Foot Care - E & L

Apr 15, 2008

  1. schealthagent
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    schealthagent Super Genius

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    All of this talk about how bad GR is or isnt got me looking at their e & l and i noticed that there don't seem to be any exclusions on treatment of the foot. I called broker services and they said it all depends on what is deemed medically necessary and wouldn't give any details. Any of you guys who have been through lots of claims have any experiences to share on who treats foot problems what way? THanks.
     
  2. jbage007
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    jbage007 Guru

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    you are beginning to understand the way home office at g/r thinks, irrespective of its new ownership.

    you're on the right track, my friend.

    (good luck proving that foot care is in any way medically necessary) :skeptical:

    now here's another fun one. check the rather lengthy list of states where g/r does not offer coverage. they're licensed just about everywhere, but they do not offer coverage in many states where other major players do offer coverage (omitting the obvious of nj, ma, etc.). ever wonder about that? you may not have reason to with your marketing, but it just so happens that it became an issue in mine (I do business in about 40 states)

    hint: do you think they really "voluntarily" withdrew from those states?
     
    jbage007, Apr 15, 2008
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  3. somarco
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    somarco That Medicare Expert Guy

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    So when did GR fire you?
     
    somarco, Apr 15, 2008
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  4. schealthagent
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    schealthagent Super Genius

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  5. somarco
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    somarco That Medicare Expert Guy

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    Carriers adjudicate claims according to contract. If the claim is a covered expense, it is paid (or discounted).

    There are well over 10,000 CPT codes. There is no way, in this forum, or this life, to address all the "what if's" of a claim.

    And there are plenty of foot injuries and illnesses that would be a covered item in almost any carrier's policy (assuming it is not a revealed and excluded pre-ex condition).

    Some are localized while others may be related to other conditions such as neuropathy.

    If you think a claim should be paid, and the carrier is not honoring the claim, then compare the EOB with the contract and either accept that the carrier is right or fight it.

    In more than 30 years assisting clients with all the major carriers, I have had very few claims that were paid incorrectly. The few that were challenged were eventually resolved once more information was forthcoming.
     
    somarco, Apr 15, 2008
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  6. schealthagent
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    schealthagent Super Genius

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    I understand that it would take for ever to go through all the what ifs. But was just looking for any advise. The reason I asked you guys is that none of the carriers will help. I started studying the Humana E&L and it flat out says
    that "foot care services" are not covered. I am waiting to hear back from the area sales manager.

    Assurant: "Routine hearing care, routine vision care, vision therapy, surery to correct vision, routine foot care or foot orthotics."

    Similar language with BCBS.

    Anyway, so what has Golden Rule not paid to make you hate them so much?
     
  7. somarco
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    somarco That Medicare Expert Guy

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    I don't hate them. Use them quite a bit.

    If you get hung up on exclusions & limitations (and all the other nuances) you will never sell anything.

    More claims are denied (or reduced) for undisclosed PX and OON charges than anything.
     
    somarco, Apr 15, 2008
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  8. schealthagent
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    schealthagent Super Genius

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    Somarco,

    I was asking JBAGE007 why he hates 'em so much. It is hard not to get hung up when someone asks you point blank. What do you tell them?
     
  9. somarco
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    somarco That Medicare Expert Guy

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    I pre-screen everything that is questionable. If someone specifically asks about turf toe (to use your example) I do a pre-screen with the underwriter.

    Assurant: "Routine hearing care, routine vision care, vision therapy, surery to correct vision, routine foot care or foot orthotics."

    Similar language with BCBS.


    I don't know of any carrier that covers ROUTINE care. Medical care following an injury or illness is different.
     
    somarco, Apr 15, 2008
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  10. jbage007
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    jbage007 Guru

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    Here is just one teenie weenie example. You will have to note that this is not something "in the policy" so to speak. I have hinted to you folks that you have to look beyond the wording of a contract to try and get a glimpse into the soul of the company.

    Part of the problems, a big part really, with Golden Rule was that it was a mickey mouse company for many, many years. It was family owned forever, and well, that's never a good sign, generally speaking.

    Any of you who care to do so can verify this fact: Golden Rule has in fact pulled out of several states.

    As you know, companies are not allowed to cancel individual contracts--they can only cancel one family if they withdraw from a state (I'm oversimplifying for the sake of certain posters on this board).
    :nah:
    One of my clients in Louisiana is someone who was personally impacted by Golden Rule's departure from that state. His wife had just developed breast cancer, while being insured with Golden Rule. Within months of the original diagnosis, these folks were shocked and dismayed to find that their individual insurance was being canceled--because their company was pulling out of the state. (Why were they withdrawing, you might ask? Hint: It was not exactly voluntary, and Louisiana is not exactly the friendliest state for litigation, if you catch my drift.)

    Now tell me, what are the chances that the wife of a self employed person is going to be able to get any kind of insurance coverage after being diagnosed with breast cancer and while just beginning treatment?
    :mad:

    Withdrawing from a state is not something a legitimate company does on a routine basis. Company "X" (which shall remain nameless) has NEVER withdrawn from a state. Couldn't they do it tomorrow? Certainly. But this is where you have to look into the soul of a company and see what those people are really like who run that company.

    This is only one of countless horror stories I could recant about the good ole' boys in Indianapolis.

    Anyone ever heard of Medical Savings Ins. Co.? Ha. Now that's a good one. No, it's not exactly the "same" company as Golden Rule. But check out that company's history--see what happened to it after a certain Mr. Rooney took it over. Pathetic. Useless excuse of an insurance company.

    Granted, it's a new day at Golden Rule. But the problem is the same people remain in prominent positions at that company, with some exceptions of course. Over time, the company may actually become a legitimate player. But for now, it's not worth the risk in my book.

    MY REPUTATION IS TOO IMPORTANT TO STAKE IT ON A BUNCH OF NO-GOODERS WHO HAVE PROVEN THEIR PROPENSITY TO ACT IN THE MOST UNPROFESSIONAL MANNER.

    Back to the foot thing. Toe turf is an "accident." Just like a broken ankle in that regard. Not routine foot care, which virtually no company is going to cover--and some will put it out there in writing plain as day. Others try to play hide the ball -- give an agent the chance to spin the yarn, and it indeed is going to happen. That's why I prefer the approach of the companies that are as straight-up as possible about what they will not cover.

    Because you just can't trust health agents don't you know? :jiggy:
     
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