Kurt Heidemann:
Today's SWAPA number is $3.5 million. That's the amount of money Resolute Healthcare Advisors have recovered for pilots since 2012 when they began working with SWAPA.
Amy Robinson:
This is a benefit that SWAPA provides for all of our pilots and is available for anyone to use regardless of their healthcare benefit plan.
Kurt Heidemann:
On today's show, we spoke with Kerrey Hunt from Resolute Healthcare about some of the things she's seeing on what Resolute Healthcare provides and how they can potentially help you get your medical claim covered.
Amy Robinson:
I'm Amy Robinson.
Kurt Heidemann:
And I'm Kurt Heidemann. And here's our interview with Kerrey. Kerrey, tell us a little bit about what Resolute Healthcare is.
Kerrey Hunt:
Well, good morning. Resolute Healthcare is a concierge service to help SWAPA pilots and their families with health insurance issues.
Amy Robinson:
And so when you say help with insurance issues, give us an example of what you mean by that.
Kerrey Hunt:
It can take several different forms. It can be medical, dental, prescription. It can be benefits education, prior authorizations, claims and appeals.
Amy Robinson:
What is your background?
Kerrey Hunt:
My background is in healthcare. I've worked for Cigna in the past and also different healthcare markets as a compliance officer, as a claims director, project management and federal auditing.
Kurt Heidemann:
So when did you get started with SWAPA?
Kerrey Hunt:
We got started with SWAPA in 2012. It came about because the union was getting increased calls about health insurance issues and they just didn't have the resources to address those issues. And so they were looking for an outside resource to help.
Amy Robinson:
Were they getting a lot of denials at the time?
Kerrey Hunt:
It primarily focused on claim denials, usually higher dollar claims that would warrant more involvement.
Kurt Heidemann:
And what do you see? Is that trend continuing now? Is there one type of claim that is denied more often than another or is there a certain monetary threshold or what do you see?
Kerrey Hunt:
We don't have a monetary threshold. It's important to understand that medical necessity for all plans is the same, should be the same.
Kurt Heidemann:
Is or should be?
Kerrey Hunt:
Should be. Meaning if you have the regular plan health savings or choice plus the criteria for you to have a procedure shouldn't be different. We are seeing some variations between Cigna and Aetna and what they'll cover. However, the process for us is still the same in terms of researching policy. We are seeing a similar amount of denials for regular plan members that we saw with United Healthcare in regard to preventive versus diagnostic benefits.
Amy Robinson:
So has that increased with the change from United Healthcare to Cigna?
Kerrey Hunt:
The increase is tied to appeals. Historically with United Healthcare, we could request reconsideration, which was a normal 10 day process to have a simple claim turned around that didn't involve any type of medical review. With the transition to Cigna and Aetna, those now require formal appeals.
Kurt Heidemann:
So it's a more formal process. So explain that, because a lot of people don't know what that review process would look like then and now.
Kerrey Hunt:
Sure. Let's say you get an invoice for LabCorp and you have a lab that was denied by your insurance company. We could take a look at that particular lab. We get down to a code level that described the type of lab that you had. We compare it to your policy with Southwest Airlines, determine if it should be preventive or diagnostic. If it is diagnostic, then we used to call the insurance company and let them know that Southwest Airlines plan supersedes Aetna and Cigna documents. These days, they don't have a copy of the summary plan description in front of them or the specific rules about what's preventive or diagnostic. So they go by what they see in their system. If their system says preventive, then they say you need to appeal it.
Kurt Heidemann:
And that's a more formal process. So how does that differ from just calling in?
Kerrey Hunt:
So we will take a copy of your explanation of benefits. We will get a copy of your invoice. We will verify the codes that were billed and then we draft an appeal on the member's behalf or the patient's behalf. And then we have the member review the appeal before we submit it. And then we ask for your electronic signature. You actually sign your own appeal, it's your copy. And then we attach any exhibits and we file the appeal with the insurance company and then monitor the outcome.
Amy Robinson:
Do you ever run into, or have you run into things where you've helped where the provider actually put the wrong codes, diagnostic or preventative, and kind of had to send the patient back to the diagnostician?
