I'm going to have you take the slightest shit this way?
One thing I don't have like I might mention you know contact our office we
have people who can provide assistance I don't have all of our numbers memorized
so like if you guys you know in the story you can like put that up on the
screen like OCI consumer affairs contact number that type of thing yeah
unfortunately we don't have like a good like 1-800 like health help or
something yeah it's like just know what it is yes I know that's as far as I
always get to like 1-800 I know but that's just confusing to like
rattle it off yeah it'd be great if it was actually 1-800-something that
would be a hundred something
so I'll just start with you know name title and what your world does okay Nathan
and the insurance commissioner for the state of Wisconsin and our office the
office of the commissioner of insurance regulates insurance companies in the
state so specific to health insurance can you provide some examples of health
insurance claim disputes that your office receives from Wisconsin residents
sure anytime there's there's a dispute over maybe coverage or whether claims
should be paid our office can help answer questions and help resolve those
issues we have a team of people on our consumer affairs team that are here to
help answer questions for people because we know health insurance can be
complicated and confusing and you know oftentimes people don't know where to
turn if they have questions about their health insurance or if they need help
resolving an issue or a coverage dispute with their health insurance
company and it's important to know that our office is here to be a resource and
we have people who are trained and experts in helping resolve coverage
issues or claim issues and so on the whole would you say it's common knowledge for
people that they can file a complete appeal a denial or dispute a claim
yeah unfortunately too many people just don't know what their rights are if
they do have a claim denied and there are ways for people to dispute a claim
denial or a coverage denial and our office can can help with that they can
help answer questions help people walk through that process and actually be a
resource in in helping file the necessary paperwork and kind of appeal a coverage
denial and you know try to get people the care and coverage that they need and
that they have a right to and unfortunately studies have shown that of all the
coverage and claim denials only a small percentage are appealed and that's
really because people don't know what their rights are people don't know that
there is a place where they can turn to answer questions to be a resource and
our office is here to help with that so switching gears a little bit can you
describe the authority OCI has over self-funded plans and any kind of
interactions OCI has with self-funded plans sure so again we know health
insurance is complicated it's confusing people oftentimes don't know where to
turn if they have questions or if they need assistance and what makes it even
more confusing for people is that health insurance is really regulated by a
number of different agencies at both the federal and state levels so for example
you have Medicare which is health insurance for older people that is
regulated at the federal level by CMS you have Medicaid which is public health
insurance for lower-income individuals people with certain disabilities and
that's regulated at the state level by the Department of Health Services but
then you also have the commercial market and in the commercial market you have
what's commonly referred to as the individual health insurance market that's
kind of the affordable care act market there's about a little over 300,000
people who are enrolled in coverage through that market and then you have
what's referred to often as the employer sponsored coverage and what a lot of
people don't understand if they have employer sponsored coverage is whether
that's fully insured coverage or whether that is self-funded coverage and so
oftentimes people will have a claim dispute or a coverage dispute and you
know they can contact our office we can provide assistance but if it's a self-
funded plan those plans are actually regulated by the federal Department of
Labor so that's that's a challenge because people don't always know the
difference between self-funded insurance or self-funded coverage and fully
insured so I guess you answered this a little bit but what do you do when
someone comes to you with a complaint about a self-funded plan? Sure so we
always encourage anyone who has a question or potential dispute with their
insurance company to contact our office we have a team of experts who are
trained in helping people answering questions resolving disputes now
sometimes we can provide direct assistance if a person has the type of
insurance that we directly regulate but if someone has health insurance coverage
through a self-funded plan then we will kind of hand them off do you like to
refer to as kind of a warm handoff to the Department of Labor because it's
the federal Department of Labor that actually regulates self-funded plans so
we still encourage people if you if you don't know if you have fully
insured coverage or self-funded coverage you can still contact our office we can
be a resource but we may end up kind of handing you off in terms of the
assistance that would be provided at the federal level instead of by our office
so because of that handoff I guess you don't necessarily see how some of
these are resolved yeah and that you know that frankly can be a challenge so for
example last year our consumer affairs team which is our team that really the
experts that help people if they have questions or any problems with their
health insurance company so our consumer affairs team provided assistance to over
1,600 people who call their office with issues with their health insurance now
the challenge is that about a quarter of those a little over 400 were self-funded
coverage so we did help those people you know make contact with the Department of
Labor and get the assistance that they need but ultimately that's outside of
our regulatory jurisdiction so we don't know how those those issues or disputes
are ultimately resolved is it your understanding that the Department of
Labor is pretty responsive because you are doing that warm handoff you do at
least have an idea that they're connected with someone that's our
understanding I mean we try to facilitate a warm handoff make sure people know
who they can contact at the Department of Labor and try to make that connection
as much as we can but one second action is made you know it's really up to
Department of Labor in terms of how they handle it from there
so as I've discovered talking to patients in many cases people have an
insurance card that has the name of an actual health insurance company on it
but they don't realize that they actually have a self-funded plan so for
example United Healthcare owns UMR and UMR is the third party administrator
how confusing is it for consumers to understand what kind of plan they have
what that means how difficult is it yes there's a lot of consumer confusion and
the system is you know admittedly very complicated and you know if you have
your health care coverage through your employer if you're fully insured you
would have an insurance card and it's the insurance company that essentially
bears the risk for paying for health care related claims if your employer
self-funds that coverage they usually still contract with an insurance company
or what's called a third party administrator and oftentimes as an employee
you still receive a card from the insurance company that is serving as
that third party administrator so from the employee experience you know you're
still paying claims sorry from the employee experience you're still paying
premium and you have cost sharing and really it looks the same whether you
have fully insured coverage or self-funded and again you know you have that card
