Be sure to hit all the touch points that self-funded employer representatives want to see when they come for a medical tourism familiarization (fam) tour at your location.
Employer-sponsored self-funded health benefit plans are increasing in number like never before. Many are investigating health travel (not “medical tourism”) as an option for their workforce to access medically necessary care, with one significant admonition: They’re not looking to “slingshot” employees to locations outside the USA. Instead they are seeking designated providers with whom they can steer their expatriate and local national workers for quality care and superb customer service.
Expatriate (expat) benefit programs are becoming increasingly complex, as companies strive to maintain global consistency that is often required by labor regulation and international treaties. These employers need inspected, vetted providers to ensure appropriate and adequate coverage in an increasing number of, often challenging, locations around the world. The trend in recent years is to reduce the number of cases coming all the way back to the USA, especially if there are qualified providers in safe locations closer to where the expat workforces are deployed.
International Private Medical Insurance (IPMI) cost containment is a must have for expatriate employers.
Alternatively, they could self-fund their IPMI supplemental cover as an enhancement to any statutory cover required for all workers in your country. With the cost of medical treatment rising all around the world and with real pressure on public finances, access to publicly funded healthcare for expats is more and more of a challenge. Expatriates look to their employers to provide international private medical insurance (IPMI) with benefit parity to their colleagues back home or face the real possibility of being unable to access private healthcare when they most need it.
“Solutions Selling” to the Plan Administrator
In the past, Mercury Healthcare International operated MHI Benefits Group. From 2003 until 2013, we worked with ERISA Plan Administrators that held the fiduciary responsibility for expatriate benefits for Employers that operated their own health benefit program funded through a 501C9 trust fund or the assets of the corporation. Typically, they seek transparency, good value and superb, culturally-sensitive customer service from an independent source they can rely upon when moving country or location.
MHI Benefits Group producers were independent international medical, health and expat insurance brokers and agencies that provide the right level of cover tailored to the need of each customer. They worked closely with the employee benefit plan administrators and accompanied them on tours of short-listed hospitals and clinics together with our implementation team and the company’s CFO and plan administrator. Sometimes, the entourage also included the plan’s chief medical officer, but this was rare, as many companies don’t have a chief medical officer on staff.
Often, most members of the entourage that will arrive at your clinic or hospital may have no clue what the advanced medical technologies are, how they work, why they cost so much, what they replaced, and when they should be utilized in favor of other advanced medical technologies. To conduct the tour using medical terminology and an assumption that they understand the purpose and capabilities and advantages of the technology is tantamount to conducting a tour in Hungarian for a group that speaks Mandarin Chinese.
Know Your Audience
Conducting a tour for the employer or insurer audience is very unlike conducting a tour for medical tourism facilitators, physicians, hospital administrators, investors, or even the media.
American health benefit administrators of self-funded health plans come in essentially two levels: very sophisticated, or much less involved because they depend largely on their TPA and other outsourced service agencies to assist them with the plan day-to-day operations. So, the preliminary piece of information you want to know is into which group the tour participants fall. Either one is fine, but to conduct a tour with the incorrect assumption will not go well and will be seen as a waste of time, money and opportunity for all concerned. There are no “do-overs”.
Who will be in attendance and what are their roles?
Insurance and billing, revenue cycle
Expect someone from insurance with domain knowledge of claims throughput processing to want to understand which plans you already work with, which other employers, and to check references. They will also want to see the format used to submit bills, claiming code sets, the monetary currency of the bill, and how medical records can be transferred for audit of bills prior to adjudication. Assume all bills will be audited so prepare for this process and share with that person what you can do to make things easier for them to process and you to get paid. These days with electronic medical records, PACS and cloud access, it should be quite easy for a provider to transfer records securely via a client .ftp virtual private network (VPN).
If you require guarantee letters or credit applications and approval, have samples, templates and forms which will need to be completed in a packet available for their review. To offer a contract at this point may be too aggressive.
The plan administrator
A plan administrator role carries with it serious fiduciary liability. Among other things, ERISA, the Employee Income Retirement Security Act of 1974, provides that those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct. Therefore, your solutions selling pitch is to assure them that you can help them maintain that compliance, not cause additional hassle.
An ERISA-covered group health plan is an employment-based plan that provides coverage for medical care, including hospitalization, sickness, prescription drugs, vision, or dental. A group health plan can provide benefits by using funds in a plan trust, the purchase of insurance, or by self-funding benefits from the employer’s general assets. These regulations are not subject to “insurance” laws, but instead, to U.S. Department of Labor laws.
Each plan has certain key elements. These include:
- A written plan that describes the benefit structure and guides day-to-day operations;
- A trust fund to hold the plan’s assets, including the providers they choose to pay to provide care for employees, how much, and the qualifications of the providers
- A recordkeeping system to track contribution and benefit payments, maintain participant and beneficiary information, and to accurately prepare reporting documents; and
- Documents to provide plan information to employees participating in the plan and to the government.
Employers often hire outside professionals (sometimes called third-party service providers) or, if applicable, use an internal administrative committee or human resources department to manage some or all of a plan’s day-to-day operations. Indeed, there may be one or a number of officials with discretion over the plan. These are the plan’s fiduciaries.
The one you are most concerned with will be element 2.