Kerrey Hunt:
That's a tough one to answer because we try not to get in the middle of telling someone how to code a claim. Maybe if there's a missing element to the claim, we can bring that to their attention. Maybe it's missing a digit or maybe what we call a procedure code modifier. Very rarely do we ever get involved between the provider and tell them how to code. We have run across it where the insurance company tries to ask the provider for a corrected claim and we don't always agree that that's the best route. We think it's the insurance company that needs to change their denial.
Amy Robinson:
Do you currently have more regular plan pilots or benefit plus pilots you're working with?
Kerrey Hunt:
We work about 70% with the regular plan.
Kurt Heidemann:
And isn't that about what the breakdown is or do we know what the breakdown is among pilots?
Kerrey Hunt:
My understanding is about 50%.
Kurt Heidemann:
So the regular plan has a little bit more exposure to, or you have a little more exposure to the regular plan participants?
Kerrey Hunt:
Yes we do.
Kurt Heidemann:
And is that basically because of the diagnostic versus preventative care?
Kerrey Hunt:
Yes.
Kurt Heidemann:
That's really what it comes down to.
Amy Robinson:
Because the regular plan covers more preventative care?
Kurt Heidemann:
No.
Amy Robinson:
No? Opposite, diagnostic.
Kurt Heidemann:
Yeah. The regular plan does not provide preventative care.
Amy Robinson:
Correct.
Kerrey Hunt:
It's before the Affordable Care Act, so they're not required to offer preventive care.
Kurt Heidemann:
Tell the pilots that are listening to this exactly the steps that they would go through if they had a problem with their bill. Do they contact SWAPA benefits? Can they call you directly? How do they get in touch with you?
Kerrey Hunt:
There's a variety of ways to get in contact with us. They're more than welcome to call us directly. We have an email address that they can reach out to. They can call the union. Sometimes it's word of mouth. They might get a referral and any of those ways they can reach out.
Amy Robinson:
Okay. So can you give us an example, de-identified obviously, of a fairly big claim that you have worked on or are currently working on?
Kerrey Hunt:
Yeah, air ambulance is a big ticket item. Someone's airlifted due to an emergency situation. Most air ambulance companies are out of network. The insurance company will hire a third party to negotiate a rate, but the truth is they don't negotiate. They just tell you, this is what we're going to pay. We're going to pay you $25,000. And then the member is billed for the balance. Could be anywhere between 25 or $50,000. And so we will work with the third party to see if they can renegotiate with the air ambulance company. And if they can't, the claim is supposed to be sent back to insurance company to pay at 100% of the bill charge.
Kurt Heidemann:
So you said supposed to be?
Kerrey Hunt:
Yes.
Kurt Heidemann:
So then does that not happen or what happens if it doesn't?
Kerrey Hunt:
It happened regularly under United Healthcare until the account terminated. Once the account terminated, we've lost traction with that policy provision. So we're going through the appeals process to make sure that those get reimbursed. The good news is is for air ambulance claims in 2022, they're subject to the Federal No Surprises Act. The difference is ground ambulance is the loop.
Kurt Heidemann:
And explain that.
Kerrey Hunt:
Air ambulance companies in 2022 have to accept the rate that the insurance company pays. Doesn't mean you might still be responsible for your deductible or co-insurance, but they can't balance bill you for the difference between the bill charge and what was allowed. For ground ambulance, it is a loophole. They can still balance bill you for the difference and that's where Resolute would come in and argue that they need to pay up to the full amount billed.
Amy Robinson:
So asked a different way, what are some things that you would say are pretty common or that you're seeing more regularly being denied on whichever plan?
Kerrey Hunt:
Sure. So colonoscopies are a big one for regular plan members. And that has to do with industry coding compared to summary plan description compared to insurance company policy. So we do see a lot of those come through, but we're ready and able to handle those appeals as they arrive.
Kurt Heidemann:
I'll actually speak up here and I know Kerrey from a previous endoscopy, a little bit different but same difference. And that was when our family contacted her. I had a procedure that was in network, regular plan, everything was going fine and then the anesthesiologist was out of network. And so in our case, we weren't able to get it removed, but what we ended up doing I think was having the, she negotiated it down to just paying in network. So it was a much lower 20% rate. So that's what we had done. Is that a common thing that happens? Or is that an issue that you're seeing still is the third party or balance billing?
