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Top 4 Ways to Prevent Health Insurance Claims Problems

November 29, 2012 by helpinsureus

Of the many health insurance companies I represent, the following guidelines are valid for each. Here are four steps you can take to help minimize any “claims surprises.” Follow these steps and you may be stress-free.

  • Never rely on the assumption that a certain benefit is covered or that a particular health provider belongs to your HMO or PPO. Always double-check on whether the benefits, services or providers you need are covered before you go to get treatment. You can do this by calling your health plan’s customer-service department. Remember to take notes. Get the representative’s name and write it down, along with the date, time and general details of your conversation.  Keep these notes with your policy. If a claim problem arises and you need to file a grievance, these notes will come in handy. Most insurers customer-service phone calls are tape recorded. Having the date and time of your call will make locating your call history with the representative much easier.

  • Should you have a problem with a claim, call the insurance company CLAIMS DEPARTMENT and ask for an explanation. Again, remember to take detailed notes.

  • If the explanation is not consistent with your understanding of your health benefits, call your agent. Because of their position and their greater knowledge of the health plan details, they might be able to quickly resolve your problem.

  • If you have a claim problem that’s unresolved, file a grievance with your health plan. If you get a denial, don’t give up. In many states, the complaint eventually goes before a state sponsored grievance committee that’s outside the plan (an “external review”) or a “peer review committee” of other health care professionals. There’s always a chance the denial might be reversed.

Otherwise, your health plan is regulated by your state’s insurance department. Your state has a complaint procedure that will trigger an investigation into your problem.

You are Not Paranoid! Your Confusing Health Policy is on Purpose

March 4, 2012 by helpinsureus

Please Say What You Mean

About a generation ago it became fashionable to put fancy titles to common jobs. Janitor became maintenance engineer; stewardess became flight attendant; receptionist became front office administrator; used car salesman became transportation specialist. These days the health insurance companies have decided they want into the act. Most of them have begun misusing the term out-of-pocket maximum (OOPM).  The result is that people are being confused and the insurance company continues a tradition of selling a confusing health policy.

Please tell me – when you hear an insurance company says the words out-of-pocket maximum what do you think? Silly question, you say? Of course, it’s the maximum of out-of-pocket that you will have to pay on your medical expenses.  “Not so!” replies the insurance company. Are they purposefully trying to deceive people with that wording?

Using a real life example, let’s listen in to a conversation between an agent and his new customer.

Agent: “Ok, John, your new policy will have a $3,000 deductible and a $5,000 out-of-pocket maximum.”

John:  “Great! So if I land in the hospital it will only cost me $5,000, right?”

Agent:  “No, the $5,000 is your out-of-pocket maximum.”

John:  “Isn’t that what I said?”

Agent: “If you land in the hospital it will cost you $8,000.”

John:  “I thought you said my OOPM is $5,000.”

Agent: “It is!”

John: “What?”

Get the idea?  It’s like listening to Abbott and Costello doing their “Who’s on First?” comedy routine. See their hilarious skit here:


No More Confusing Health Policy Terms

Let’s set this straight. Other than copays and preventive care:

  • The deductible is the amount you pay before the policy begins paying.
  • Co-insurance is the amount you and the insurance company share in paying after the deductible. Generally, after the deductible the policy pays 80% and you pay 20%. Like the deductible, there is a limit set on coinsurance. This is now what they are calling OOPM.
  • OOPM is – well, should be – the combination of your deductible AND the shared amount.

To avoid confusing a client and getting wrapped up in a Who’s on First dialog, I do not use the term OOPM as defined by insurance companies today. To do so would be like continuing a ruse.

I use the term Total Out-of-Pocket and I explain that it’s a combination of the deductible and coinsurance or shared amount. In a nutshell, all the client really wants to is how much it will cost them if they land in the hospital. Keep it simple.


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