Help Me Clear Up a Bet!!

[vic120]

I found many times I can get things done without client on the phone but sometimes there are issues with reps, one time one maj carrier would not let me get new cards sent without client on the phone, I called back 3 times and no dice

It is what it is, its the cost of doing buis, If everything were easy I suppose there would be more competition

Its a pain but its not a major issue

 

[traceyemoon]

Have you read the privacy of PHI section of HIPPA yet to answer your question? It states that the "business associates" of a covered entity (ie-agents) are covered under HIPPA too. As in, we cannot disclose information without the express written consent of the member. Not the same thing as obtaining info from member services.

It's not an information free-for-all to share info between the medical insurance company and the agent.

https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/

See the Business associate defined and business associate contract. As an agent, I have no need to know anything about my client's medical treatment or care. Sometimes, the client needs to do the work of calling their medical insurance provider on their own or conference-call with you.

 

[DS4]

I have a vendor that is telling me that it is a HIPAA violation to speak to me without the member on the line.

Just another step in eliminating the agent from health insurance sales.

 

[somarco]

Most of the time I tell the client who to call and how to address the issue. No complaints and almost always solved.

The few times it didn't happen I secured a HIPAA release form from the carrier, had the policyholder sign it, and took over the situation. Used this approach more than once on IFP business. Helped clients through some very large (xs of $50k) claims and a few over $100k.

Never had to resort to that for Medigap.

 

[Midlevel]

What is frustrating is if I just want to change a client's address and can't without client sitting there with me. AARP Med Sups won't even allow you to change address without them. They are only Med Sup company I have ran into that won't.

 

[horskj]

Have you read the privacy of PHI section of HIPPA yet to answer your question? It states that the "business associates" of a covered entity (ie-agents) are covered under HIPPA too. As in, we cannot disclose information without the express written consent of the member. Not the same thing as obtaining info from member services.

It's not an information free-for-all to share info between the medical insurance company and the agent.



See the Business associate defined and business associate contract. As an agent, I have no need to know anything about my client's medical treatment or care. Sometimes, the client needs to do the work of calling their medical insurance provider on their own or conference-call with you.

Yes I have and here is a part of the HIPAA update

Covered entities may disclose protected health information to an entity in its role as a business associate only to help the covered entity carry out its health care functions – not for the business associate’s independent use or purposes, except as needed for the proper management and administration of the business associate.
How the Rule Works
General Provision. The Privacy Rule requires that a covered entity obtain satisfactory assurances from its business associate that the business associate will appropriately safeguard the protected health information it receives or creates on behalf of the covered entity. The satisfactory assurances must be in writing, whether in the form of a contract or other agreement between the covered entity and the business associate.
What Is a “Business Associate?” A “business associate” is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.
C A member of the covered entity’s workforce is not a business associate.
C A covered health care provider, health plan, or health care clearinghouse can be a business associate of another covered entity.
The Privacy Rule lists some of the functions or activities, as well as the particular services, that make a person or entity a business associate, if the activity or service involves the use or disclosure of protected health information. The types of functions or activities that may make a person or entity a business associate include payment or health care operations activities,
1
OCR HIPAA Privacy December 3, 2002 Revised April 3, 2003 as well as other functions or activities regulated by the Administrative Simplification Rules.
C Business associate functions and activities include: claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; benefit management; practice management; and repricing.
C Business associate services are: legal; actuarial; accounting; consulting; data aggregation; management; administrative; accreditation; and financial.

So as the AOR we meet this function in most cases I am opening all the doors for member services and allowing them to walk through them.
The amazing part here is Humana...once you are identified as the AOR will talk to you all day long, Aetna the same way.

Business associate defined and business associate contract

The addition of the business associate contract was added to insure that the business associate was the AOR.

 

[traceyemoon]

I get what you are saying, but as the AOR, I don't review their claims, billing goes through the insured and have nothing to do with anything to do with any medical care they are receiving. If they get double-billed or are waiting for their cards, no problem-they call me. Usually I don't have an issue getting that straightened out for them. Do a decent amount of conference calling. I also don't deal with Humana or Aetna (except in small groups and the occasional Short Term).

Utilization review? Benefit management? That sounds as though the carrier should handle that from where I sit. Or do you have a claims or medical background, or have worked for an insurer in a specific department?