What’s changing with with your health savings account
Increased penalty on a health savings account
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.
Jacki called. She asked why she was getting a big bill from the doctor. Wasn’t her health insurance supposed to pay for it? “I thought having health insurance would reduce my medical bills!”
It’s a common question, especially from people who do not go to the doctor very often. How does a PPO network work with your insurance plan? How does it save you money? It’s simple really. Go to a doctor in your PPO network – get a discount. Go to a doctor not in your PPO – pay retail. Your choice.
Here’s a basic outline of the way it works when you go to a doctor that is in your PPO network. Let’s use the following example.
When I get a bill from ANY healthcare provider I hold on to it until I receive the EOB from my insurance company. Among other things, I want to see what services were charged and how much of a discount I received. The EOB also tells me how much was paid to the doctor by my insurance policy and finally how much I owe. The amount that I owe is shown on the EOB as “patient responsibility.”
If you don’t get an EOB then it’s either because the doctor’s office either has not submitted the claim OR the insurance company told them to correct it and re-submit it.
You see, by law the insurance company must complete a claim in 30 days UNLESS there has been a problem with the claim, such as the claim having errors from the doctor’s office or missing vital info.
For just a few dollars per month you can have the services of the KARIS GROUP. They will help you with negotiation on any medical issues dealing with any provider. They will assist you in getting help paying off medical bills – even ones that you have NOW – and will negotiate major discounts for you. They will also shop around and find you the best value for medical services you need. And more…
They claim their service reduces medical bills by as much as 60%.
There are probably other things that may cause you to have questions about insurance. Hey, if it wasn’t complicated we insurance advisers wouldn’t have to spend hundreds of hours studying it.
Feel free to call or email me with questions or just leave a comment in the box below.
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!”
Get the idea? It’s like listening to Abbott and Costello doing their “Who’s on First?” comedy routine. See their hilarious skit here:
Let’s set this straight. Other than copays and preventive care:
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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