Kerrey Hunt:
It occurred more when United Healthcare was in play. The main difference is as of January 1st, 2022, the Federal No Surprises Act came into play. So that should relieve emergency care related to anesthesiologists and other out of network providers. There's still a few loopholes, but we anticipate that that type of concern will decrease.
Amy Robinson:
What would you consider some of the smaller claims? I mean, we asked about a big ticket or whether that's indicative of a personal relief or not?
Kerrey Hunt:
Smaller claims might relate to individual chiropractic visits or preventive versus diagnostic lab tests. They're usually smaller dollar claims, but they're rightfully easy to overturn.
Kurt Heidemann:
I guess a good question would be is how busy are you? How many claims are you working on? We have almost 10,000 pilots. How many claims are you working on typical year?
Kerrey Hunt:
We look at how many pilots we work on average per month. Historically it's been about a hundred pilots per month. Of course it's grown as the SWAPA membership has grown. After the summer and with the transition to Cigna and Aetna, we're up to about 140 per month that we have going. We usually start the month with about 60 to 70 because we're able to close some out during the month. And then we have anywhere in the ballpark between 50 and 75 new referrals and new issues that are called in each month.
Kurt Heidemann:
And how long do those cases generally take to process? When you get a new case in, how long do they stay on your books?
Kerrey Hunt:
It really depends on the outcome of the appeals. We would like them to stay on the books less than a month. But what we're seeing with an elevated appeal trend is that they're staying on two to three months, sometimes as many as 18 months.
Kurt Heidemann:
And what happens if you do go through the appeal process and the appeal is denied? Is that the end? Is there any other follow up that you can do at that point?
Kerrey Hunt:
You bet. There's pre-service appeals and there's post-service appeals. All members have access to level one and level two internal appeals. That means the claim administrator's going to look at that internally. If the second level appeal is denied, then we also have a request for external review by an independent review organization. So that is someone that is not owned or operated by the insurance company. If the level three overturns the appeal, that decision's binding and the claim needs to be reprocessed or the procedure approved. If they deny the level three, then we also have the option of filing a grievance with the Employee Benefit Security Administration Department of Labor.
Kurt Heidemann:
And that's a different grievance than what SWAPA grievances are for the contract?
Kerrey Hunt:
Correct.
Amy Robinson:
How many of those have you had to file?
Kerrey Hunt:
Very few.
Kurt Heidemann:
Something that I think a lot of our pilots say is, and correct me if I'm wrong, but Southwest self funds its insurance, it's health benefits, right? So they say, well, if Southwest is paying out of pocket, then they should be able to just tell Aetna or tell Cigna that they should cover this and it should just be done. Is that how it works? Or why wouldn't that work?
Kerrey Hunt:
We do hear that from time to time. Unfortunately that's not how it works. Medical necessity comes into play. I think there's a lot of well intended people, but there are a few that are going to spoil the game and try to get procedures that would not normally be covered or seen as medically necessary. A broad example is a cosmetic procedure versus a reconstructive procedure. And there's also safety and effectiveness that come into play. They want to make sure that procedures are well documented because you don't want to set precedents by approving a certain procedure and then the procedure fails and they come back to sue you for approving a procedure they should have never had in the first place.
Amy Robinson:
When a pilot calls you, what is the process specifically for the very first phone call going forward?
Kerrey Hunt:
For the first phone call, we like to get some basic information. We're going to ask for your Southwest employee id. We document to make sure that we're handling information for the pilots union. And then we're going to ask you what plan you're on, Cigna or Aetna, or it could be United Healthcare. And then what plan choice is it choice plus, health Savings, regular plan, choice plan C? So then we can get it frames the context of the conversation. Then we're going to ask you to share a little bit about the situation. This can happen via email or it can happen over the phone. And then based on the conversation, we're going to ask you for a series of documents. We're going to need explanation of benefits from the insurance carrier, we're going to need invoices, possibly medical records, and any letters or other documents that are pertinent to your situation.
