Singular Pay Loophole

[Crabcake Johnny]

Just watch the Blue Cross bashing. Mega tore into Blue Cross when I started there and couldn't stop pointing out their $500 drug cap.

The truth is Blue Cross OWNS Maryland and I'm stilling looking for all the traumatized clients going BK on their $500 drug cap plan with almost zero outpatient benefits. 72% of everyone in MD that has an individual health plan has Carefirst.

The real reason for bashing the Blue's is simple; in most states they pay crap commissions so agents have to mentally convince themselves there's a flaw with the plans so they can sleep at night. That's bullshit.

I don't sell Blue Cross is my state for no other reason then I can't live off $17.50 a month and I think it sucks they offer commissions that low. That "drug caps" stuff is a bunch of malarkey. There are small group plans in MD don't even offer name brand coverage. Just a discount. When I worked at Pontiac/GMC our plan only offered 30% off name brand drugs.

We have heard not to worry about commissions - just take care of clients and money will follow. Yes and no. Go start in a market selling 10% as-earned companies and see if the money follows. It will....in 5 years.

 

[blaze1x]

Just watch the Blue Cross bashing. Mega tore into Blue Cross when I started there and couldn't stop pointing out their $500 drug cap.

The truth is Blue Cross OWNS Maryland and I'm stilling looking for all the traumatized clients going BK on their $500 drug cap plan with almost zero outpatient benefits. 72% of everyone in MD that has an individual health plan has Carefirst.

The real reason for bashing the Blue's is simple; in most states they pay crap commissions so agents have to mentally convince themselves there's a flaw with the plans so they can sleep at night. That's bullshit.

I don't sell Blue Cross is my state for no other reason then I can't live off $17.50 a month and I think it sucks they offer commissions that low. That "drug caps" stuff is a bunch of malarkey. There are small group plans in MD don't even offer name brand coverage. Just a discount. When I worked at Pontiac/GMC our plan only offered 30% off name brand drugs.

We have heard not to worry about commissions - just take care of clients and money will follow. Yes and no. Go start in a market selling 10% as-earned companies and see if the money follows. It will....in 5 years.

This forum has proven to be an invaluable resource. Often during weekly meetings I know stuff way before anyone else does (GR's plan changes that just became effective, as well as an Assurant rate increase). Also, the wisdom and insight offer here gives me hope that this will be an industry that will provide for me and my family for many years to come.

Having said that, I feel like there's a perceived malice in my word when I mention the problems/loopholes in health insurance policies on the market. It's got nothing to do with commissions. I would like to make money, but my commission is not affected by a loophole. If I don't tell a client about a deficiency in a policy, then it won't have an affect on whether they sign or not.

My issue, and it really isn't more complicated than this, is: Has anyone run into a problem with the singular pay loophole, or in the instance of Blue Cross of Florida the incidental surgery exclusion? I can scan the language and print it up, but it's definitely there. People make their living off this business and I'm not trying to knock it.

Guys, I'm fat. I've got a nice banker's paunch. But I'm still a nice guy. My point is one can be critical without meaning to be mean or offend.

Also, I don't know how you present a product (product x, for example) without explaining why someone shouldn't sign with insurance company y. Or is this something I will learn how to do in time?

 

[Crabcake Johnny]

Well, getting back to my original post, I have a feeling that language in the FL Blue Cross policies simply applies to doctor reimbursement. Call and ask. If Blue Cross of FL does not allow balance billing then you're worrying your potential clients about nothing. If Blue Cross does not allow balance billing then a client seeking in-network authorized treatment CANNOT get a bill over their deductible and OOP. Logic dictatates if Blue Cross in FL has hitting patients with huge bills IN NETWORK they're be a DOI investigation. If you're talking about companies playing fast and loose with claims then note Assurant is in HUGE trouble in many states right now for denying claims improperly. Are you also passing that info onto your clients? In fact, the CEO is Assurant just stepped down and executives are under SEC investigation for securities fraud - just happened days ago. Print that out and take it to your clients.

Also again posting that this is also a non-issue for out of network. Use an Assurant policy and the ass't surgeon or anestesiologist is out of network. The client is on the hook for all charges over UC with no cap.

 

[Crabcake Johnny]

Blaze1x - I think I need to clarify my position.

If you want to sell Assurant captive I think that's fine. I'm not sold on one of the tactics being "bashing" other company's products even if the flaws are legitimate one.

The reason is all companies have flaws so to play devil's advocate you'd have to sit down with a client, pull out the Blue Cross plan and say "see this clause?" but then you'd also have to pull out the very recent Assurant articles and say "But also Tim, I need to point out that Assurant has a recent problem with not paying claims."

So the point is either mention nothing or mention everything.

