NEW YORK -- May 23, 2008--"A settlement has been proposed in a class action lawsuit involving Health Net, also formerly known as Physicians Health Services, PHS, and First Option Health Plan. The Settlement will provide up to $215,000,000.00 for payments to subscribers or beneficiaries of various Health Net Plans from July 1995 to July 2007. If you qualify, you may send in a claim form to get benefits, or you can exclude yourself from the Settlement, or object to it. The United States District Court for the District of New Jersey authorized this Notice. Before any money is paid, the Court will have a hearing to decide whether to approve the settlement."
The link for more information on this matter is here:
http://www.insurancenewsnet.com/article.asp?n=1&neid=20080523290.2_de5101890833b0c9
Friday, June 27, 2008
National Scandal: Number of Underinsured up 60%
This is a national scandal: the number of Underinsured is up 60% last year (over 2003) -- and we have about 47 million Americans who are completely UNinsured.
Read more about it here, from a report by the Commonwealth Fund.
Read more about it here, from a report by the Commonwealth Fund.
Book Review, "Who Killed Health Care?"
Found another great book review by the same person on Newsvine. This book is by Regina Herzlinger and is titled, "Who Killed Health Care?" Believe it or not, your parents or grandparents remember a time when you didn't have to mortgage your home to pay for your hospital bill.
Read more here and tell 'em I sent ya.
Read more here and tell 'em I sent ya.
Great Book Review, "American the Uninsured"
Please go read this great book review on the history of the American health insurance industry and just it is that ours is the only major country WITHOUT national health care. We could have instituted a national program back in 1919 but..Oh, I'll let you read it yourselves.
I found it on a wonderful website called Newsvine that has lots of good articles, seeds, and commentary on lots of current events. Go here to read the review. Ciao!
I found it on a wonderful website called Newsvine that has lots of good articles, seeds, and commentary on lots of current events. Go here to read the review. Ciao!
Thursday, June 26, 2008
RECOMMENDED READING AND SOURCES:
RECOMMENDED READING AND SOURCES:
“Accounting for the Cost of Health Care in the United States,” McKinsey Global Institute, http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp
Alzheimers Reading Room, web log with a variety of info for caregivers, http://alzheimersreadingroom.blogspot.com/2007/08/training-helps-alzheimers-caregivers.html
Appeal letters available for a fee at Health Symphony website, http://www.healthsymphony.com/
Barton, Laura, “A hug a day keeps the doctor away,” The Age, July 31, 2007, http://www.theage.com.au/news/health/a-hug-a-day-keeps-the-doctor-away/2007/07/31/1185647872383.html?page=fullpage#contentSwap1
Bazell, Robert, “The costly side effects of Nexium's ad blitz” MSNBC.com, Aug 14, 2007, http://www.msnbc.msn.com/id/20249591/
Bolen, Jennifer, “Exposing the Department of Health and Human Services/American Medical Association Health Care Monopoly”, Townsend Letter, Feb-March 2007 issue, http://www.townsendletter.com/FebMarch2007/exposeama0207.htm
Boseley, Sarah, Government warning on DIY cancer treatments, The Guardian, April 28, 2008, http://www.guardian.co.uk/society/2008/apr/28/health.cancer.
Boseley, Sarah, “NHS GPs at new Virgin health centres will get 10% of profits”, The Guardian, April 9, 2008, http://www.guardian.co.uk/society/2008/apr/09/nhs.health2
Boseley, Sarah, “Three more deaths at 'special measures' maternity hospital”, The Guardian, April 15, 2008, http://www.guardian.co.uk/society/2008/apr/15/health.nhs.
Boseley, Sarah, “Tranquillisers putting children's lives at risk”, The Guardian, April 7, 2008, http://www.guardian.co.uk/society/2008/apr/07/mentalhealth.drugs.
Butki, Scott, “An Unhappy Pharmacy Visit,” Newsvine.com, http://sbutki.newsvine.com/_news/2007/06/29/810673-an-unhappy-pharmacy-visit
Carvel, John, “GPs to provide 5-year health checks for all aged between 40 and 74”, The Guardian, April 2, 2008. http://www.guardian.co.uk/politics/2008/apr/02/health.nhs
Carvel, John, Nurses 'spend 1m hours a week on bureaucracy', The Guardian, April 28, 2008, http://www.guardian.co.uk/society/2008/apr/28/nhs.health.
Carvel, John, “Patients who go to A&E instead of local surgery could cost Gps 1B pounds” http://www.guardian.co.uk/society/2008/apr/17/nhs.health, The Guardian, April 17, 2008.
Chang, Alicia, “Many doctors say L to e-mail”, Chicago Tribune (via AP), April 22, 2008, http://www.chicagotribune.com/news/chi-doctor-emailapr23,0,6511095.story.
“Changes Ahead for Medicare Drug Program,” AP wire story by Kevin Freking, November 4, 2007, http://www.newsvine.com/_news/2007/11/03/1070133-changes-ahead-for-medicare-drug-program?threadId=171361&cmt=1156346#c1156346COBRA law explained: http://www.dol.gov/dol/topic/health-plans/cobra.htm
Coding for billing Acupuncture services, Acupuncture Today, Feb. 2005,
http://www.acupuncturetoday.com/mpacms/at/article.php?id=30032&MERCURYSID=918c70b396ad0a2c4cec8b179efa75c8.
Coding for billing Nutritionist services, please see their 2007 bulletin at . http://www.eatrightnc.org/PDF2007/CodesInsert.pdf
Coding for billing Vitaflo products (enteral and parenteral supplies) at http://www.vitaflousa.com/content.aspx?PFAlias=howtoorderbillingcodesERISA law explained: http://www.dol.gov/dol/topic/health-plans/erisa.htm
Gratzer, David, “The Ugly Truth About Canadian Health Care,” City Journal, Summer 2007, Gratzer is biased against the whole nationalized healthcare concept and has taken aim at the problems of Canadian & other single-payer systems; he proposes vouchers and a two-tier system: http://www.city-journal.org/html/17_3_canadian_healthcare.html
Foster, Kate, “Open all-hours plan for Scottish doctors”, Scotland on Sunday, Feb. 3, 2008, http://scotlandonsunday.scotsman.com/latestnews/Open-allhours-plan-for-doctors.3739044.jp.
Health Symphony, an online resource that includes appeal letters, at http://www.healthsymphony.com/
Health Care Crisis in America, Michael Moore’s appearance on Oprah, 2007, http://www2.oprah.com/world/health/slide/20070927/health_284_101.jhtml
“Health Care Options at a Glance” compares Canada, U.K., France and U.S. systems, Yes Magazine website, http://www.yesmagazine.org/article.asp?ID=1515
The Henry J. Kaiser Family Foundation for reports on a health benefits survey and health care costs at http://www.kff.org/insurance/index.cfm
The Henry J. Kaiser Family Foundation at
http://www.kff.org/uninsured/upload/7651.pdf for a policy brief on Medicaid and the Uninsured, “Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Adults”
Herzlinger, Regina E. , Who Killed Health Care? June 2007 and her article “Who Killed U.S. Medicine?” in the Washington Post July 25, 2007 at http://www.washingtonpost.com/wp-dyn/content/article/2007/07/24/AR2007072401850.htmlHIPAA law explained: http://www.dol.gov/dol/topic/health-plans/portability.htm -- also at HIPAA.org
Holstein, William, “A Drug Maker’s Views of What Ails Health Care”, NY Times, September 8, 2007
http://www.nytimes.com/2007/09/08/business/08interview.html?_r=1&ref=health&oref=slogin
Insurance Transparency Project - All the riveting insurance industry news you can stand, http://insurancetransparencyproject.com/general-theory-of-insurance-transparency/
“Industry wouldn't fund cancer drug, so Alberta town rode to the rescue,” CBC News, October 4, 2007
http://www.cbc.ca/health/story/2007/10/04/fundraising-dca.htmlInsurance coverage for families www.coveringkidsandfamilies.org, from the Robert Wood Johnson Foundation
Insure Kids Now at www.insurekidsnow.gov, where parents click on their state and enroll their children automatically in that state’s children’s health insurance program.
Komen Foundation, Cancer Care Partnership Helps Qualified Patients Meet Some Costs Associated with Breast Cancer Treatment, Assistance Grants ($300) for Medication, Lymphadema Care, Medical Equipm’t, http://cms.komen.org/komen/NewsEvents/KomenNews/CancerCare?ssSourceNodeId=298&ssSourceSiteId=Komen
Krugman, Paul, “Health Care Excuses,” New York Times Op-Ed column, Nov. 9, 2007, http://www.nytimes.com/2007/11/09/opinion/09krugman.html?hpLetters of Medical Necessity, (samples of), see Dr. Bach website at http://www.doctorbach.com/letters/
Meikle, James, “Let dads bond with newborns, says study”, The Guardian, April 14, 2008 http://www.guardian.co.uk/society/2008/apr/14/children.health
Miller, Jennifer, “Federal government taps ancient healing methods to treat native American soldiers,” Christian Science Monitor, Sept. 13, 2007, http://www.csmonitor.com/2007/0913/p20s01-usmi.html
Neergaard, Lauran, “Training Helps Alzheimer's Caregivers,” Washington Post, August 12, 2007, http://www.washingtonpost.com/wp-dyn/content/article/2007/08/12/AR2007081200509_pf.html
Newborns' & Mothers' Protections (Newborns' Act): (Maternity coverage must pay for at least a 48-hr hospital stay.) http://www.dol.gov/dol/topic/health-plans/newborns.htm
Pear, Robert, “Medicare Audits Show Problems in Private Plans,” Oct. 7, 2007, New York Times, http://www.nytimes.com/2007/10/07/us/07medicare.html?_r=1&hp=&adxnnl=1&oref=slogin&adxnnlx=1191729902-/QFjVc2aBDuzO96/FhKk9gPrescription Drugs: What’s the Issue?, an essay on Open Secrets dot org, http://www.opensecrets.org/news/drug/index.htm
Quadragno, Jill, book “One Nation, Uninsured” 2005, published by Oxford University Press. You can read an excellent review of this book on Newsvine on my column. If link does not work use this URL -- http://minnieapolis.newsvine.com/_news/2007/10/27/1054611-one-nation-uninsured-analyzes-a-century-of-failure-to-enact-a-national-health-plan-in-spite-of-public-support-book-review
Ruttley, Marilyn, Henderson hospital threatened with closure - blog, 4-10-08, http://blogs.guardian.co.uk/joepublic/2008/04/vulnerable_people_troubled_by.html.
