The Role Of Advocacy In The Canadian Benefits Environment- by Kim Siddall at AQ Group Solutions (Benefits Canada)

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The role of advocacy in the Canadian benefits environment 

Kim Siddall  | July 12, 2013   (Benefits Canada)

AQ Group Solutions

The American benefits landscape has been the birthplace of a number of concepts and strategies that have migrated to Canada: targeted health population programs, wellness and prevention programs, and worksite health management all began in the U.S. With the high cost of healthcare, these programs and strategies are intended to reduce costs for employers, increase employee productivity and reduce the incidence of disability claims. A similar strategy, which is gaining more attention in the U.S. landscape, is benefits advocacy.

Benefits advocacy is at its core a conduit for employees to get assistance with claims submission and adjudication, navigate treatment and have their healthcare fees negotiated. While advocacy is a valued service by plan members, a significant side benefit of this service is the freeing up of time for HR, which is often called upon to resolve escalated issues or provide assistance to employees with claims questions or issues, distracting them from their core business objectives.

In Canada, advocacy is not a concept presently discussed in the context of benefits management. Often, when there’s an issue with a claim or a claimant, and the employee is unable to get satisfaction by going directly through an insurer’s call centre themselves, a representative of the plan sponsor is called upon to advocate for the employee about the escalated issue often during work hours. This can be a frustrating exercise for the organization’s representative for a number of reasons: they have a number of competing priorities, they don’t know who to speak to for support with the insurer, and the intricacies of the benefits plan contract is not their area of expertise.

Although this scenario can lead to a favourable resolution, it often presents a significant confidentiality problem for both the employer and employee: in order to provide their employer with the complete picture so that the issue can be resolved, an employee often must share personal details of a health issue. In doing so, the employer representative now has personal information about an employee that may prove problematic down the road.

For example, an employee is struggling with substance abuse and is trying to get his outpatient treatment paid for while he continues to work. His claim is not paid as expected, so he turns to the HR department for assistance and tells the representative of his substance issue. The HR representative works with the employee and the insurer to explain the situation and work toward a resolution for the employee. Later, the employer goes through a round of layoffs, and the employee is identified for layoff. He contends that he’s now being singled out because his employer knows about his substance issue. The employer now has a plausible deniability issue and may be legally challenged for the layoff decision.

Plan sponsors looking to formalize benefits advocacy for their employees should strongly consider using an independent third party to provide this service in order to maintain employee confidentiality and create an arm’s length separation for employee perceptions about the organization over unfavourable claims decisions. In the U.S., plan sponsors look to their benefits advisors to fulfill this role.

I expect that the role of advocacy is on the rise for Canadian employers and will broaden in scope. In addition to benefits advocacy increasing in both popularity and prevalence, other complementary forms of advocacy are likely to emerge for plan sponsors and their employees as well.

With the increasing complexity of the Canadian healthcare system, patient referrals to specialists, decentralized patient records and treatment teams, insurers and plan sponsors in Canada are starting to face pressure to provide some form of patient advocacy for employees and their families.

There are a number of options already available in the Canadian marketplace. However, they are sometimes quite specialized in the patients they assist (for example, those dealing with cancer treatment only) or exist outside of the group benefits plan arena for patients to locate and engage with when they are in the early stages of treatment. As our population ages and we as Canadians continue to struggle with healthcare navigation, this specialized form of advocacy will likely gain momentum in the near future and add to the value provided to employees through their benefits plans.

Kim Siddall is a principal with AQ Group Solutions, a benefits consulting and plan member advocacy firm. These are the views of the author and not necessarily that of Benefits Canada.