that can be from an insurance company either way so you really don't know and
it's important for individuals who have coverage through their employer to
really understand that difference to really understand is this fully
insured coverage or is it self-funded coverage because the way those two
types of coverage are regulated are very different
one advocate I spoke with said some of this feels like it's designed to
escape kind of the how to navigate the system
what's your reaction to that I mean I think
we've heard comments made I know when the Affordable Care Act was being debated
and oftentimes in Congress and at the federal level when there have been
efforts to to enact major health insurance and health care reform you
often hear comments to the effect of we would never design a system like this
from scratch right it's there's so many different
government agencies that have regulatory oversight there's so much complexity
whether it's Medicare Medicaid individual insurance market
a group self-funded group fully insured you know all of those different types
of health care coverage have different regulatory bodies different rules
so it's really a system that you know if you're a consumer understandably it's
complicated it's confusing and you just don't know where to turn when you have
issues can you talk about OCI's oversight over pharmacy benefit
managers so a few years ago there was a law enacted that gave OCI a kind of
limited authority regulatory authority over pharmacy benefit managers so
pharmacy benefit managers or PBMs as we call them now have to be licensed by our
office and there are certain reporting and disclosure requirements and there are
also certain prohibitions on kind of what's called gay clauses so pharmacists
are now able to basically tell someone at the point of sale if there's a lower
cost option and using their insurance or just other lower cost options for paying
for their their pharmacy or their pharmaceuticals
I think there's more that we could do in terms of oversight of PBMs and
more that we could do in terms of addressing some of the kind of anti-consumer practices of PBMs
and I know there's been a lot of discussion about that in the legislature and the governor
actually in his state budget put forward a number of additional provisions that would
provided more consumer protections for people in terms of interacting with PBMs and making sure
they can get lower cost prescription drugs
and so your website says the goal of this increased oversight is to increase transparency control
cost protect consumers has it done that to your note you know the challenge is that
prescription drug pricing the prescription drug supply chain is so complicated and I think the
law that's been enacted to require PBM licensure and some level of oversight by our office
is an important step forward but there's more work that can be done and we all know that there's
more that needs to be done in terms of bringing down the price of prescription drugs overall
I think there's more that we could do at the state level we know at the federal level there's
been a lot of discussion and different prescription drug reform initiatives so
our office and the oversight that we have of PBMs has provided kind of an important step
but there's more steps that we need to take in order to really address the high cost of prescription
drugs would senator felds or I guess senate president felds kausky's bill
do more of what you're speaking of I know the senator's bill is really focused on addressing
some of the more concerning practices related to PBMs and really trying to make sure consumers
are protected and getting the lowest cost prescription drugs available to them in terms of
additional steps that can be taken I know governor evers also had provisions in his budget that
would have required PBMs to have a fiduciary duty he also would have required PBM brokers
and consultants to be licensed so I think there are more steps that we can take other states
also have have taken more action in terms of more oversight of PBMs so there's a lot of different
options out there and I think it's important that we have that conversation and really look at what
can we do to make sure ultimately the consumer benefits and kind of another consumer
information question you know there's also in addition to PBMs there's alternative funders
there's accumulator maximizer and sometimes all of these are so tangled up with one another and
and some of these are part of fully insured plans as well as self-funded plans again how
our consumers are supposed to make informed decisions again it's challenging for a consumer
because health insurance prescription drug coverage it's so complicated it can be so confusing
there are resources out there for people to turn if you do get your insurance through your employer
whether it's fully insured or self-funded your employer can provide information about your
benefit design and the types of prescription drugs that are covered the formulary so that
would be the first place to go in terms of getting information if you do have an interaction or
if you do have an issue with an insurance company you feel that a claim is being improperly denied
or a service is not being covered you can contact our office and we encourage people to contact
our office to help resolve those claim and coverage disputes is there anything else you would like
to add the other thing we like to always talk about is the importance of being aware of scams
you know there are a lot of health insurance and prescription drug scams out there so if people
receive a unsolicited phone call email text messages whatever it might be just be cautious
about that you know and and if you are contacted by someone who's trying to sell you insurance
coverage or prescription drug coverage um you know ask questions you can ask for their what's
called their npn other uh forget what it stands for anyway you can ask questions um to make sure
that it is a legitimate source that's contacting you and you can also contact our office and we can
help answer questions uh we just want to make sure that people don't end up signing up for
improper health insurance coverage improper prescription drug coverage and there's a lot of
people out there unfortunately who are trying to take advantage of people and so we just always
try to raise awareness and make sure people are being smart about them
um those are all the questions i have um one thing that um you know you don't have to answer but
i'm just curious because it's come up a couple times as i've been working on this um have you
learned of ai denials and is that at all a problem people have voice concerns about
uh what yeah what i would say is i mean i know there have been news stories about
health insurance companies that have been utilizing ai to essentially deny claims
and make decisions about coverage or or claim payments um but we you know two things one
insurance companies have to abide by the laws of the state regardless of how they're making
decisions about coverage or paying claims and whether that's using ai uh using a human you know
whatever that process is that they're using to make a decision they still have to follow the laws
of the state and if someone feels that their claim has been denied improperly again they can
contact our office and we recently put out a bulletin that essentially is a it's a bulletin
to all insurers in the state about how they should be using ai and using it in a way that
complies with the insurance laws and regulations of the state so essentially saying you know we know
ai is a new technology right we know companies are utilizing it across all lines of insurance
and there's a lot of benefit to consumers and we know that that's going to be a technology
of the future right but as companies are using this new technology they still have to make
sure they're complying with existing laws and regulations thank you sure extra uh question in
there yeah um that's all i have okay yeah