Slota, Linda, “Training Goes a Long Way for Alzheimer's Spouses” at Christopher Heights.com webpage, http://www.christopherheights.com/page/AlzheimerTraining.cfm
StopHospitalInfections.org. We are all at risk because we cannot judge the relative safety of our hospitals. Consumers Union has developed a selection of Internet-ready public service announcements that can be used to link to StopHospitalInfections.org from any web site. Just click on the links below or scroll down the page to get started. Thanks again for your help!
The Internet Health Library, excellent resource for studies, etc. at http://www.internethealthlibrary.com/
The Medical Insurance Store online -- Includes “Five Ways to Cut Your Health Insurance Costs” & many other topics written at a basic level at http://www.medicalinsurancestore.info/Options%20for%20Those%20Who%20Cannot%20Afford%20Health%20Insurance.php
Pear, Robert, “Medicare Audits Show Problems in Private Plans,” New York Times, October 7, 2007, http://www.nytimes.com/2007/10/07/us/07medicare.html?_r=1&hp=&adxnnl=1&oref=slogin&adxnnlx=1191729902-/QFjVc2aBDuzO96/FhKk9g
Quammen, David, “Deadly Contact: How Animals and Human Exchange Disease,” National Geographic, (unknown date) http://magma.nationalgeographic.com/ngm/2007-10/infectious-animals/quammen-text.html
Sosnowski, Laura A, “Minnesotans Fight Hi Cost of Healthcare With Databases, Walk-in Clinics”, Nov. 2007,
http://minnieapolis.newsvine.com/_news/2007/11/12/1092663-minnesotans-fight-hi-cost-of-healthcare-with-databases-walk-in-clinics#dynamicCommentBox_1180552
Travel insurance website at www.insuremytrip.com. Companies that offer travel insurance are CSA Travel Protection, Access America, and AIG Travel Guard . Carefully compare the terms and conditions of each plan before making your final selection. Check first if you are covered under your credit card or homeowner’s insurance.
Vamosi, Robert, “Security Watch: Spam that just might kill you,” (about fake prescription drugs sold over the Internet) MSN.com, undated, http://tech.msn.com/security/articlecnet.aspx?cp-documentid=5406724&page=1
Whitman, Glen, “Hazards of the Individual Health Care Mandate,” Cato Policy Report, Fall 2007, http://cato.org/pubs/policy_report/v29n5/cpr29n5-1.html
“Why Obama, Edwards, Hillary, Romney, Schwarzenegger Don’t Support Single Payer? It Would Mean the Death of the Health Insurance Industry, and Reduced Profits for Big Pharma,” Corporate Crime Reporter, 1209 National Press Bldg., Washington, D.C. 20045, 202.737.1680, February 21, 2007, http://www.corporatecrimereporter.com/pnhp022107.
Health & Cancer Rights Protections: (Reconstructive surgery is covered as a post-mastectomy benefit.)
http://www.dol.gov/dol/topic/health-plans/womens.htm
“World’s Best Medical Care?”, NY Times editorial, August 12, 2007
http://www.nytimes.com/2007/08/12/opinion/12sun1.html?ei=5124&en=44da5cf6d4bf91c6&ex=1344571200&partner=newsvine&exprod=newsvine&pagewanted=print
“Accounting for the Cost of Health Care in the United States,” McKinsey Global Institute, http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp
Alzheimers Reading Room, web log with a variety of info for caregivers, http://alzheimersreadingroom.blogspot.com/2007/08/training-helps-alzheimers-caregivers.html
Appeal letters available for a fee at Health Symphony website, http://www.healthsymphony.com/
Barton, Laura, “A hug a day keeps the doctor away,” The Age, July 31, 2007, http://www.theage.com.au/news/health/a-hug-a-day-keeps-the-doctor-away/2007/07/31/1185647872383.html?page=fullpage#contentSwap1
Bazell, Robert, “The costly side effects of Nexium's ad blitz” MSNBC.com, Aug 14, 2007, http://www.msnbc.msn.com/id/20249591/
Bolen, Jennifer, “Exposing the Department of Health and Human Services/American Medical Association Health Care Monopoly”, Townsend Letter, Feb-March 2007 issue, http://www.townsendletter.com/FebMarch2007/exposeama0207.htm
Boseley, Sarah, Government warning on DIY cancer treatments, The Guardian, April 28, 2008, http://www.guardian.co.uk/society/2008/apr/28/health.cancer.
Boseley, Sarah, “NHS GPs at new Virgin health centres will get 10% of profits”, The Guardian, April 9, 2008, http://www.guardian.co.uk/society/2008/apr/09/nhs.health2
Boseley, Sarah, “Three more deaths at 'special measures' maternity hospital”, The Guardian, April 15, 2008, http://www.guardian.co.uk/society/2008/apr/15/health.nhs.
Boseley, Sarah, “Tranquillisers putting children's lives at risk”, The Guardian, April 7, 2008, http://www.guardian.co.uk/society/2008/apr/07/mentalhealth.drugs.
Butki, Scott, “An Unhappy Pharmacy Visit,” Newsvine.com, http://sbutki.newsvine.com/_news/2007/06/29/810673-an-unhappy-pharmacy-visit
Carvel, John, “GPs to provide 5-year health checks for all aged between 40 and 74”, The Guardian, April 2, 2008. http://www.guardian.co.uk/politics/2008/apr/02/health.nhs
Carvel, John, Nurses 'spend 1m hours a week on bureaucracy', The Guardian, April 28, 2008, http://www.guardian.co.uk/society/2008/apr/28/nhs.health.
Carvel, John, “Patients who go to A&E instead of local surgery could cost Gps 1B pounds” http://www.guardian.co.uk/society/2008/apr/17/nhs.health, The Guardian, April 17, 2008.
Chang, Alicia, “Many doctors say L to e-mail”, Chicago Tribune (via AP), April 22, 2008, http://www.chicagotribune.com/news/chi-doctor-emailapr23,0,6511095.story.
“Changes Ahead for Medicare Drug Program,” AP wire story by Kevin Freking, November 4, 2007, http://www.newsvine.com/_news/2007/11/03/1070133-changes-ahead-for-medicare-drug-program?threadId=171361&cmt=1156346#c1156346COBRA law explained: http://www.dol.gov/dol/topic/health-plans/cobra.htm
Coding for billing Acupuncture services, Acupuncture Today, Feb. 2005,
http://www.acupuncturetoday.com/mpacms/at/article.php?id=30032&MERCURYSID=918c70b396ad0a2c4cec8b179efa75c8.
Coding for billing Nutritionist services, please see their 2007 bulletin at . http://www.eatrightnc.org/PDF2007/CodesInsert.pdf
Coding for billing Vitaflo products (enteral and parenteral supplies) at http://www.vitaflousa.com/content.aspx?PFAlias=howtoorderbillingcodesERISA law explained: http://www.dol.gov/dol/topic/health-plans/erisa.htm
Gratzer, David, “The Ugly Truth About Canadian Health Care,” City Journal, Summer 2007, Gratzer is biased against the whole nationalized healthcare concept and has taken aim at the problems of Canadian & other single-payer systems; he proposes vouchers and a two-tier system: http://www.city-journal.org/html/17_3_canadian_healthcare.html
Foster, Kate, “Open all-hours plan for Scottish doctors”, Scotland on Sunday, Feb. 3, 2008, http://scotlandonsunday.scotsman.com/latestnews/Open-allhours-plan-for-doctors.3739044.jp.
Health Symphony, an online resource that includes appeal letters, at http://www.healthsymphony.com/
Health Care Crisis in America, Michael Moore’s appearance on Oprah, 2007, http://www2.oprah.com/world/health/slide/20070927/health_284_101.jhtml
“Health Care Options at a Glance” compares Canada, U.K., France and U.S. systems, Yes Magazine website, http://www.yesmagazine.org/article.asp?ID=1515
The Henry J. Kaiser Family Foundation for reports on a health benefits survey and health care costs at http://www.kff.org/insurance/index.cfm
The Henry J. Kaiser Family Foundation at
http://www.kff.org/uninsured/upload/7651.pdf for a policy brief on Medicaid and the Uninsured, “Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Adults”
Herzlinger, Regina E. , Who Killed Health Care? June 2007 and her article “Who Killed U.S. Medicine?” in the Washington Post July 25, 2007 at http://www.washingtonpost.com/wp-dyn/content/article/2007/07/24/AR2007072401850.htmlHIPAA law explained: http://www.dol.gov/dol/topic/health-plans/portability.htm -- also at HIPAA.org
Holstein, William, “A Drug Maker’s Views of What Ails Health Care”, NY Times, September 8, 2007
http://www.nytimes.com/2007/09/08/business/08interview.html?_r=1&ref=health&oref=slogin
Insurance Transparency Project - All the riveting insurance industry news you can stand, http://insurancetransparencyproject.com/general-theory-of-insurance-transparency/
“Industry wouldn't fund cancer drug, so Alberta town rode to the rescue,” CBC News, October 4, 2007
http://www.cbc.ca/health/story/2007/10/04/fundraising-dca.htmlInsurance coverage for families www.coveringkidsandfamilies.org, from the Robert Wood Johnson Foundation
Insure Kids Now at www.insurekidsnow.gov, where parents click on their state and enroll their children automatically in that state’s children’s health insurance program.