A plan’s fiduciaries will ordinarily include plan administrators, trustees, investment managers, all individuals exercising discretion in the administration of the plan, all members of a plan’s administrative committee (if it has such a committee), and those who select committee officials. Attorneys, accountants, and actuaries generally are not fiduciaries when acting solely in their professional capacities. Similarly, a third party administrator, recordkeeper or utilization reviewer who performs solely ministerial tasks is not a fiduciary; however, that may change if he or she exercises discretion in making decisions regarding a participant’s eligibility for benefits. The key to determining whether individuals or entities are fiduciaries is whether they are exercising discretion or control over the plan.
A number of decisions are not fiduciary actions but rather are business decisions made by the employer. For example, the decisions to establish a plan, to determine the benefit package, to include certain features in a plan, to amend a plan, and to terminate a plan are employer business decisions not governed by ERISA. When making these decisions, an employer is acting on behalf of its business, not the plan, and, therefore, is not a fiduciary. However, when an employer (or someone hired by the employer) takes steps to implement these decisions, that person is acting on behalf of the plan and, in carrying out these actions, may be a fiduciary.
Fiduciaries have important responsibilities and are subject to standards of conduct because they act on behalf of participants in a group health plan and their beneficiaries. These responsibilities include:
- Acting solely in the interest of plan participants and their beneficiaries and with the exclusive purpose of providing benefits to them;
- Carrying out their duties prudently;
- Following the plan documents (unless inconsistent with ERISA);
- Holding plan assets (if the plan has any) in trust; and
- Paying only reasonable plan expenses.
The duty to act prudently is one of a fiduciary’s central responsibilities under ERISA. It requires expertise in a variety of areas. Lacking that expertise, a fiduciary will want to hire someone with that professional knowledge to carry out those functions. Prudence focuses on the process for making fiduciary decisions. Therefore, it is wise to document decisions and the basis for those decisions. For instance, in hiring any plan service provider, a fiduciary may want to survey a number of potential providers, asking for the same information and providing the same requirements. By doing so, a fiduciary can document the process and make a meaningful comparison and selection.
To adequately prepare for their visit, obtain a copy of the Summary Plan Description (SPD) to determine which services are covered and to what extent.
For example, if the plan does not cover in vitro fertilization, the plan administrator may be curious about what you offer in that service line, but not at the expense of learning about your expertise as a center of excellence in other service lines that are covered expenses of the plan. The SPD may also indicate if there are dollar limitations on a particular service or treatment, which you would be wise to take under advisement.
Walking the floors and the facility
When they tour the facility, they are looking at cleanliness, safety, furnishings, and friendliness and engagement of the staff. When visitors come on the floor, do the staff nurses look down at the floor (culturally correct in some parts of the world) or look up warmly, engagingly and smile as if to say “Welcome”.
Make sure all lights are on, toilets and showers impeccably spotless, and exit signs are present along with fall precaution signs in every room.
If the SPD states that the plan pays for semi-private accommodations or standard private accommodations, don’t spend time showing them 3-bed and other rooms. Likewise, they won’t be interested in your VIP accommodations.
Discuss nursing fluency, cultural sensitivity training you’ve conducted with staff, meal options, any patient satisfaction studies recently conducted, the nurse-to-patient ratio, infection rates, and return admissions within 30-days. The nursing supervisor of that floor should have a short, prepared welcome statement that explains what goes on in his or her area, staffing organization, etc., at each floor. No more than 10-15 seconds in duration, just enough to demonstrate English language proficiency.
Once the site tour is concluded, repair to a conference room
At this meeting, your revenue cycle manager, hospital finance executive, director of admissions, discharge coordinator, quality director, health information systems, and medical director should be present, if only to say hello and stay for a short while. While the CEO may make a short welcome speech and appearance, it is not expected that the CEO will attend the entire meeting.
The key personnel for this meeting will be the revenue cycle manager, hospital finance executive, director of admissions, discharge coordinator, and any director of business development.
The type of business agreement you will execute may include two types of patients: Local nationals and expatriates who work for the company or one of its contractors, or near market health travel patients arriving from locations that require telehealth coordination, luggage storage, visa and immigration, logistics planning and pre-admission and pre-discharge continuity of care coordination.
Be prepared to discuss how each will be handled and by whom. Describe patient and medical records intake and flow for the health travel patients. Who coordinates on behalf of the hospital, when are they available, (during business hours or around the clock). Describe the payment protocols you require for each.
Be prepared to discuss professional liability coverage, arbitration requirements, dispute resolution, and the like. Explain any accreditation or certifications and awards and recognition your hospital has received, highlight any published and highly regarded medical thought leaders and experts, any new techniques pioneered, and stay on message: you want to be their designated provider to deliver value innovation, quality, safety, efficiency and good stewardship of the plan administrator’s budget better than any of their other choices in the local area or region. Describe it in terms of benefits, not features.
Often, hospital representatives prepare a small token gift for the visitors, and many times they include a huge shopping bag with all kinds of heavy, printed materials. With luggage rules as they are these days, everyone packs light. The most thoughtful gift is a small USB pen drive with all the materials you wish to share loaded on to the drive, along with lots of photos, a technology summary listing each advanced technology item, what it does, and when it is indicated for use.
If you have standard check up packages, include the menu of packages available that might be appropriate for executive health. For health travel patients, make sure that your corporate visitors have a chance to see where travelers will stay, where companions may be accommodated, how the traveler will communicate with family and friends (wi-fi, amenities, etc.), and how they will be met at the airport and transported to the facilities.
Hospitals, clinics, employers and insurers who require assistance to plan this tour should contact Maria Todd through the Mercury Advisory Group to discuss how we can help you build a winning strategy and preparation for doing business with employers who operate self-insured and self-funded health benefit plans. She can be reached at +1.303.823.4662.