Singular Pay Loophole

[Expat]

Better darned well contact the carriers with those clauses and find out the scoop. If you run around telling clients falsehoods about the competition that's no only unethical but opens you up for a lawsuit. In the case of Carefirst it's a non-issue if it's in network. If you're having a major surgery out of network it's neither her nor there since you're screwed with any company.

If you have Assurant managers telling you to trash talk the competition I'd walk off that job in a day. Sitting down with clients and whipping out "competitors" plans and trashing them is no way I'd want to make a living.

I agree, you will fall on your arse more times than you think.
Selling by running down the competition causes you to walk a very fine line as you run the danger of causing your potential client to feel stupid for buying the plan he currently has. That does'nt earn you any brownie points, most likely you have just pissed him off.
Also you had better be very sure of what you say about your competition, because sooner or later it will come back to bite you. Any plan that has to rely on running down others is probably not worth selling.

 

[Crabcake Johnny]

Right...some agent's gonna come over our house and proceed to tell my wife and I how much Blue Cross sucks and how many holes they have....in the meantime they paid insane claims all throughout my wife's pregnancy. Likely we'd say "great, there's the door."

 

[somarco]

Non emergency services, such as a scheduled surgery will require the patient to check & make sure everyone who is going to touch them is in network. Most don't, they just assume since the hospital & attending are par providers that everyone else is as well.

Therein lies the rub.

Sometimes if they complain loud enough the penalties will be waived by the carrier. However that does not obligate the provider to accept the amount offered by the carrier as "paid in full". The non-par providers can, and will, balance bill.

It becomes worse when the patient ignores the xs billing by the non-par provider and it is turned over to collection. By then it is too late to do anything.

 

[BKrocko]

Non emergency services, such as a scheduled surgery will require the patient to check & make sure everyone who is going to touch them is in network. Most don't, they just assume since the hospital & attending are par providers that everyone else is as well.

Therein lies the rub.

Sometimes if they complain loud enough the penalties will be waived by the carrier. However that does not obligate the provider to accept the amount offered by the carrier as "paid in full". The non-par providers can, and will, balance bill.

It becomes worse when the patient ignores the xs billing by the non-par provider and it is turned over to collection. By then it is too late to do anything.

IMHO - If the client calls the carrier ahead of time and requests approval for the procedure, the burden should be placed on the carrier to conduct the due diligence. The client has enough on their mind getting ready for the operation - I'm surprised that the DOI does not take mandated action to cover that loophole.
Do you guys cover that point with the client? It's enough to scare away most people.

 

[somarco]

Barry, it is impossible to cover everything with your client. They are given a policy (which most of them never read) and it spells out what is covered, what is not.

As I said, most carriers will waive the penalties for OON providers when it is clear the insured had no way of knowing the 2nd assistant to the 3rd assisting surgeon was out of network. However there is nothing the carrier can do to force a provider to join a network or force a provider to accept R&C as payment in full.

A partial list of hidden providers follows.

Anesthesiologists, radiologists, medical transport, pathologists, almost any kind of therapist (oxygen, physical, occupational, etc.), many ER docs, etc..

Any interaction with any of these professions should be a warning that their claim may not be paid in full and the provider can & will balance bill.

And the DOI has no control over this at all.

InsureBlog: Wrong Number

InsureBlog: At Risk

InsureBlog: Hidden Providers

InsureBlog: Mangled Care

 

[BKrocko]

Thanks Bob - I have visited your blog (InsureBlog) numerous times in the past and must confess that you do an outstanding job - very impressive. You have a way of making it an enjoyable read as well as very informative.

I know I drive myself crazy attempting to investigate every nook and cranny - but I always place myself in the shoes of the client and don't like surprises that end up costing money. It seems that half our job is to find an insurance company to protect the client and the other half is to protect the client from the insurance company!

