circumstances they can save you a bunch of stress and phone tag and potentially money. Worth a shot.
posted by february at 3:14 AM on April 8, 2021

Coming back in to add that there was one instance in The Great Billing Snafu that I had to do myself, but the Care Team did enough legwork that instead of just throwing me into the phone limbo, they tracked down "Okay, you call this other number, and at the first option press '3' and then press '0' and you should be sent straight to a human, tell them your case number is blah blah blah and ask for this specific thing. That will cut straight to the chase."
posted by EmpressCallipygos at 4:13 AM on April 8, 2021

I worked with one for a short period of time during an acute medical situation. They had decent advice and were also able to make appointments with specialists far more quickly than I was able to going through the normal process.
posted by answergrape at 1:35 PM on April 8, 2021