Kurt Heidemann:
When you say the explanation of benefits, is that something that we have as pilots or is that something you have?
Kerrey Hunt:
It is something that you have as pilots. So each insurance carrier has their own website and you would log on to mycigna.com or aetna.com, myuhc.com, and there are options to locate the claim and then view an explanation of benefits statement, and then you can download that as a PDF and send it to us.
Kurt Heidemann:
And I'm sure a lot of pilots are concerned. What's the privacy requirements that you have? Is that something, any information that they share with you, is it protected information?
Kerrey Hunt:
Yes, the information is protected in several ways. If we're to communicate on your behalf, we do ask to have HIPAA releases in place. Those are privacy releases that allow Resolute to speak on your behalf. No information is shared back to the union without your express approval. And then at some point, if we do have to refer you back to the union for a case that needs to be elevated, Resolute is then, we'll frame the conversation, but then we'll remove ourselves. So then that becomes a conversation between you and the company.
Amy Robinson:
So you said that when a pilot calls you, you talked about HIPAA, HIPAA releases and things like that. What information do you have about our pilots prior to that first phone call?
Kerrey Hunt:
People have a misconception that we know more than we know. We don't know anything about you. We don't know your claim history, we don't know anything. So we're really dependent on what you share with us. And if you only give us a partial story, we may not be as successful. So sometimes it's us taking all these different pieces of the puzzle and putting them together and we're realizing you didn't send us everything.
Kurt Heidemann:
So when a pilot calls you, what is his out of pocket cost?
Kerrey Hunt:
There is no out of pocket cost to the pilot or the family to use our services. Our services are covered through our agreement with SWAPA.
Kurt Heidemann:
So you're saying the pilot pays for it out of his union dues?
Kerrey Hunt:
Yes.
Kurt Heidemann:
What if a pilot doesn't know if his claim should or shouldn't be covered?
Kerrey Hunt:
If anyone has a question, I just recommend calling and even asking the question, if something doesn't seem right. For example, timely filing guidelines are not in play during the public health emergency for COVID 19. So we can effectively work claims back to 2020 if needed. Reach out sooner than later, and sometimes we might even be able to resolve it just with a simple phone call.
Amy Robinson:
You did say earlier, you talked about one of the things that you do is sometimes education. And so I think does that fall in that guidance there? When you say call for anything, even if you have questions? Or what do you mean by education?
Kerrey Hunt:
Education to us means helping you understand how your summary plan description is written. Helping you understand your benefits and how they apply. So maybe something was applied towards your deductible or your out of pocket maximum. And sometimes those terms can be interchanged, but they're not technically interchangeable terms. They mean completely different things. So we can help you understand why claims were processed a certain way, maybe why they were adjusted or how a particular benefit works. If something requires prior authorization from a general level, like MRIs and CAT scans or certain mental health procedures, things like that, we can help guide you so you know what to expect and not be surprised.
Kurt Heidemann:
So Kerrey, if our pilots have listened to this podcast and have an issue that they want to bring to you directly, how do they get in touch with you?
Kerrey Hunt:
The easiest way is to go to the SWAPA benefits page where all our information is listed. Or they can call 877-847-3992.
Amy Robinson:
So when should a pilot call you?
Kerrey Hunt:
We prefer calls sooner than later. If you have a question before a procedure, give us a call. We can tell you how we think it will be processed. Or if you have a situation and you receive an invoice that you don't think is correct, reach out before two or three months pass so we can get involved sooner.
Amy Robinson:
Our thanks to Kerrey for being on the show today. Her help to our pilots has been undeniable. And as she mentioned, all of that is covered by your union dues. So feel free to reach out to her or SWAPA Benefits if you have any questions or issues with your medical claims. All of her contact information is available on the benefits page on SWAPA.org.
Kurt Heidemann:
And as always, we'd like to hear from you. If you have any ideas for us at all, please drop us a line at [email protected].
Amy Robinson:
And finally, today's bonus number is 1,297. That's the number of individual pilots Kerrey and her group have helped since the start of their relationship with SWAPA.