Komen Foundation, Cancer Care Partnership Helps Qualified Patients Meet Some Costs Associated with Breast Cancer Treatment, Assistance Grants ($300) for Medication, Lymphadema Care, Medical Equipm’t, http://cms.komen.org/komen/NewsEvents/KomenNews/CancerCare?ssSourceNodeId=298&ssSourceSiteId=Komen
Krugman, Paul, “Health Care Excuses,” New York Times Op-Ed column, Nov. 9, 2007, http://www.nytimes.com/2007/11/09/opinion/09krugman.html?hpLetters of Medical Necessity, (samples of), see Dr. Bach website at http://www.doctorbach.com/letters/
Meikle, James, “Let dads bond with newborns, says study”, The Guardian, April 14, 2008 http://www.guardian.co.uk/society/2008/apr/14/children.health
Miller, Jennifer, “Federal government taps ancient healing methods to treat native American soldiers,” Christian Science Monitor, Sept. 13, 2007, http://www.csmonitor.com/2007/0913/p20s01-usmi.html
Neergaard, Lauran, “Training Helps Alzheimer's Caregivers,” Washington Post, August 12, 2007, http://www.washingtonpost.com/wp-dyn/content/article/2007/08/12/AR2007081200509_pf.html
Newborns' & Mothers' Protections (Newborns' Act): (Maternity coverage must pay for at least a 48-hr hospital stay.) http://www.dol.gov/dol/topic/health-plans/newborns.htm
Pear, Robert, “Medicare Audits Show Problems in Private Plans,” Oct. 7, 2007, New York Times, http://www.nytimes.com/2007/10/07/us/07medicare.html?_r=1&hp=&adxnnl=1&oref=slogin&adxnnlx=1191729902-/QFjVc2aBDuzO96/FhKk9gPrescription Drugs: What’s the Issue?, an essay on Open Secrets dot org, http://www.opensecrets.org/news/drug/index.htm
Quadragno, Jill, book “One Nation, Uninsured” 2005, published by Oxford University Press. You can read an excellent review of this book on Newsvine on my column. If link does not work use this URL -- http://minnieapolis.newsvine.com/_news/2007/10/27/1054611-one-nation-uninsured-analyzes-a-century-of-failure-to-enact-a-national-health-plan-in-spite-of-public-support-book-review
Ruttley, Marilyn, Henderson hospital threatened with closure - blog, 4-10-08, http://blogs.guardian.co.uk/joepublic/2008/04/vulnerable_people_troubled_by.html.
Slota, Linda, “Training Goes a Long Way for Alzheimer's Spouses” at Christopher Heights.com webpage, http://www.christopherheights.com/page/AlzheimerTraining.cfm
StopHospitalInfections.org. We are all at risk because we cannot judge the relative safety of our hospitals. Consumers Union has developed a selection of Internet-ready public service announcements that can be used to link to StopHospitalInfections.org from any web site. Just click on the links below or scroll down the page to get started. Thanks again for your help!
The Internet Health Library, excellent resource for studies, etc. at http://www.internethealthlibrary.com/
The Medical Insurance Store online -- Includes “Five Ways to Cut Your Health Insurance Costs” & many other topics written at a basic level at http://www.medicalinsurancestore.info/Options%20for%20Those%20Who%20Cannot%20Afford%20Health%20Insurance.php
Pear, Robert, “Medicare Audits Show Problems in Private Plans,” New York Times, October 7, 2007, http://www.nytimes.com/2007/10/07/us/07medicare.html?_r=1&hp=&adxnnl=1&oref=slogin&adxnnlx=1191729902-/QFjVc2aBDuzO96/FhKk9g
Quammen, David, “Deadly Contact: How Animals and Human Exchange Disease,” National Geographic, (unknown date) http://magma.nationalgeographic.com/ngm/2007-10/infectious-animals/quammen-text.html
Sosnowski, Laura A, “Minnesotans Fight Hi Cost of Healthcare With Databases, Walk-in Clinics”, Nov. 2007,
http://minnieapolis.newsvine.com/_news/2007/11/12/1092663-minnesotans-fight-hi-cost-of-healthcare-with-databases-walk-in-clinics#dynamicCommentBox_1180552
Travel insurance website at www.insuremytrip.com. Companies that offer travel insurance are CSA Travel Protection, Access America, and AIG Travel Guard . Carefully compare the terms and conditions of each plan before making your final selection. Check first if you are covered under your credit card or homeowner’s insurance.
Vamosi, Robert, “Security Watch: Spam that just might kill you,” (about fake prescription drugs sold over the Internet) MSN.com, undated, http://tech.msn.com/security/articlecnet.aspx?cp-documentid=5406724&page=1
Whitman, Glen, “Hazards of the Individual Health Care Mandate,” Cato Policy Report, Fall 2007, http://cato.org/pubs/policy_report/v29n5/cpr29n5-1.html
“Why Obama, Edwards, Hillary, Romney, Schwarzenegger Don’t Support Single Payer? It Would Mean the Death of the Health Insurance Industry, and Reduced Profits for Big Pharma,” Corporate Crime Reporter, 1209 National Press Bldg., Washington, D.C. 20045, 202.737.1680, February 21, 2007, http://www.corporatecrimereporter.com/pnhp022107.
Health & Cancer Rights Protections: (Reconstructive surgery is covered as a post-mastectomy benefit.)
http://www.dol.gov/dol/topic/health-plans/womens.htm
“World’s Best Medical Care?”, NY Times editorial, August 12, 2007
http://www.nytimes.com/2007/08/12/opinion/12sun1.html?ei=5124&en=44da5cf6d4bf91c6&ex=1344571200&partner=newsvine&exprod=newsvine&pagewanted=print
What to do in an auto accident, and why
What the Auto Insurance Industry Hopes You Never Find Out
There are at least fifteen things that the average auto insurance company hopes you never find out about. Knowing them can mean the difference between getting an offer that covers your loss, and an offer that is far less than that amount or even zero.
These tidbits were passed on to me by an attorney in a very successful law practice. He offered to represent my accident case several years ago. Fortunately my accident was very cut and dried, and did not require his expertise to cover the damages caused by a young man driving on a revoked license.
The attorney’s friendship meant that he told me many specifics of getting the best possible settlement from the insurance carrier. In return, I was happy to refer several people to him for his professional skills.
First, let me cover the basics of what to do when an accident occurs. Stop. You have no idea how many drivers compound their problems because they panic and leave, hoping no one saw them. Someone always, or almost always, sees you - and they call 911 on their cell phones. Remain calm. If necessary, call an ambulance at least for getting you and your family checked over with x-rays. Call the police department, or ask someone at a nearby home to call for you.
Pull out paper and pen and start writing down the date and time, and information about the other driver: name, address, car license number with make and model, driver’s license number, date of birth, any apparent injuries. Get the name of the owner if different from the driver. Ask who their insurance company is and if they have an agent’s card or proof of insurance. Do not discuss accident with anyone or assign blame. It is too easy to get drawn into an argument in the heat of the moment. Do not accept any bait, just keep asking for facts. See if anyone is around that may have witnessed the accident, and get their name and phone number, or better yet, a business card. It is very easy to be unable to read your nervous scribble later on.
And make any notes on weather or other conditions at the time. Anticipate a police officer’s questions. I was once asked how long I sat in a turn lane before being struck, and how long was it between the time I saw the other vehicle and the moment of impact. Being totally unprepared for this line of questioning made me flustered. Try to think ahead of time about how long it took between events.
Call your insurance agent and tell him that there was a collision, or whatever event it was. Contact an experienced lawyer if anyone was hurt, or if the full extent of effects will not be known immediately. One friend’s pregnant wife was in a collision, and their lawyer told them not to sign off on anything until three months after the child’s birth. Fortunately for all concerned, everyone was fine.
Now, all that material just given is on most pocket cards handed out by insurance companies or police departments everywhere. What follows is inside information that not everyone has access to.
1) Do not give a statement to an insurance adjuster. They are looking for information to use against you and deny your claim. Do not accept blame for the accident, and do not blame others. Stick to the barest minimum of facts possible.
2) Hire a lawyer. Surely you must have some idea of which are the prominent and reputable law firms that deal in this kind of case. Now I do NOT mean for you to hire a lawyer when very little damage was done and you were darn lucky things were not worse. BUT When you have an inkling that even an overnight stay at the hospital is involved, take the precaution of engaging a lawyer who specializes in your type of injury.
3) All law firms will say that you won’t pay if you don’t win. But the bottom feeders tell you that, and then when it looks like they will have to go to court, ask them what you stand to gain or lose by having a trial. It turns out that you pay a percentage of the award if you win, but you could pay a few thousand in trial expenses if you lose. And by that time, it is too late to switch lawyers. The first and second lawyers will have to split the contingency, so most refuse a case that anyone else touched. So get the best you can the first time.
4) The insurance company stays in business by taking in more money than they pay out. They also make money by investing their funds, if they are a sizable firm. But your attorney only makes money if you win. So who would you expect to work harder for you? Granted, insurance is one of the most highly regulated businesses in America, but they will split hairs to stay on the right side of the laws.
5) A personal injury lawyer is the only type of professional who can determine what a fair settlement might be. This makes it especially important to go to a lawyer who specializes, not a generalist. The specialist sees hundreds, if not thousands, of cases in his career, and hears of many more. He can calculate the factors that go into arriving at a settlement with much more data on paper and in his head far better than you ever will.
