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Case Studies
CLAIMS ASSISTANCE
In a perfect world all claims would be processed correctly and in a timely manner. Even if this were the case, we would still be assisting clients with questions regarding their explanation of benefit statements. Our world is not perfect. At
Acorn Benefits, LLC, we include in our reviews our evaluation of the claims service from different carriers. Many business decisions place a strong emphasis on cost. After the decision is made, claims service becomes the priority. No company President, CFO or Human Resources Director wants to hear their employees grumbling about an insurance company incorrectly processing claims or delaying claims. Even with the best insurance carrier or third-party administrators, there are times when claims will require intervention. We believe we bring a level of experience
and credibility not readily available to most employers. Below are some recent examples of Acorn Benefits direct claims assistance.
CASE ONE
A single parent called Acorn Benefits, LLC. Her teenage son had a substance abuse problem. In-network, she was directed towards a substance abuse center and a specific program. The parent and her son were dissatisfied with the center and plan of treatment. Her son needed treatment, but he did not want to go back to the facility. The problem was that the facility was contracted through the HMO/carrier to provide all treatment for people in a specified region. Her company plan had an out-of-network benefit but as a single parent her resources were limited. In further discussion, it was revealed that the boy’s father died at age 40 “drinking himself to death”. Acorn Benefits, LLC contacted the carrier's medical director, bypassing several layers of administration and informed them of the situation. The medical director worked out arrangements with a new facility for the child. As a follow-up, the insured was very pleased with the new facility and plan of treatment.
CASE TWO
At a meeting with a pension client whose benefit plan was insured at that time through another firm, the president told us about an employee who had a claim that the insurance company insisted was 50% above reasonable and customary. The physician, who is a prominent orthopedic surgeon, would not budge from his fee and was threatening legal action. We, Acorn Benefits, LLC, provided our pension client with a list of steps to take including as a last resort, a peer review committee. We also obtained a reasonable and customary fee from several other carriers to substantiate a basis for a fair fee. This information was forwarded to the current carrier who contacted the physician and worked out an equitable settlement.
CASE THREE
An insured’s child was undergoing her third and final leg lengthening procedure.The first two procedures were performed about four years ago with a differentcarrier. This procedure would be done at the Alfred I. Dupont Institute inDelaware. The physician who performed the first two surgeries and would beperforming the final procedure was not “in-network”. The procedure was notcommonplace to say the least. Original recommendations at three other prominenthospitals were to amputate and fit a prosthesis. Initial communication between thechild’s parent and the customer service department of the carrier did not work. Theleg lengthening process is a five-month process. It did not fit the “regular”parameters of the plan and the customer service representatives were not skilled orable to delineate from the “norms”. We, Acorn Benefits, LLC, communicated withour account representative. We forwarded a 20-page outline of the procedure andrecovery steps to the carrier medical director. We requested the involvement of acase manager to authorize and facilitate the care. Since the procedure is unusual,we requested that the services be considered in-network. The surgeon is veryspecialized and there are few that perform this procedure. The Medical directoragreed. All of the care was considered “in” network. Physical therapy wasextended beyond the contractual guidelines to meet the needs of this young girl.We at Acorn Benefits, LLC pride ourselves on going the extra mile for ourcustomers. These are a few examples of our claim’s intervention on behalf of ourclients. We are also involved with numerous claims inquiries and more mundaneactivities that are none the less important to our customers. The above cases areservices that we offer to avoid some of the bureaucracy to solve a problem for aclient. The pension client in example two now utilized our services for all theiremployee benefit programs.
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