Not every employee takes a job or keeps it because it’s the highest pay level available. Although money plays a big part in many individuals' satisfaction with their employment, health insurance is a significant draw. In fact, more than half of adults in the United States with employer-sponsored health benefits say whether or not they like their health coverage is a key factor in deciding to stay at their current job.

Group health insurance plans were established to provide coverage to a group of members, typically consisting of company employees or members of an organization. These plans, which can’t be purchased by individuals, enable members to receive insurance at a reduced cost because the insurer’s risk is spread across a group of policyholders. Depending on the employer or organization, coverage of group health plans (GHP) can include members’ families. By providing health insurance to employees through a group plan, employers usually receive tax benefits.

GHP Industry Overview

Almost half of U.S. employees have employer-sponsored group health insurance, with the average policy for single coverage in 2020 being $7,470. Of this total, employers paid – on average – 83 percent, or $6,227 annually. The average family coverage policy in 2020 totaled $21,342 annually, with employers contributing about 75 percent.

There are three most common types of group health insurance policies: health maintenance organizations (HMOs), preferred provider organizations (PPOs) and exclusive provider organizations (EPOs). A majority of private-sector group health plans are covered by the Employee Retirement Income Security Act, which provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information.

Group health insurance has been available for many years but was not required for employers with 50 or more full-time employees until the enactment of the Patient Protection and Affordable Care Act. These “applicable large employers” that don’t offer adequate health coverage are subject to assessment if their employees receive premium tax credits to buy their own insurance. Small businesses with fewer than 25 employees may be eligible for a tax credit for purchasing health insurance for their employees.

In addition to spreading risk over multiple insured individuals, group health plans enable employers to attract and retain the most qualified employees. Approximately 30 percent of employees report being unlikely to look for an external position because of their benefits package, and four-in-five employees prefer benefits or perks over a pay raise.

One study found that 88 percent of workers say they would give the benefit of “better health, dental and vision insurance” “some or heavy consideration” before accepting a job. Another reported that businesses that strategically leverage benefits to recruit employees are almost twice as likely to have more satisfied employees and report better business performance than those that don’t.

On the flip side, employers offering group health insurance may have to handle the administrative tasks associated with it. They also are responsible for selecting which insurer to use. Plus, the option can be expensive for small businesses, especially with group health plans becoming 15 percent more expensive over the past two years in some states.

Reasons for Specialized Medical Review

In cases where specialized medical review is needed to review a group health claim, often the services of an independent review organization (IRO) are sought. The IRO might be tasked with conducting a utilization review, which is designed to help payers improve coordination of care, verify members receive high-quality, medically necessary care and improve organizational oversight.

In other cases, an IRO may be asked to perform a physician-level review of medical records. This process is employed by payers to determine whether or not to uphold a denial of coverage for a specific claim. It has similarities to the process of drug utilization review (DUR), which payers utilize to assess the necessity and safety of drugs and/or medication regimens.

Some small to mid-sized health plans only have two or three physicians on staff, so partnering with an IRO gives them the extra resources to handle specialized medical reviews. Other payers collaborate with IROs for increased regulatory compliance, both at the federal and state levels.

At the MLS Group of Companies, we ensure timely, accurate and evidence-based reviews from a nationwide, specialized network of physician reviewers and other allied health professionals. Our federal and state-level peer reviews are conducted by board-certified, actively practicing physicians versed in the latest medical research and current guidelines for medical care.

MLS offers independent medical review for a variety of areas, including medical necessity, experimental/investigational, standard of care, plan language review, length of stay, quality of care and more.

Contact us today if you’re interested in joining our physician reviewer network!

IROs: a Reliable Resource for Group Health Insurance Providers