6) Less than 5% of personal injury cases go to court. This is in your favor. The lawyer can hire experts to present the true cost of your accident for the rest of your working life. And if you never suffered that particular type of injury before, your case is so much stronger than any insurer could tear down. And by going with one of the “name” law firms, their reputation is such that the insurer is more likely to forego a trial.
7) Insurance companies are so annoyed when you hire a lawyer. They are focused on their bottom line, and they prefer to avoid the expense of sending their own lawyers into a courtroom. They know that insurance settlements handled without an attorney are significantly lower.
8) Corporations routinely use lawyers to protect themselves. Why shouldn’t you? Trying to fight an insurance company is like fighting city hall - you are going to wind up on the short end. And the insurance company is never going to volunteer information that will benefit you, while the lawyer is only too glad to inform you of how rights would apply to your situation.
9) The insurance company will try to settle quickly, and rush you into accepting the first offer. They will do this even before all the facts have come in, because the more information that comes in about the injury and whether you recover sufficiently to go back to work full time, the more money the insurer will likely have to pay out. This lawyer friend told me, “Wait until all the treatment has been done, all the symptoms have surfaced and been repaired, and then count up your losses. Your losses are not only the medical bills, but lost work time, lost family time, property damage, use of a rental car, transportation to a doctor or hospital, time spent in physical therapy, whether there is permanent damage, emotional distress, pain and suffering. THEN decide what it takes to put things right.”
10) Pain and suffering, and disability compensation can be substantial. Defining pain and suffering is very difficult, and arriving at a number is even harder. That is why you should at least talk to an attorney who has handled many such cases.
11) Do not ever sign a release from the insurance company. They will push a release at you as soon as possible, and this will most often mean that they will pay no further bills connected to that accident. Then the other bills arrive for ancillary services - everything from ambulance to medications, nursing and physical therapy, lost future income because you can no longer work overtime for example, periodic trips to the emergency room for recurring symptoms. All those items will come out of YOUR pocket if you sign away your proper rights.
12) Tactics that the insurance company uses to reduce or deny your claim: Frustrate you into giving up. Sending the adjuster to play the good guy (he will offer a very low settlement and make it seem reasonable).
13) Just one phone call from your lawyer can result in immediate relief from dealing with bills and paperwork. The law firm can help you keep your life together and keep you from being overwhelmed. It handles phone calls to the body shop. It calls the insurance company so you don’t have to answer multiple calls from their reps. Your job is to recuperate and get well! Make things easier on yourself.
14) You deserve the best medical attention, and experienced personal injury law firms know who the best specialists are in each field. You will get thorough and unbiased opinions and treatment.
15) Don’t talk to anyone about your case except your lawyer. Do not go to the corner bar and joke about screwing the insurance company for a million bucks. Do not even stand for anyone else’s jokes about lawyers or neck braces or anything of the kind. Just say, “My lawyer will take of it.” Friends or others who offer help may have what they think are your best interests in mind, but they may sabotage your case and keep it from being handled properly.
There are at least fifteen things that the average auto insurance company hopes you never find out about. Knowing them can mean the difference between getting an offer that covers your loss, and an offer that is far less than that amount or even zero.
These tidbits were passed on to me by an attorney in a very successful law practice. He offered to represent my accident case several years ago. Fortunately my accident was very cut and dried, and did not require his expertise to cover the damages caused by a young man driving on a revoked license.
The attorney’s friendship meant that he told me many specifics of getting the best possible settlement from the insurance carrier. In return, I was happy to refer several people to him for his professional skills.
First, let me cover the basics of what to do when an accident occurs. Stop. You have no idea how many drivers compound their problems because they panic and leave, hoping no one saw them. Someone always, or almost always, sees you - and they call 911 on their cell phones. Remain calm. If necessary, call an ambulance at least for getting you and your family checked over with x-rays. Call the police department, or ask someone at a nearby home to call for you.
Pull out paper and pen and start writing down the date and time, and information about the other driver: name, address, car license number with make and model, driver’s license number, date of birth, any apparent injuries. Get the name of the owner if different from the driver. Ask who their insurance company is and if they have an agent’s card or proof of insurance. Do not discuss accident with anyone or assign blame. It is too easy to get drawn into an argument in the heat of the moment. Do not accept any bait, just keep asking for facts. See if anyone is around that may have witnessed the accident, and get their name and phone number, or better yet, a business card. It is very easy to be unable to read your nervous scribble later on.
And make any notes on weather or other conditions at the time. Anticipate a police officer’s questions. I was once asked how long I sat in a turn lane before being struck, and how long was it between the time I saw the other vehicle and the moment of impact. Being totally unprepared for this line of questioning made me flustered. Try to think ahead of time about how long it took between events.
Call your insurance agent and tell him that there was a collision, or whatever event it was. Contact an experienced lawyer if anyone was hurt, or if the full extent of effects will not be known immediately. One friend’s pregnant wife was in a collision, and their lawyer told them not to sign off on anything until three months after the child’s birth. Fortunately for all concerned, everyone was fine.
Now, all that material just given is on most pocket cards handed out by insurance companies or police departments everywhere. What follows is inside information that not everyone has access to.
1) Do not give a statement to an insurance adjuster. They are looking for information to use against you and deny your claim. Do not accept blame for the accident, and do not blame others. Stick to the barest minimum of facts possible.
2) Hire a lawyer. Surely you must have some idea of which are the prominent and reputable law firms that deal in this kind of case. Now I do NOT mean for you to hire a lawyer when very little damage was done and you were darn lucky things were not worse. BUT When you have an inkling that even an overnight stay at the hospital is involved, take the precaution of engaging a lawyer who specializes in your type of injury.
3) All law firms will say that you won’t pay if you don’t win. But the bottom feeders tell you that, and then when it looks like they will have to go to court, ask them what you stand to gain or lose by having a trial. It turns out that you pay a percentage of the award if you win, but you could pay a few thousand in trial expenses if you lose. And by that time, it is too late to switch lawyers. The first and second lawyers will have to split the contingency, so most refuse a case that anyone else touched. So get the best you can the first time.
4) The insurance company stays in business by taking in more money than they pay out. They also make money by investing their funds, if they are a sizable firm. But your attorney only makes money if you win. So who would you expect to work harder for you? Granted, insurance is one of the most highly regulated businesses in America, but they will split hairs to stay on the right side of the laws.
5) A personal injury lawyer is the only type of professional who can determine what a fair settlement might be. This makes it especially important to go to a lawyer who specializes, not a generalist. The specialist sees hundreds, if not thousands, of cases in his career, and hears of many more. He can calculate the factors that go into arriving at a settlement with much more data on paper and in his head far better than you ever will.
6) Less than 5% of personal injury cases go to court. This is in your favor. The lawyer can hire experts to present the true cost of your accident for the rest of your working life. And if you never suffered that particular type of injury before, your case is so much stronger than any insurer could tear down. And by going with one of the “name” law firms, their reputation is such that the insurer is more likely to forego a trial.
7) Insurance companies are so annoyed when you hire a lawyer. They are focused on their bottom line, and they prefer to avoid the expense of sending their own lawyers into a courtroom. They know that insurance settlements handled without an attorney are significantly lower.
8) Corporations routinely use lawyers to protect themselves. Why shouldn’t you? Trying to fight an insurance company is like fighting city hall - you are going to wind up on the short end. And the insurance company is never going to volunteer information that will benefit you, while the lawyer is only too glad to inform you of how rights would apply to your situation.
9) The insurance company will try to settle quickly, and rush you into accepting the first offer. They will do this even before all the facts have come in, because the more information that comes in about the injury and whether you recover sufficiently to go back to work full time, the more money the insurer will likely have to pay out. This lawyer friend told me, “Wait until all the treatment has been done, all the symptoms have surfaced and been repaired, and then count up your losses. Your losses are not only the medical bills, but lost work time, lost family time, property damage, use of a rental car, transportation to a doctor or hospital, time spent in physical therapy, whether there is permanent damage, emotional distress, pain and suffering. THEN decide what it takes to put things right.”
10) Pain and suffering, and disability compensation can be substantial. Defining pain and suffering is very difficult, and arriving at a number is even harder. That is why you should at least talk to an attorney who has handled many such cases.
11) Do not ever sign a release from the insurance company. They will push a release at you as soon as possible, and this will most often mean that they will pay no further bills connected to that accident. Then the other bills arrive for ancillary services - everything from ambulance to medications, nursing and physical therapy, lost future income because you can no longer work overtime for example, periodic trips to the emergency room for recurring symptoms. All those items will come out of YOUR pocket if you sign away your proper rights.
12) Tactics that the insurance company uses to reduce or deny your claim: Frustrate you into giving up. Sending the adjuster to play the good guy (he will offer a very low settlement and make it seem reasonable).
13) Just one phone call from your lawyer can result in immediate relief from dealing with bills and paperwork. The law firm can help you keep your life together and keep you from being overwhelmed. It handles phone calls to the body shop. It calls the insurance company so you don’t have to answer multiple calls from their reps. Your job is to recuperate and get well! Make things easier on yourself.
14) You deserve the best medical attention, and experienced personal injury law firms know who the best specialists are in each field. You will get thorough and unbiased opinions and treatment.
15) Don’t talk to anyone about your case except your lawyer. Do not go to the corner bar and joke about screwing the insurance company for a million bucks. Do not even stand for anyone else’s jokes about lawyers or neck braces or anything of the kind. Just say, “My lawyer will take of it.” Friends or others who offer help may have what they think are your best interests in mind, but they may sabotage your case and keep it from being handled properly.
MORE ABOUT DENIALS
Sometimes getting a claim paid is like trying to get a promised mail-in rebate. That is, if you had to pay yourself for all the work you had to do to get it, you’d be in negative territory.
The most common reason for denial is: any guesses? It is an incomplete claim.
