Helping Navigate Health Insurance

Marin Independent Journal
Saturday, March 09, 2002
By Keri Brenner

(Reprinted with permission.)

Arsenio Abad didn't know what to do when his Kaiser Permanente insurance plan at work refused to pay more than $4,000 in medical bills from his wife's late-night visit to a non-Kaiser hospital emergency room last year.

So Abad, accounting manager for WestEd in Southern California, turned to a Marin company, CareCounsel LLC, of San Rafael, for help. Like more than 20 other companies or agencies, WestEd pays CareCounsel to mediate and expedite its employees' HMO or insurance-related questions and problems.

"They're able to help, especially when dealing with HMOs," Abad said. "If you didn't have someone to guide you, you'd be lost."

A CareCounsel staff member gave Abad guidelines for writing an appeal to Kaiser's denial of coverage. Using the guidelines, Abad wrote a draft and gave it to the staff person for review. He then sent a final copy to Kaiser. Kaiser officials agreed with his appeal arguments and paid the bills.

"The only thing I had to pay were some charges on my deductible," Abad said. "I'm very satisfied with (CareCounsel's) service."

Abad is one of more than 60,000 employees, retirees and their dependents at 22 companies around the country who have access to the free, telephone-based CareCounsel benefit. CareCounsel's fees - about $2 to $2.50 per employee per month - are paid by the employer.

Many employers feel they get the cost back in having happier employees and in lightening the burden of individual casework on their own human resource personnel, said Lawrence N. Gelb, CareCounsel president and chief executive.

"There's a real need for this," said Gelb, 50, of Tiburon. "If you look at the research, one survey found that 52 percent of the people interviewed had had at least one health care-related problem in the past year.

"Employers are spending a lot of money on benefits," he added, "and the last thing they want is their employees grumbling that the health plan stinks."

Workers who use CareCounsel also appreciate that their health care issues are kept private from the in-house human resource department, Gelb said.

Gelb, a licensed psychologist, founded CareCounsel in mid-1997 after noticing problems in the late 1980s and early 1990s as managed care was taking over in various clinical settings.

"It seemed to me that managed care was missing the mark in meeting consumer needs," said Gelb, who also has a master's degree in business administration from Harvard Business School. "It was all focused on a cost game."

CareCounsel, which broke even for the first time in 2001 and should turn a profit sometime in the near future, has been growing by about 50 percent every year since it started, Gelb said. Once the only game in town, CareCounsel now has a handful of competitors, mostly special employee advocacy divisions of major corporations.

"We started and pioneered this process," Gelb said. "Now, we're flattered that we're seeing some imitators."

Clients range from the City of San Diego Employees' Retirement Association to Oakland-based Cost Plus World Market, to the county of Santa Barbara, American Cancer Society, Bristol-Myers Squibb, Fairmont Hotels & Resorts and United Green Mark in Novato.

On March 1, CareCounsel added the 2,500-employee Beringer Vineyards in St. Helena to its client list.

"We've been growing entirely by word of mouth," said Gelb, who employs eight staffers. "We have no sales staff."

Each of the major health insurance plans has an "Achilles heel," Gelb added, and CareCounsel is familiar with each one and how to navigate around it.

For example, Gelb said, one major insurance plan may require enrollees to use a plan-recommended specialist, but often that particular doctor is not taking new patients.

Kelley Cope, benefits administrator at Cost Plus World Market, said CareCounsel takes some of the pressure off her in her job by doing the time-consuming customer service calls for the company's more than 1,800 employees.

"It helps me out a whole lot," said Cope, one of only two or three people in her department. "It's faster. It will take me two days to get back to my employees, because of the number of calls.

"The employees get an advocate for themselves and it's all confidential," she added. "The only time I get involved is if there's a question on eligibility."

Cost Plus started with CareCounsel in November, Cope said.

Gelb said most of his clients report that at least 20 percent of their employees use the service every year. Of those employees who have used the service, many - like Abad at WestEd - are so grateful that they send in dozens of testimonial letters to CareCounsel's San Rafael office.

"It's amazing," Gelb said, "how much people appreciate having a confidential, independent coach they can turn to when they are trying to use the health care system."

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