September 23, 2016
There are Certain Types of Medical Treatment Not Covered by Your Health Policy
When a serious medical need arises there are often multiple stages that one goes through on the path to recovery. For instance, a stroke victim may stay in a hospital for several days but then will be released to either the care of a family member or to a skilled care facility. Why? There is an indefinite period of time after a stroke that a stroke victim needs assistance with many daily activities. The hospital stay is part of health insurance. The assistance with daily activities is not part of a health insurance policy.
Example of possible needs beyond health insurance
- Acute Care – medical care aimed at treating physical problems directly in an attempt to permanently cure or control them. This is typically covered under a health policy.
- Skilled Nursing Care – services for those who require ongoing medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Some health insurance policies offer limited care in a skilled nursing facility, typically 20-60 days. Some do not include coverage for it at all.
- Long term care (LTC) – This type of care is not part of a health insurance policy. Insurance coverage for this is called LONG-TERM-CARE insurance. The goal of LTC is not to cure an illness, but to allow an individual to attain and maintain an optimal level of functioning. This type of care is designed to meet the medical, personal, and social needs of those who cannot fully perform many daily activities. When something happens that limits a person’s ability to carry out basic self-care tasks, LTC is needed. (The average annual cost to care for someone with a LTC need is between $30,000 and $70,000 annually. That’s why we all should have some type of LTC insurance coverage.)
November 29, 2012
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.
March 22, 2012
Use of PPO Networks Reduces Medical Bills
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!”
The Short Answer
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.
- CIGNA is your PPO network.
- When a doctor signs an agreement with CIGNA to be in their PPO then that doctor is agreeing to discount the cost of his services to anyone having a health insurance policy that participates in the CIGNA PPO network.
- When you go to a doctor in the CIGNA PPO the doctor sends the CLAIM to your insurance company. The doctor doesn’t care whether you’ve reached your deductible or not.
- Upon receiving the claim your insurance company discounts each service listed on the bill based upon the amount of discount agreed upon by the doctor.
- Your insurance company sends you an EXPLANATION OF BENEFITS (EOB) showing several things such as:
- the normal cost of the services you received
- the discount by the PPO
- the amount the insurance company paid to the doctor, if any
- the amount you owe
- You compare the doctor’s bill with the EOB from the insurance company to ensure you are being correctly billed and that you are getting discounts
A Tip on Tracking Doctor Bills
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.”
Missing an EOB?
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.
Help Has Arrived that Reduces Medical Bills
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%.
- A PPO network is not an insurance company. It is a separate organization.
- The discount applies even if you have not reached your deductible
- The doctors are obligated by contract to give you a discount
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.