Client First Insurance

What are we seeing?
Over the past decade, employees of our client companies have seen greater difficulty in obtaining the benefits they pay for. The frequency of rejected claims, eligibility disputes and claim processing errors has increased. More and more often employees are told they are not covered for particular services without understandable explanations, or they are billed more than they expected after the services have been performed.

Insurance carriers are doing everything they can to keep expenses down in order to increase profits. This sometimes results in understaffing, which increases the frequency of errors. Sometimes carriers adopt claim processing policies that result in a greater number of patients being denied services for inappropriate reasons, or charged more for their share of the cost than anticipated.

Overall benefit plans have become more complex and difficult for employees to understand and use correctly.

And providers - especially hospitals – routinely bill incorrectly, adding thousands of dollars of unexpected charges to patients’ bills.

What are we doing?
In this environment, Client First has continually developed better strategies for helping members:

Understand their benefit programs and how to use them.
Obtain the coverage to which they are entitled.
Appeal denials of eligibility and coverage.
Be assured that they are billed correctly when extensive care is needed and expenses are significant.
With resources to assist in hospital claim reviews

How do we do this?
For Example:

The bulk of one group’s membership uses a national chain pharmacy located very close to their site. After multiple service complaints, instead of simply complaining to the pharmacists, Client First Insurance worked with the insurance carrier, specifically the department in charge of working with pharmacies in their network. As a result of our intercession the carrier had the pharmacy provide additional training for pharmacy personnel and initiated a new process of customer service review. Since that intervention, complaints have been reduced by 95%.

A Member attempted to clarify the benefits available for her autistic child, whose care she expected to be extensive and expensive. She wanted to know what would be covered and what out of pocket expenses to expect. The insurance carrier’s front-line customer service agents told her they could not estimate costs in advance. She was instructed to obtain the services, after which they would then be retrospectively reviewed to determine if they were covered at all and what the cost would be. Client First Insurance stepped in and contacted the insurance carrier’s Regional Medical Director. The Director than contacted the member directly to work directly to assure a clear explanation of coverage and to develop a rational plan of care in advance.

We have developed processes to quickly analyze the rationale behind an insurance carrier’s failure to pay what appears to be a legitimate claim. We seek more extensive explanations for denials to reveal whether the denial is a result of miscommunication, misdiagnosis, inappropriate internal policies or simple processing error. We methodically build the case for appeals.

This approach has yielded favorable results in the following situations:

RX preauthorization requirements and denials - Client First Insurance principals work with clients to assure that their employees understand any pre-authorization requirements for securing certain medications, and their rights to appeal on Rx’s that have been denied. We also provide assistance to individuals using the appeal process.

Payment denials - The lack of pre-authorizations in emergency situations/ambulance use is particularly fertile ground for payment denials. We routinely assist in securing retro-authorizations when necessary and/or work with the carriers to demonstrate that the situations did not require an authorization and therefore, the claims should be paid. Examples of our success include:

Securing 100% payment for an ambulance claim that was not initially paid in full for lack of an authorization although it was an emergency.

A member had surgery pre-authorized by a Carrier to find out later that was not the primary Carrier. Client First worked with the Carriers and member to ensure payment despite attempts by both Carriers to deny coverage.

How can we help YOU?
Whatever problems you encounter in obtaining benefits, we will individually review the details of your situation. Unless the circumstances are clear, we do not routinely accept standard explanations for denials and we pursue answers until we are satisfied that the appropriate decisions have been made. We use our extensive health care and insurance experience and contacts to find reasons to provide coverage rather than to deny it.

We believe that the primary mission of our business is to obtain the health care coverage our clients have purchased.