The insurance company needs what is called a “clean claim.” A clean claim has all the required information on it, your identifying information (like name, address, date of birth, policy number), provider identification (dr. name, address, etc.), the date of service, and information about the service itself (office visit, code, diagnosis code or description). That sounds like a lot, doesn’t it? Not really. All that fits on a standard one-page form called a HCFA (for doctor, clinic, and medical equipment claims), or on a UB-92 (for hospital claims).
Do not give up automatically upon receipt of a denial letter. Often a claim will be resolved without your doing a thing, because a duplicate letter has gone to the provider. The deficiency letter is more likely than not, perfectly intelligible to the billing department, and the followup claim with the requested material is quickly sent by return mail or fax to the insurer. However, the handling of the reply is not handled with the same urgency as the initial claim. If the insurer requests medical records, x-rays, a pathologist report, etc., the process will stretch over a month.
So before launching a full-scale attack on the insurer, please call the provider’s billing department and check if they have received the same letter and what their response will be. If they are already handling it, or if they treat it as a routine matter, you can resume your normal life. If on the other hand they do not deal with insurers, or do not waste energy on appeals, etc., then you will have to go into high gear.
Typically ninety percent of consumers drop their appeals before exhausting their options. According to a study by the Kaiser Family Foundation, 52% of patients won their first appeal for each claim made. If your first appeal gets turned down, make a second appeal because second appeals won 44% of the time. And third appeals won in 45% of cases. There is no reason to give up if you truly believe that your policy covers a given procedure. Follow the instructions for an appeal. An informal appeal is fine for routine services.
First, pull out your denial form or letter and look up what the denial code is and what it denotes. Then pull out your copy of the policy and go through its provisions with a fine toothed comb. It is true that some of the finer points are not given in the copy that you own, such as definitions of terms, or which doctors are in the network, etc. But the insurance laws are such that the policy you have been given, with the application and any riders, constitutes the whole contract between the insurer and you -- (see section on Your Rights As An Insurance Consumer) -- and they cannot add new material wholesale after the fact of granting you coverage. (Language in the contract will refer to providers in the network, and even though the providers are not listed in the contract, this is a valid part of the contract by virtue of being referred to in the section on how payments are calculated.)
So now you have read through your policy and you still feel that your procedure should be covered. Gather together your denial, explanation of benefits, your appt. calendar, any notes you kept on doctor visits and doctor recommendations. This is especially true for emergency visits to the E.R., when they will want to know if you called your doctor’s office and did he/she send you to the emergency room.
Call the insurance company’s customer service line, or go to their website, and make an inquiry as to the exact reason for the denial or why payment is delayed. It may be that the definition of a term is not the same as in ordinary English usage; many definitions are specific to insurance. You should be able to check this information on the insurer’s website, or look up material on the FAQ page of the website. Try asking the customer service rep what the reason is for the denial, and do so politely. The rep may not have that information available yet, as your claim may be stuck in processing. Get a name of a department supervisor and his/her phone number to call next. Then call that person to ask him/her to check into your problem and ask for a followup letter.
The next step is to go online to the NAIC website. This is the National Association of Insurance Commissioners. On the website you can click on a button to contact your state commission. Then you will be able to access a great deal of information about health insurance in general, and about how to proceed in your case. (Your state office will often have email or instant response to your complaint.) Your HMO may also have an appeal task force; ask about the correct procedure to appeal your denial.
Make note of any deadlines for receiving an appeal. If one is given and you are mailing a reply within a week of that deadline, send it certified mail to prove that you met the deadline. Never send originals of insurer paperwork (but keep copies for your file).
The most common reason for denial is: any guesses? It is an incomplete claim.
The insurance company needs what is called a “clean claim.” A clean claim has all the required information on it, your identifying information (like name, address, date of birth, policy number), provider identification (dr. name, address, etc.), the date of service, and information about the service itself (office visit, code, diagnosis code or description). That sounds like a lot, doesn’t it? Not really. All that fits on a standard one-page form called a HCFA (for doctor, clinic, and medical equipment claims), or on a UB-92 (for hospital claims).
Do not give up automatically upon receipt of a denial letter. Often a claim will be resolved without your doing a thing, because a duplicate letter has gone to the provider. The deficiency letter is more likely than not, perfectly intelligible to the billing department, and the followup claim with the requested material is quickly sent by return mail or fax to the insurer. However, the handling of the reply is not handled with the same urgency as the initial claim. If the insurer requests medical records, x-rays, a pathologist report, etc., the process will stretch over a month.
So before launching a full-scale attack on the insurer, please call the provider’s billing department and check if they have received the same letter and what their response will be. If they are already handling it, or if they treat it as a routine matter, you can resume your normal life. If on the other hand they do not deal with insurers, or do not waste energy on appeals, etc., then you will have to go into high gear.
Typically ninety percent of consumers drop their appeals before exhausting their options. According to a study by the Kaiser Family Foundation, 52% of patients won their first appeal for each claim made. If your first appeal gets turned down, make a second appeal because second appeals won 44% of the time. And third appeals won in 45% of cases. There is no reason to give up if you truly believe that your policy covers a given procedure. Follow the instructions for an appeal. An informal appeal is fine for routine services.
First, pull out your denial form or letter and look up what the denial code is and what it denotes. Then pull out your copy of the policy and go through its provisions with a fine toothed comb. It is true that some of the finer points are not given in the copy that you own, such as definitions of terms, or which doctors are in the network, etc. But the insurance laws are such that the policy you have been given, with the application and any riders, constitutes the whole contract between the insurer and you -- (see section on Your Rights As An Insurance Consumer) -- and they cannot add new material wholesale after the fact of granting you coverage. (Language in the contract will refer to providers in the network, and even though the providers are not listed in the contract, this is a valid part of the contract by virtue of being referred to in the section on how payments are calculated.)
So now you have read through your policy and you still feel that your procedure should be covered. Gather together your denial, explanation of benefits, your appt. calendar, any notes you kept on doctor visits and doctor recommendations. This is especially true for emergency visits to the E.R., when they will want to know if you called your doctor’s office and did he/she send you to the emergency room.
Call the insurance company’s customer service line, or go to their website, and make an inquiry as to the exact reason for the denial or why payment is delayed. It may be that the definition of a term is not the same as in ordinary English usage; many definitions are specific to insurance. You should be able to check this information on the insurer’s website, or look up material on the FAQ page of the website. Try asking the customer service rep what the reason is for the denial, and do so politely. The rep may not have that information available yet, as your claim may be stuck in processing. Get a name of a department supervisor and his/her phone number to call next. Then call that person to ask him/her to check into your problem and ask for a followup letter.
The next step is to go online to the NAIC website. This is the National Association of Insurance Commissioners. On the website you can click on a button to contact your state commission. Then you will be able to access a great deal of information about health insurance in general, and about how to proceed in your case. (Your state office will often have email or instant response to your complaint.) Your HMO may also have an appeal task force; ask about the correct procedure to appeal your denial.
Make note of any deadlines for receiving an appeal. If one is given and you are mailing a reply within a week of that deadline, send it certified mail to prove that you met the deadline. Never send originals of insurer paperwork (but keep copies for your file).
MEDICAL CLAIMS
MEDICAL CLAIMS
Here I am going to lump together both doctor and hospital bills together, even though they use different claim forms. They are both medical claims as opposed to dental or prescription claims. We will also look at another type of medical claim and that is the one for medical supplies.
Thousands of policy owners are filing their own claims by sending in the receipt for the doctor visit. They are led to believe that this is sufficient but they are kept in (not so) blissful ignorance. You see, in most states laws were passed saying that insurance companies could not reject a claim because it was not on a claim form. And there are several insurers that help you by allowing you to print out a form off their websites online. This is helpful of them.
But the receipt, itemized bill, or even an EOB (explanation of benefits) is rarely enough because they lack the one essential item required to process your bill: the diagnosis code.
All claims for a medical expense require a diagnosis code for processing. (Most dental and prescription claims do not.) By diagnosis, I do not necessarily mean that the doctor arrives at a name for your condition or illness. The diagnosis code may reflect the fact of an annual exam, a flu shot, a clearance for participating in school sports, or other administrative reasons.
Here I am going to lump together both doctor and hospital bills together, even though they use different claim forms. They are both medical claims as opposed to dental or prescription claims. We will also look at another type of medical claim and that is the one for medical supplies.
Thousands of policy owners are filing their own claims by sending in the receipt for the doctor visit. They are led to believe that this is sufficient but they are kept in (not so) blissful ignorance. You see, in most states laws were passed saying that insurance companies could not reject a claim because it was not on a claim form. And there are several insurers that help you by allowing you to print out a form off their websites online. This is helpful of them.
But the receipt, itemized bill, or even an EOB (explanation of benefits) is rarely enough because they lack the one essential item required to process your bill: the diagnosis code.
All claims for a medical expense require a diagnosis code for processing. (Most dental and prescription claims do not.) By diagnosis, I do not necessarily mean that the doctor arrives at a name for your condition or illness. The diagnosis code may reflect the fact of an annual exam, a flu shot, a clearance for participating in school sports, or other administrative reasons.
HIPAA: What it is, What it was supposed to be, How it affects your claims…
HIPAA: What it is, What it was supposed to be, How it affects your claims…
The Health Insurance Portability and Accountability Act of 1996 was an act of Congress intended to address the security and privacy of health data. Provisions of the act apply to paper, phone, and especially electronic transfers of this sensitive information. HIPAA provides basic protections for your information and gives you certain rights.
Among them are: the rights to see your records, request changes or additions, receive a copy, and receive a list of those who have seen your records. Unfortunately, you don’t have the right to change them even if horrendously wrong, nor can you remove them from the provider’s office.
The fact is, the insurance industry is increasingly computerized, and is moving toward a majority of claims being submitted electronically rather than by mail or even by fax. Your paper claim is probably keyed into, or electronically read, and the original image kept in virtual form while the paper form is shredded. All this improves their productivity, however there is the chance that sensitive records can be hacked into and so that was the rationale for this law.
