Health and Benefits

Employee Advocacy Case Study – Carrier Confusion

Employee Advocacy

Employer-sponsored health insurance and group benefits can be confusing. It is important to have trusted advisors available to assist plan participants in understanding their coverage and navigating the claims process. RMC’s employee advocacy team is a live resource available to assist plan participants with any questions or issues they may experience while using their coverage.

Below is a recent example of RMC’s employee advocacy team stepping in to quickly resolve an issue that a plan participant experienced while filing a claim.

The Accident

An employee fell at home and suffered a serious bone fracture. The employee received immediate medical attention, and their employer-sponsored health insurance covered the initial setting of the bone and all necessary rehabilitation. Due to the severity of the break, the employee was directed by their doctor not to return to work for approximately 90 days to avoid aggravating the injury. Luckily, the employee’s employer also provided Short-Term Disability and Accident Insurance to replace some of the income lost during the rehabilitation period.

Trouble Filing the Claim

Unfortunately, filing the Short-Term Disability and Accident claim was not as straight forward as the employee had hoped. First, the employee attempted to contact the insurance company to start the paperwork for the Short-Term Disability and Accident Insurance claim. After two weeks without success the employee contacted their Human Resources Manager for assistance. Over the next week the HR Manager was also unsuccessful in initiating the claim. Finally, the HR Manager contacted RMC to ask for assistance.

The Resolution

Within ten minutes RMC’s employee advocacy team determined that the employee and HR Manager had been contacting the wrong insurance company. Instead of the contacting their current carrier, they were attempting to file a claim with a carrier they used several years ago. RMC contacted the current carrier and received confirmation of benefits and the forms required to file a claim right away.

RMC’s employee advocacy team assisted the employee in completing the forms and submitting the claim. The team was also able to streamline the claims submittal process, eliminating several unnecessary and redundant steps that resulted from poor communication between the carrier and employee. On the day following the claim submittal, the carrier informed RMC’s team that the Accident funds would be sent to the employee the next day and the Short-Term Disability funds would follow within a week.

The employee was extremely thankful to have this claim resolved. Now that the burden of financial uncertainty had been removed, their attention could be focused on what matters most: recovery. RMC’s “human touch” approach made all the difference!

Health and Benefits

Case Study: Narrow Network

How a narrow network enabled an assisted living facility in the rural South to increase healthcare access while saving costs

Is it possible for narrow network providers to actually increase access to healthcare coverage? In some cases, cost savings aren’t the only reason for employers to choose a narrow network. Under served, rural areas may slip through the cracks in wide networks. What can an employer do to ensure that employees in remote areas get the coverage they need? Specialized, locally-oriented narrow network care could be the answer.

The Problem

An assisted living facility in rural Florida, located outside Naples on the fringes of the Everglades, was having trouble finding a healthcare network that would cover its 250+ employees spread across multiple rural counties. These areas were under served by two major networks.

Wide networks aren’t always universal networks

It’s easy to mistake wide networks for universal networks.

For this facility, local health care providers were not included in the major networks. This meant that, in order for an employee to get needed care, they had to decide between a local out-of-network provider at increased cost or traveling a great distance to visit an in-network provider.

The Solution
How did a narrow network solve this rural facility’s healthcare problem?

With the help of a Naples-based healthcare system, the employer thought outside-the-box and put together a narrow network of healthcare providers.  This narrow network was comprised of local providers exclusively; the employees were now able to get in-network coverage from local primary care providers and avoid out-of-network costs.

What did a narrow network accomplish?

The employees were able to benefit from easy access to local healthcare providers, who guaranteed high-quality care at preferred rates. This meant that the covered employees enjoyed better care for less.

By guaranteeing a steady flow of local clients, the facility negotiated preferential rates with the providers, which allowed them to reduce costs compared to those of wide network providers.


According to a study by the Kaiser Family Foundation, only six percent of small-to-medium firms offer a narrow network healthcare plan to employees. That number is not much higher for larger firms. While there are challenges, choosing a narrow network can significantly reduce your overall insurance costs. Plus, if you do business in some of the more remote parts of the country, narrow networks can help employees get coverage they wouldn’t otherwise be able to access.

Health and Benefits

Case Study: Risk Segmentation

How a Midwestern firm used creative risk segmentation to provide health insurance coverage for an employee with chronic illness

The Problem

A Midwestern company with 100 employees across seven locations discovered that an employee in their Northeast office was disqualified from coverage under their new self-funded health plan. As a result, the company had to consider returning to a more costly fully-insured health plan for all employees.

The company did not discover this problem until it was able to analyze health data from their self-insured plan, which wasn’t available under their prior fully-insured carrier.

What is risk segmentation?

One way for companies to deal with higher risks is to segment groups into risk tiers and charge different premiums for each tier.

The Solution
How did the company implement risk segmentation?

By adopting a risk segmentation strategy, the Midwestern company was able to segment its Northeast office onto a fully-insured plan that covered the high-risk employee. Meanwhile, employees at the other six locations remained on the company’s self-insured health plan.

By removing the 16 employees in their Northeast office, the company had enough employees to meet the legal requirements to maintain a self-funded health plan.

As an added bonus, risk segmentation helped the company achieve significant savings.  By creatively structuring its self-funded health plan and segmenting out the Northeast location, the company realized greater underwriting profit. This savings went straight to the company’s bottom line.

Is risk segmentation right for your business?

To assess a self-insured health plan or risk segmentation is right for you, contact an RMC professional today.