 

[somarco]

The 50% Rx copay on Core Med is a deal killer. Not real keen on the 20% with Max either.

If you don't know why, you will figure it out eventually. Perhaps it will be when one of your clients wants to know why they are paying an extra $400 per month in addition to their copay for meds. By then it is too late to do anything about it.

The facility fees are no big deal. I actually like them. Would like to see other carriers off that as a way to hold down premiums.

All plans have "loopholes" if that is the term you want to use. The best way to cover your clients butt is to only sell HSA plans. All other plans are garbage, especially if they have copays.

Sorry. Had you confused with someone else who spent 10 yrs with Mega.

 

[blaze1x]

Well, getting back to my original post, I have a feeling that language in the FL Blue Cross policies simply applies to doctor reimbursement. Call and ask. If Blue Cross of FL does not allow balance billing then you're worrying your potential clients about nothing. If Blue Cross does not allow balance billing then a client seeking in-network authorized treatment CANNOT get a bill over their deductible and OOP. Logic dictatates if Blue Cross in FL has hitting patients with huge bills IN NETWORK they're be a DOI investigation. If you're talking about companies playing fast and loose with claims then note Assurant is in HUGE trouble in many states right now for denying claims improperly. Are you also passing that info onto your clients? In fact, the CEO is Assurant just stepped down and executives are under SEC investigation for securities fraud - just happened days ago. Print that out and take it to your clients.

Also again posting that this is also a non-issue for out of network. Use an Assurant policy and the ass't surgeon or anestesiologist is out of network. The client is on the hook for all charges over UC with no cap.

"The client is on the hook for all charges over UC with no cap."
Could you explain this to me? What does UC mean?

We're told, and I'm not saying this is true, that the unpaid claims have mainly to do with their lower end products and not the HSA, Max, Coremed, or Traditional One Deductible. The short term medical is a killer as well.



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[Crabcake Johnny]

With any PPO policy through every company if you're out of network and it's a non-emergency the insurance company will only pay usual and customary charges. The client owes the rest and it doesn't count towards the deductible or out of pocket.

I've had clients run into snags where they had surgeries at in-network facilities and received bills for assistant surgeons and anestesiologists claiming they were not in network.

 

[somarco]

OON charges have a separate deductible & coinsurance. OOP on OON means almost nothing since the provider can balance bill the client.

Many specialists are not in any network and free to charge whatever they wish. This includes anesthesiologists, radiologists, therapists (of many flavors), medical transport companies, etc.

If you are going to get hung up on singular pay and are presenting your product as the cure-all for these deficiencies you are going to have a tough time when your client comes back to you because a portion of their bill was not paid.

Time has good policies but so do other carriers. Any time you are dealing with a managed care product there are plenty of areas where claims can be denied or limited.

I can come behind you and tear your presentation apart by pointing out areas where the policy you sold leaves the client vulnerable. If you want to play the game of my policy can beat up your policy you will eventually lose.

There is an IMO for Time here in GA that does that. Has regular meetings to teach people how to tear down the competition in order to justify the higher priced Time products (vs. the competitors products). (Of course they also promote the Right Start & Save Right policies rather heavily and those two plans comprise almost half their sales).

They give their agents a book showing bills that other carriers did not pay and claim that if you had a Time policy this would not have happened. They collect EOB's from all the major carriers (especially BX) and use this as a scare tactic to sell their product. This IMO has a big contract with Time but pays their agents squat. This kind of terroristic selling is unprofessional in my opinion.

 

[BKrocko]

OON charges have a separate deductible & coinsurance. OOP on OON means almost nothing since the provider can balance bill the client.

Many specialists are not in any network and free to charge whatever they wish. This includes anesthesiologists, radiologists, therapists (of many flavors), medical transport companies, etc.
.

This subject has been touched upon in the past but there does not seem to be a uniform answer as to how it is handled. From your experience, what is the most common outcome pertaining to billing for those services? I know that if it is an emergency situation, it is normally considered in network, but what about scheduled procedures. The client does not really have a say (and would not even know to ask) if all of the support personnel are part of the network.

 

[Crabcake Johnny]

I have won two out of network fights - one regarding an ass't surgeon. My client got balanced billed over $8,000. Turns out he just didn't show up in network but he was a hospital staff doctor and since the hospital was in network by default anyone on hospital payroll must also be in network. Won that.

Another was an anestesiologist. Apparently a lot of these clowns are just independent and float around "on call" from hospital to hospital charging insane rates. This was a longer fight but we won. The anestesiologist had a contract with that hospital and again, we argued that since they had a contract with a network hospital by default they were in-network. My client also argued that it would have been impossible to find out before the surgery and he did his diligence by making sure his doctor and the hospital where both in network.

Only an agent can really help in these situations. The client alone can't get crap done.