There are many gaps in your rights, such as your consent is not required when information is needed for your treatment or for the payment of treatment. But many providers are bending over backwards to protect your privacy even if the insurance company requests records, so you will have to ask your provider what their policy is.
If you have a complaint, your first contact is the provider who can often resolve any issue promptly. However you must file a complaint with HHS within 180 days of learning about the incident -- another way they avoid being swamped with complaints. And HIPAA does not give you the right to sue in court for violating your privacy. You have to rely on some other state or federal law to protect your rights to sue.
I personally have seen problems with the application of the HIPAA rules to the point of ridiculousness. In the case of an adult child who is away at college, the parent may not discuss an insurance or treatment issue with the provider without an express letter from the student giving permission for Mom and Dad to do so.
Also I had a case where the parent was not on a policy for the children, and this fact meant that we could not update their address on the policy (even though the children were minors). Make a point of asking providers how they handle these issues sooner rather than later.
The Health Insurance Portability and Accountability Act of 1996 was an act of Congress intended to address the security and privacy of health data. Provisions of the act apply to paper, phone, and especially electronic transfers of this sensitive information. HIPAA provides basic protections for your information and gives you certain rights.
Among them are: the rights to see your records, request changes or additions, receive a copy, and receive a list of those who have seen your records. Unfortunately, you don’t have the right to change them even if horrendously wrong, nor can you remove them from the provider’s office.
The fact is, the insurance industry is increasingly computerized, and is moving toward a majority of claims being submitted electronically rather than by mail or even by fax. Your paper claim is probably keyed into, or electronically read, and the original image kept in virtual form while the paper form is shredded. All this improves their productivity, however there is the chance that sensitive records can be hacked into and so that was the rationale for this law.
There are many gaps in your rights, such as your consent is not required when information is needed for your treatment or for the payment of treatment. But many providers are bending over backwards to protect your privacy even if the insurance company requests records, so you will have to ask your provider what their policy is.
If you have a complaint, your first contact is the provider who can often resolve any issue promptly. However you must file a complaint with HHS within 180 days of learning about the incident -- another way they avoid being swamped with complaints. And HIPAA does not give you the right to sue in court for violating your privacy. You have to rely on some other state or federal law to protect your rights to sue.
I personally have seen problems with the application of the HIPAA rules to the point of ridiculousness. In the case of an adult child who is away at college, the parent may not discuss an insurance or treatment issue with the provider without an express letter from the student giving permission for Mom and Dad to do so.
Also I had a case where the parent was not on a policy for the children, and this fact meant that we could not update their address on the policy (even though the children were minors). Make a point of asking providers how they handle these issues sooner rather than later.
The COBRA Law: Portability of Group Health Insurance
The COBRA Law: Portability of Group Health Insurance
Most people have by now heard of the Cobra law and think they know what it says. However, there are several sections of the law, and each one covers a different class of persons. (For the entire COBRA law, please contact your senator or representative’s office, as they can usually send you a copy in the mail.
Participants in group medical plans are protected by this federal law (passed in 1985) that guarantees their right to opt to continue coverage under the same group plan. To be explicit, the terminated employee is not converting his group coverage to an individual certificate; he is continuing the group coverage. However, if the employee is terminated for reasons of gross misconduct, then he is not covered by COBRA. In other words, COBRA protects employees who are laid off but not those who are let go for cause, IF your employer has 20 or more employees.
*For the terminated employee, coverage is extended for 18 months, at a premium of 102% of the group premium to cover the extra handling.
*For the terminated disabled employee, coverage is extended for up to 29 months. For the first 18 months his premium will be 102% of the group premium; for months 19-29 his premium is 150% of the group rate. This group must meet the Social Security definition of total disability, which is very narrow.
*The dependents of the terminated employee may extend their coverage for 36 months, and their premium is 102% of the group rate for all 36 months. These dependents are those who lose coverage due to death, divorce, or in the case of a minor child, aging past the definition of a dependent.
*There are also provisions for a terminated or retired employee who becomes eligible for Medicare to continue the group insurance for three years.
*The employee’s hours are reduced so that he no longer qualifies: 18 months of continued coverage under the group plan (or 29 months if disabled).
*The employee dies: -- his dependents are covered for 36 months.
While this law was a landmark in giving employees some coverage in the event of job loss, it often gives employees a case of sticker shock when they are quoted the full cost of their premium. My advice is to take the COBRA plan right away, and take advantage of the time to shop around for a lower cost plan that will cover your priorities for you and your family.
Try to avoid a break in coverage at all costs because it will cost you dearly later on. If your break in coverage exceeds 63 days, the next insurer can deny expenses related to any pre-existing condition.
Most people have by now heard of the Cobra law and think they know what it says. However, there are several sections of the law, and each one covers a different class of persons. (For the entire COBRA law, please contact your senator or representative’s office, as they can usually send you a copy in the mail.
Participants in group medical plans are protected by this federal law (passed in 1985) that guarantees their right to opt to continue coverage under the same group plan. To be explicit, the terminated employee is not converting his group coverage to an individual certificate; he is continuing the group coverage. However, if the employee is terminated for reasons of gross misconduct, then he is not covered by COBRA. In other words, COBRA protects employees who are laid off but not those who are let go for cause, IF your employer has 20 or more employees.
*For the terminated employee, coverage is extended for 18 months, at a premium of 102% of the group premium to cover the extra handling.
*For the terminated disabled employee, coverage is extended for up to 29 months. For the first 18 months his premium will be 102% of the group premium; for months 19-29 his premium is 150% of the group rate. This group must meet the Social Security definition of total disability, which is very narrow.
*The dependents of the terminated employee may extend their coverage for 36 months, and their premium is 102% of the group rate for all 36 months. These dependents are those who lose coverage due to death, divorce, or in the case of a minor child, aging past the definition of a dependent.
*There are also provisions for a terminated or retired employee who becomes eligible for Medicare to continue the group insurance for three years.
*The employee’s hours are reduced so that he no longer qualifies: 18 months of continued coverage under the group plan (or 29 months if disabled).
*The employee dies: -- his dependents are covered for 36 months.
While this law was a landmark in giving employees some coverage in the event of job loss, it often gives employees a case of sticker shock when they are quoted the full cost of their premium. My advice is to take the COBRA plan right away, and take advantage of the time to shop around for a lower cost plan that will cover your priorities for you and your family.
Try to avoid a break in coverage at all costs because it will cost you dearly later on. If your break in coverage exceeds 63 days, the next insurer can deny expenses related to any pre-existing condition.
STANDARD EXCLUSIONS
STANDARD EXCLUSIONS
1) Suicide Exclusion - If the insured commits suicide within two years of the policy issue date, the death benefits will not be paid. Instead, the beneficiary will receive the refunded premiums.
2) War Exclusion - If the insured dies as a direct result of war, the death benefit will not be paid. Instead, the beneficiary will receive the refunded premiums plus interest.
3) Aviation Exclusion - If the insured is a private pilot or member of the crew, the death benefit will not be paid if the insured dies in an air accident. Instead, the beneficiary will receive the premiums with interest. You might purchase an aviation rider which will remove this exclusion.
1) Suicide Exclusion - If the insured commits suicide within two years of the policy issue date, the death benefits will not be paid. Instead, the beneficiary will receive the refunded premiums.
2) War Exclusion - If the insured dies as a direct result of war, the death benefit will not be paid. Instead, the beneficiary will receive the refunded premiums plus interest.
3) Aviation Exclusion - If the insured is a private pilot or member of the crew, the death benefit will not be paid if the insured dies in an air accident. Instead, the beneficiary will receive the premiums with interest. You might purchase an aviation rider which will remove this exclusion.
Standard Policy Provisions on Life Policies
LIFE INSURANCE POLICY PROVISIONS, RIDERS, RIGHTS
Standard Policy Provisions on Life Policies
1) Ownership Clause - The policy owner has ALL contractual rights in the policy while the insured is still alive. The policy owner has the right to name the beneficiary or beneficiaries, borrow against cash value, or select dividend options.
2) Assignment Clause - The policy owner may designate a new owner by filling an appropriate form. The assignee then becomes the new owner of the policy. This is commonly done when a parent bought a life policy for a newborn, and wishes to transfer it to the now-adult child. This is also an option if you do not need a given policy anymore, and it is paid up. You may wish to assign it as a gift to your church or alma mater or other charity. I might add that using the policy as collateral on a loan is an example of temporary assignment.
3) Entire Contract - Just like with the health insurance policy, this states that the whole of the policy is contained in the application, the policy itself, and any riders.
4) Free Look - You have the right to examine the policy and decide whether you want to keep it; you can cancel it and owe nothing if within the stated period of time. Usually this is 10 to 20 days, depending on your state, or 30 days for senior products. The count begins from the date the policy is delivered to your hands.
5) Grace Period - The policy owner has 31 days in which he or she may pay the premium late without the policy lapsing. It lapses on the 32nd day after the due date. IF THE INSURED DIES during the grace period, the policy does not lapse! The face amount is paid, minus the premium.
6) Reinstatement Period - This is very different from the rules for a health policy, so look sharp. Your LIFE policy may be reinstated up to three years after the last premium due date. To reinstate, you need to fill out the reinstatement form, prove insurability (which usually involves a new physical exam), and pay all back premiums with interest. You will have to wait thru a new incontestability period (2 years) - but NOT a new suicide exclusion. However, if there was no cash value when the policy lapsed, then coverage ends and you cannot reinstate. Ex: A term policy may lapse permanently because it has no cash value. Also, you may have the option with a whole life policy to convert it to an extended term life policy. This is what happens if your policy has an automatic non-lapse option.
