How HR Can Help Workers Become Better Advocates for Their Health

Healthcare benefits have become increasingly complex. Between preauthorization requirements, provider network restrictions, claim denials, rising out-of-pocket costs, and a growing array of healthcare choices, employees often struggle to navigate the system effectively.

As a result, organizations are recognizing that offering benefits is only part of the equation. Employees also need the knowledge, tools, and confidence to navigate their healthcare journey successfully. This creates an important opportunity for HR leaders. By promoting healthcare literacy and providing access to advocacy resources, HR can help employees make informed decisions, access quality care, improve health outcomes, and avoid unnecessary costs.

Employees who understand how to navigate preauthorizations, appeal denied claims, identify high-quality in-network providers, and know when to escalate issues are better positioned to maximize the value of their healthcare benefits. For employers, these capabilities can contribute to a healthier workforce, improved employee experience, and more sustainable healthcare spending.

Article: Benefits Complexity Is Becoming HR’s Next Healthcare Challenge

The Strategic Role of HR Leaders

While employees ultimately make their own healthcare decisions, HR leaders play a critical role in creating an environment where informed advocacy is possible. Healthcare benefits have become increasingly complex, and employees often turn to HR as their first source of guidance when faced with confusing insurance requirements, denied claims, or questions about provider quality.

Forward-thinking HR leaders can support healthcare advocacy in several ways.

Provide Healthcare Navigation Education

Many employees have never been taught how to navigate the healthcare system. HR can offer educational programs that cover:

• Understanding health plan design and coverage rules
• Preauthorization requirements
• How to read an Explanation of Benefits (EOB)
• Appeals and grievance processes
• In-network versus out-of-network care
• Healthcare cost transparency tools

Annual enrollment meetings, new hire orientation programs, and year-round benefits education campaigns can all serve as opportunities to reinforce these concepts.

Promote Available Advocacy Resources

Many organizations already provide resources that employees may not realize exist, including:

• Health plan case managers
• Nurse navigators
• Employee assistance programs
• Healthcare advocacy vendors
• Benefits service centers
• Ombudsman services
• Centers of excellence programs

Regular communication can increase awareness and use of these resources. HR does not have to become the employee's healthcare advocate; its role is to make sure employees know where to go for help.

Encourage Employees to Ask Questions

Employees often feel intimidated by healthcare providers, insurers, and complex medical terminology. HR leaders can help foster a culture that encourages employees to:

• Ask providers about treatment options and outcomes
• Request cost estimates before receiving services
• Verify network participation before scheduling care
• Seek second opinions for major diagnoses or procedures
• Challenge confusing bills or claim determinations

Fact Sheet: What to Know About Total Compensation Statements

Use Data to Guide Better Decisions

Many health plans and benefits partners provide quality and cost comparison tools. HR can help employees understand how to use these resources to identify:

• High-performing physicians and specialists
• Centers of excellence
• High-quality in-network hospitals
• Lower-cost sites of care for imaging, laboratory services, and outpatient procedures

Helping employees make informed provider choices can improve clinical outcomes while reducing unnecessary healthcare spending.

Establish Clear Escalation Pathways

When employees encounter complex healthcare challenges, they should know where to turn for assistance. HR can establish and communicate clear escalation processes that identify when employees should contact:

• Health plan member services
• A case manager or nurse navigator
• An internal benefits specialist
• A healthcare advocacy vendor
• An ombudsman
• State insurance regulators when appropriate

Creating a roadmap for escalation reduces frustration and helps employees resolve issues more efficiently.

Understanding Preauthorization Requirements

One of the most common sources of frustration for employees is the preauthorization process.

Many medical services, procedures, medications, and imaging studies require approval from a health plan before care is delivered. Employees often assume their physician's recommendation automatically guarantees coverage, only to discover later that authorization was required.

HR leaders can help employees understand:

• What preauthorization is and why health plans require it
• Which services typically require advance approval
• How to verify authorization status before receiving care

Understanding this process can help employees avoid unexpected bills, treatment delays, and unnecessary administrative challenges.

Navigating Appeals

A denied claim should not automatically be viewed as the final answer.

Many employees are unaware that they have formal appeal rights through their health plan. Denials may occur due to missing documentation, coding errors, incomplete clinical information, or disagreements over medical necessity.

HR can encourage employees to:

• Carefully review the denial explanation
• Gather supporting medical records and physician documentation
• Submit appeals within required timeframes
• Request external review when available
• Maintain records of all communications and correspondence

Recognizing When Escalation Is Necessary

Many healthcare issues can be resolved through routine customer service channels, but employees should understand when escalation becomes appropriate.

Potential escalation triggers include:

• Multiple unsuccessful attempts to resolve an issue
• Delays that could affect patient health or treatment
• Urgent medication access concerns
• Repeated administrative errors
• Lack of response to submitted appeals
• Questions involving patient safety or quality of care

Employees should also know the appropriate escalation pathways, which may include health plan case managers, benefits administrators, healthcare advocates, state insurance regulators, or ombudsperson programs.

The goal is not confrontation but effective problem-solving and timely access to needed care.

For more complex or persistent disputes, an ombudsperson may provide additional assistance. These professionals can help individuals understand their options, navigate complicated healthcare systems, and resolve disputes with payers and providers. HR leaders should make employees aware of any ombudsperson services available through their benefits or community resources.

Finding High-Quality In-Network Care

One of the most powerful ways employees can advocate for themselves is by selecting high-quality providers within their network.

Many employees focus primarily on convenience or physician referrals without considering quality metrics, outcomes data, or network status. As a result, they may face higher out-of-pocket costs or receive care from providers whose outcomes differ significantly from those of their peers.

HR and benefits leaders can encourage employees to evaluate:

• Network participation
• Board certifications
• Clinical outcomes and quality scores
• Patient experience measures
• Hospital and specialty center performance
• Total cost of care

Healthcare navigation tools, transparency platforms, and benefits advisors can help employees make more informed decisions before treatment begins.

Make Healthcare Literacy Part of the Employee Experience

Employees do not need to become experts in the healthcare system. They need to know what questions to ask, where to find reliable information, and when to seek help.

That makes healthcare literacy an important part of the employee experience — not simply an annual enrollment topic. HR can help by providing year-round education, making advocacy and navigation resources easier to find, and giving employees clear pathways for resolving problems with their health plans and providers.

As healthcare becomes more complex, helping employees become informed advocates for their own care can benefit both employees and employers. Employees gain greater confidence in navigating their benefits and making healthcare decisions, while organizations can support a better benefits experience and more sustainable healthcare spending.

David G. Epstein, MHL, SHRM-SCP, is the director of human resources and talent strategy for Mobilization for Justice in New York City.