7) Incontestability Clause - The insurer can’t contest a claim after two full years on the basis of misrepresentation or concealment. The only cases of fraud that can be contested after two years are impersonation, no insurable interest, and intent to murder. Impersonation is pretending to be the insured when buying the policy or forging their signature on an application. Intent to murder should be pretty self-explanatory as I am sure all of us have watched enough crime shows understand how that works. Insurable interest is having a plausible interest in the life of the insured. We all have unlimited interest in our own life, or in the life of a spouse or other family member. We also have an insurable interest in a business partner or a company’s key employee.
8) Misstatement of age or gender - These are essential to arriving at a correct
premium for the policy you purchase. As with the health policies, if the misstatement in age results in a lower premium, you will be refunded the excess premium. If it results in a higher premium, you will receive a reduced death benefit; the amount is the one that your premium would have bought with accurate information. This provision is NOT subject to the incontestability provision.
9) Consideration Clause - The policy owner promises to pay all premiums due and swears all the statements on the application are true.
10) Insuring Clause - This states the policy benefits, the perils (risks) covered, and the beneficiary.
11) Payment of Claims Clause - The death benefit of the policy must be paid within two months (60 days) after the insurer receives proof of death. Unless, of course, they suspect any sort of major fraud in the purchase or irregularity in the death.
Standard Policy Provisions on Life Policies
1) Ownership Clause - The policy owner has ALL contractual rights in the policy while the insured is still alive. The policy owner has the right to name the beneficiary or beneficiaries, borrow against cash value, or select dividend options.
2) Assignment Clause - The policy owner may designate a new owner by filling an appropriate form. The assignee then becomes the new owner of the policy. This is commonly done when a parent bought a life policy for a newborn, and wishes to transfer it to the now-adult child. This is also an option if you do not need a given policy anymore, and it is paid up. You may wish to assign it as a gift to your church or alma mater or other charity. I might add that using the policy as collateral on a loan is an example of temporary assignment.
3) Entire Contract - Just like with the health insurance policy, this states that the whole of the policy is contained in the application, the policy itself, and any riders.
4) Free Look - You have the right to examine the policy and decide whether you want to keep it; you can cancel it and owe nothing if within the stated period of time. Usually this is 10 to 20 days, depending on your state, or 30 days for senior products. The count begins from the date the policy is delivered to your hands.
5) Grace Period - The policy owner has 31 days in which he or she may pay the premium late without the policy lapsing. It lapses on the 32nd day after the due date. IF THE INSURED DIES during the grace period, the policy does not lapse! The face amount is paid, minus the premium.
6) Reinstatement Period - This is very different from the rules for a health policy, so look sharp. Your LIFE policy may be reinstated up to three years after the last premium due date. To reinstate, you need to fill out the reinstatement form, prove insurability (which usually involves a new physical exam), and pay all back premiums with interest. You will have to wait thru a new incontestability period (2 years) - but NOT a new suicide exclusion. However, if there was no cash value when the policy lapsed, then coverage ends and you cannot reinstate. Ex: A term policy may lapse permanently because it has no cash value. Also, you may have the option with a whole life policy to convert it to an extended term life policy. This is what happens if your policy has an automatic non-lapse option.
7) Incontestability Clause - The insurer can’t contest a claim after two full years on the basis of misrepresentation or concealment. The only cases of fraud that can be contested after two years are impersonation, no insurable interest, and intent to murder. Impersonation is pretending to be the insured when buying the policy or forging their signature on an application. Intent to murder should be pretty self-explanatory as I am sure all of us have watched enough crime shows understand how that works. Insurable interest is having a plausible interest in the life of the insured. We all have unlimited interest in our own life, or in the life of a spouse or other family member. We also have an insurable interest in a business partner or a company’s key employee.
8) Misstatement of age or gender - These are essential to arriving at a correct
premium for the policy you purchase. As with the health policies, if the misstatement in age results in a lower premium, you will be refunded the excess premium. If it results in a higher premium, you will receive a reduced death benefit; the amount is the one that your premium would have bought with accurate information. This provision is NOT subject to the incontestability provision.
9) Consideration Clause - The policy owner promises to pay all premiums due and swears all the statements on the application are true.
10) Insuring Clause - This states the policy benefits, the perils (risks) covered, and the beneficiary.
11) Payment of Claims Clause - The death benefit of the policy must be paid within two months (60 days) after the insurer receives proof of death. Unless, of course, they suspect any sort of major fraud in the purchase or irregularity in the death.
CANCELABLE AND NON-CANCELABLE POLICIES
Now, having gotten that material out of the way, this is what you need to know about the circumstances under which your policy may be cancelled, aside from non-payment of premium.
There are five main categories that govern renewal provisions: Non-Cancellable, Guaranteed Renewable, Conditionally Renewable, Optionally Renewable, and Cancelable.
These are graded from highest to lowest, and the cost of a premium reflects each grade of policy. The top three are greatly preferred by you, the consumer, over the bottom two grades.
The Non-Cancelable is the most expensive; the insurer may not cancel on you, may not change rates, and must renew up to a certain age (usually age 65).
The Guaranteed Renewable policy has these features: the insurer may not cancel but may raise rates for the whole class of policies (ex.: everyone in your state, all smokers), and must renew to a given age.
The Conditionally Renewable policy maybe cancelled but only if they cancel an entire class (like smokers, or anyone with pre-existing conditions). They may raise rates but only if they raise rates for an entire class of insureds.
The Optionally Renewable policy is one that the insurer may cancel for you as an individual, the insurer may raise rates for you as an individual, and may even drop you at the renewal date.
The Cancelable policy may be cancelled at any date, change rates at any time --but this is the cheapest policy.
--- Ready for a breather? Just one more section of heavy-duty reading and then it gets easier, OK?
There are five main categories that govern renewal provisions: Non-Cancellable, Guaranteed Renewable, Conditionally Renewable, Optionally Renewable, and Cancelable.
These are graded from highest to lowest, and the cost of a premium reflects each grade of policy. The top three are greatly preferred by you, the consumer, over the bottom two grades.
The Non-Cancelable is the most expensive; the insurer may not cancel on you, may not change rates, and must renew up to a certain age (usually age 65).
The Guaranteed Renewable policy has these features: the insurer may not cancel but may raise rates for the whole class of policies (ex.: everyone in your state, all smokers), and must renew to a given age.
The Conditionally Renewable policy maybe cancelled but only if they cancel an entire class (like smokers, or anyone with pre-existing conditions). They may raise rates but only if they raise rates for an entire class of insureds.
The Optionally Renewable policy is one that the insurer may cancel for you as an individual, the insurer may raise rates for you as an individual, and may even drop you at the renewal date.
The Cancelable policy may be cancelled at any date, change rates at any time --but this is the cheapest policy.
--- Ready for a breather? Just one more section of heavy-duty reading and then it gets easier, OK?
NOW FOR THE ELEVEN OPTIONAL PROVISIONS:
13) Change of Occupation - If the insured changes to a more hazardous occupation, benefits may be reduced to reflect the higher premiums you would have been assessed. If the insured changes to a less hazardous occupation, premiums may be reduced OR you will be given a refund.
14) Misstatement of Age - If the misstatement resulted in an overpayment of premium, the excess will be refunded. If the misstatement resulted in an underpayment, the missing premiums will be subtracted from benefits.
15) Other insurance with same insurer - If you inadvertently buy two of the same policy with the same insurer, one policy will be cancelled and the premium returned to you. Benefits may only be paid out on the policy remaining.
16) Medical Expense Policies - If the insured has two policies with different companies, the two insurers will co-ordinate benefits just like you find with group health policies. (There are some exceptions. With Aflac for example, no coordination of benefits is done, even with multiple Aflac policies. I mention them as only one example of an insurer with this business model.)
17) Disability income policy benefits - Your disability income benefit will be divided on a pro rata basis (similar to co-ordination of benefits) if you have multiple policies.
18) Earnings to Insurance - This provision states that your total disability benefit may not exceed your pre-disability income. Insurers are so petrified that legions of insureds will sit on their haunches and just collect their checks -- Never mind that your medical expenses eat up most of what you are collecting. They will co-ordinate their benefits to you, and refund overpaid premiums.
19) Unpaid Premiums - If you are behind on premiums at the time of loss, the unpaid premium is deducted from the benefit amount before the check is issued.
20) Cancellation - Five days written notice is required, and the insurer will refund you a pro-rata amount of the unearned premium.
21) Conformity with Statutes - Any health insurance policy that does not conform to state law will automatically include any state mandated provision. This is so that the insurer does not have to print all new policies with every change in state insurance laws.
22) Illegal Occupation - If you are engaged in something illegal at the time of loss - buying street drugs, making meth, robbing a bank - the insurer does not have to pay your medical claim or your death benefit.
23) Narcotics - No benefits are payable if the insured is injured while under the influence of a narcotic UNLESS the narcotic was administered under a physician’s care. So if you get in a car accident while sleep driving under the influence of your prescription sleeping pill, your bills should still get paid.
14) Misstatement of Age - If the misstatement resulted in an overpayment of premium, the excess will be refunded. If the misstatement resulted in an underpayment, the missing premiums will be subtracted from benefits.
15) Other insurance with same insurer - If you inadvertently buy two of the same policy with the same insurer, one policy will be cancelled and the premium returned to you. Benefits may only be paid out on the policy remaining.
16) Medical Expense Policies - If the insured has two policies with different companies, the two insurers will co-ordinate benefits just like you find with group health policies. (There are some exceptions. With Aflac for example, no coordination of benefits is done, even with multiple Aflac policies. I mention them as only one example of an insurer with this business model.)
17) Disability income policy benefits - Your disability income benefit will be divided on a pro rata basis (similar to co-ordination of benefits) if you have multiple policies.
18) Earnings to Insurance - This provision states that your total disability benefit may not exceed your pre-disability income. Insurers are so petrified that legions of insureds will sit on their haunches and just collect their checks -- Never mind that your medical expenses eat up most of what you are collecting. They will co-ordinate their benefits to you, and refund overpaid premiums.
19) Unpaid Premiums - If you are behind on premiums at the time of loss, the unpaid premium is deducted from the benefit amount before the check is issued.
20) Cancellation - Five days written notice is required, and the insurer will refund you a pro-rata amount of the unearned premium.
21) Conformity with Statutes - Any health insurance policy that does not conform to state law will automatically include any state mandated provision. This is so that the insurer does not have to print all new policies with every change in state insurance laws.
22) Illegal Occupation - If you are engaged in something illegal at the time of loss - buying street drugs, making meth, robbing a bank - the insurer does not have to pay your medical claim or your death benefit.
23) Narcotics - No benefits are payable if the insured is injured while under the influence of a narcotic UNLESS the narcotic was administered under a physician’s care. So if you get in a car accident while sleep driving under the influence of your prescription sleeping pill, your bills should still get paid.
Your Rights as an Insurance Consumer
When examining your health insurance policy, you will find several provisions or riders attached. The insurance industry, policed and led by the NAIC professional guild, adopted 23 standard provisions. (NAIC, the National Association of Insurance Commissioners, has an excellent website for both professionals and consumers alike. One nice feature is that you can go to your state insurance commission and check to see if a given company or agent is licensed to do business in your state.) These standard provisions are for HEALTH policies; life policies have other common provisions or clauses, and I will treat those also.
Look at Your Insurance Card
Please take out your insurance card. (I hope you have put it where you can easily find it.) It will have these key features: your Policy Number, the name of the Primary Insured, the names of any Dependents who are also covered, the name of the insurance company.
On the back of the card is possibly the most important information: the address where claims are to be sent (usually there is also a phone number for customer service where you will often be on hold longer than the length of the actual conversation).
I cannot tell you how many hundreds of claims are deleted from our in-box because they were sent to our office in error, so we cannot do anything but ship boxes of claims to another office. Most of the dental claims are supposed to be processed in City B or sometimes City C, but we received bushels of claims at City A because it is the main office. You do see, I hope, how this causes a delay in processing, a delay in payment to the providers, and a delay to you, the policyholder, in receiving an Explanation of Benefits (EOB).
On the back of the card is possibly the most important information: the address where claims are to be sent (usually there is also a phone number for customer service where you will often be on hold longer than the length of the actual conversation).
I cannot tell you how many hundreds of claims are deleted from our in-box because they were sent to our office in error, so we cannot do anything but ship boxes of claims to another office. Most of the dental claims are supposed to be processed in City B or sometimes City C, but we received bushels of claims at City A because it is the main office. You do see, I hope, how this causes a delay in processing, a delay in payment to the providers, and a delay to you, the policyholder, in receiving an Explanation of Benefits (EOB).
INTRODUCTION
This guide is meant to teach you how to successfully submit correct and complete claim information to your insurer. It will cover medical, dental, prescription, and durable medical equipment. I will say a few words about medical supplies, also, such as those used for post-surgical care or for some chronic medical conditions.
What qualifies me to write this book? I am a licensed insurance sales person, in the health, accident and life lines. I also have several years’ experience in the claims department of a large insurer of medical and dental policies. It was there that I saw the claims sent in by policyholders that were lacking basic information so necessary for processing. (More about that later.)
I saw claims that did not have the insured’s policy number on them, and the patient name was something common like Thompson or Taylor. Sometimes there was an incomplete or incorrect policy number - which was even worse. It would go under somebody else’s policy until the system questioned why a date of birth did not match up.
Claims came in with good information about the services rendered, but we did not know which family member was the patient. Could it be the senior John Johnson or little Johnny Johnson? There is nothing to tell the processor which it is, as no birth date is provided. Who is “Maggie” when there is no Maggie or Margaret on the policy? Oh, here’s a note on the back page of the policy that Marsha goes by the name Maggie.
Claims came in with only a receipt for a total fee, no breakdown information given. In that case, we need to know if the $256 was for the office visit, an x-ray, or was some part for the office visit and part for the x-ray?
By using this reference as your guide when preparing your claims for mailing to your insurer, you can avoid the many pitfalls and errors that are often made. You will save yourself much aggravation, and you will get a speedier reply to your submissions. You may even sleep better at night.
1
On the one hand, it is unfortunate that the masses have been thrust into the position of being their own insurance billers. Medical providers and insurance companies pay very decent money to professionals to fill out (and examine, at the claims end of the claim game) your medical, dental, and equipment claims. You are not paid to do this job, you are not trained to do this job, and yet, because of the many changes in the insurance landscape, the powers that be decided that in return for a discount on your medical services, the providers will not deal with the time-consuming process of filing claims.
That leaves you to do the job. Did anyone help you learn how, or even where to find an impartial source of information? No, they did not. That leaves you stressed out by repeated letters from the insurer for more information before they will pay the bill, and you harassed by bill collectors and bad credit ratings.
I admit that before I got into the insurance industry (and that was quite by chance), I had the same negative image of the insurance field as any one of you. It seemed like a scam, betting against yourself. It seemed like they enjoyed toying with the policy-holder - kind of like the evil Catbert in the Dilbert cartoons who toys with company employees.
And yet once I got behind the scenes, so to speak, I learned that insurance is possibly the most regulated business in America. True, many of the laws were in response to rampant abuses in the past. But those laws are there to protect you and all the insurers in your state have to abide by them. You may think that the agent droning on and on in your kitchen is trying to beat you into submission, but he is obligated to tell you the whole spiel about a product so that you cannot claim you were inadequately informed. The agent has rules about how many days he has to deliver the policy to you, about explaining it to you again when he delivers it, about getting your signature when you and he are in the same physical space together, about keeping up with continuing credits in order to keep his license, etc.
Do you stop to think how almost every other business offers you inducements to buy, but not insurance? That is because it is illegal for the agent to offer you anything of value (in some states a value of $15 is the threshold) but practically speaking the agent can offer you exactly nothing to buy. You buy a car, you can have salesmen throwing thousands of dollars at you in rebate, a new TV and/or DVD player - one time the salesman tried to throw in a vacation on top of everything --- but the poor insurance agent cannot even give you a restaurant certificate or gas for your car.
So, yes, the insurance industry has to operate within very clearly defined parameters that vary with each state. Try to drop the adversarial attitude.
What qualifies me to write this book? I am a licensed insurance sales person, in the health, accident and life lines. I also have several years’ experience in the claims department of a large insurer of medical and dental policies. It was there that I saw the claims sent in by policyholders that were lacking basic information so necessary for processing. (More about that later.)
I saw claims that did not have the insured’s policy number on them, and the patient name was something common like Thompson or Taylor. Sometimes there was an incomplete or incorrect policy number - which was even worse. It would go under somebody else’s policy until the system questioned why a date of birth did not match up.
Claims came in with good information about the services rendered, but we did not know which family member was the patient. Could it be the senior John Johnson or little Johnny Johnson? There is nothing to tell the processor which it is, as no birth date is provided. Who is “Maggie” when there is no Maggie or Margaret on the policy? Oh, here’s a note on the back page of the policy that Marsha goes by the name Maggie.
Claims came in with only a receipt for a total fee, no breakdown information given. In that case, we need to know if the $256 was for the office visit, an x-ray, or was some part for the office visit and part for the x-ray?
By using this reference as your guide when preparing your claims for mailing to your insurer, you can avoid the many pitfalls and errors that are often made. You will save yourself much aggravation, and you will get a speedier reply to your submissions. You may even sleep better at night.
1
On the one hand, it is unfortunate that the masses have been thrust into the position of being their own insurance billers. Medical providers and insurance companies pay very decent money to professionals to fill out (and examine, at the claims end of the claim game) your medical, dental, and equipment claims. You are not paid to do this job, you are not trained to do this job, and yet, because of the many changes in the insurance landscape, the powers that be decided that in return for a discount on your medical services, the providers will not deal with the time-consuming process of filing claims.
That leaves you to do the job. Did anyone help you learn how, or even where to find an impartial source of information? No, they did not. That leaves you stressed out by repeated letters from the insurer for more information before they will pay the bill, and you harassed by bill collectors and bad credit ratings.
I admit that before I got into the insurance industry (and that was quite by chance), I had the same negative image of the insurance field as any one of you. It seemed like a scam, betting against yourself. It seemed like they enjoyed toying with the policy-holder - kind of like the evil Catbert in the Dilbert cartoons who toys with company employees.
And yet once I got behind the scenes, so to speak, I learned that insurance is possibly the most regulated business in America. True, many of the laws were in response to rampant abuses in the past. But those laws are there to protect you and all the insurers in your state have to abide by them. You may think that the agent droning on and on in your kitchen is trying to beat you into submission, but he is obligated to tell you the whole spiel about a product so that you cannot claim you were inadequately informed. The agent has rules about how many days he has to deliver the policy to you, about explaining it to you again when he delivers it, about getting your signature when you and he are in the same physical space together, about keeping up with continuing credits in order to keep his license, etc.
Do you stop to think how almost every other business offers you inducements to buy, but not insurance? That is because it is illegal for the agent to offer you anything of value (in some states a value of $15 is the threshold) but practically speaking the agent can offer you exactly nothing to buy. You buy a car, you can have salesmen throwing thousands of dollars at you in rebate, a new TV and/or DVD player - one time the salesman tried to throw in a vacation on top of everything --- but the poor insurance agent cannot even give you a restaurant certificate or gas for your car.
So, yes, the insurance industry has to operate within very clearly defined parameters that vary with each state. Try to drop the adversarial attitude.
Subscribe to:
Posts (Atom)
Posts