 

[somarco]

No one likes surprises, Barry. With managed care, the internet, carriers squeezing contracts in ways to make the plan seem competitive it is a jungle out there. The consumer is ill equipped to navigate and God help them if they end up with some *** agent who is only in it for the money. Slam, bam, make the sale & move on.

There is no such thing as a truly comprehensive major med. All have limits on DAMN coverage (but some are more liberal that others), almost any kind of therapy (occ, speech, physical) and extended care. In order to keep the coverage affordable many also limit what they will pay for Rx, they set annual or per incident limits on coverage and penalize the crap out of you for going OON.

They limit your OOP but that means nothing if you have a copay plan. Of course most consumers don't know that and they assume their copays accumulate toward their deductible and of course a log assume the deductible is all they have OOP. They don't understand coinsurance and even if they think they know what it is they opt for a more expensive 80/20 to $2000 vs 60/40 to $2000.

They go for a check up & the doc orders an endoscopy and they just assume that is part of their wellness. Then they get the bill for $1800 and find it is applied to their deductible.

Guess who they call then?

I do what I can to educate consumers but also tell them to stay in contact with me, especially if they are going to have some kind of elective procedure. Some call, some don't until after the fact then I have to settle them down.

The biggest complaint I see from consumers involves emergency care & medical transport. They don't understand why the ambulance charge was $700 (or $6000 if by air) and the plan only paid $300. They also don't understand why the doc who treated them in the ER (a par hospital) is billing them for double what the carrier allows.

In many cases a lot of this can be overcome with a solid HSA plan but even that does not cover everything. These hidden providers can really put a dent in your wallet. I tell folks to calculate their OOP on a plan & figure on doubling that in an emergency.

Some listen, some do not. Nothing I can do about that.

 

[blaze1x]

I agree, you will fall on your arse more times than you think.
Selling by running down the competition causes you to walk a very fine line as you run the danger of causing your potential client to feel stupid for buying the plan he currently has. That does'nt earn you any brownie points, most likely you have just pissed him off.
Also you had better be very sure of what you say about your competition, because sooner or later it will come back to bite you. Any plan that has to rely on running down others is probably not worth selling.

I'm somewhat convinced that throwing daggers at the competition may not be the best way to go...but, and there's always a "but," if:

1. If a company like Golden Rule has been advised in several states that they can't issue insurance anymore because of questionable business practices, shouldn't an agent mention that? What is they get a pre-existing condition and their company leaves the state?

2. When I read a Blue Cross Policy and it says that if, during a hysterectomy surgery, they have a need to perform an appendectomy, they won't pay it (this is the example the policy uses), shouldn't you say something?

3. With Humana's plan that don't have a max out of pocket for out of network and just five years ago they canceled fifty-thousand policy holders in your state, shouldn't you say something?

I understand that maybe I should say that in Connecticut with some of Assurant's lower-end policies they've run into some trouble (I kinda hint at that now by saying as an agent I'm not allowed to market those policies to them), but as a new agent some of this crap in the other policies does keep me up at night. And no, I don't have a nice and fuzzy feeling about Assurant's either. But it scares me just a little bit less.

That leads me to something else...

Except for a true one deductible plan, it's my understanding that all of the insurance plans, including Assurant's, have tremendous loopholes with respect to expensive injections which are often handled as prescriptions (for cancer and transplants, etc) and no plan really does a whole hell lot in the way of protecting anyone from a true worst case scenario.

Please tell me I'm wrong. Those one deductible plans, especially for a family are really expensive.

 

[BKrocko]

If it was an emergency appendectomy, interpretation of the procedure would fall under the emergency clause and it should be covered. It is not often that a person goes into surgery and the surgeon decides to remove additional parts or perform other non essential duties that were not already scheduled.

In CO, Humana has an oop cap on level 4 (self injectables) of $2500. Assurant does not - and I think that the Max Plan 20% Rx would destroy a person who needs Rx of $1000 or more/month . They would be much better off with any of the other (non HSA) plans that offer Rx co-pay at a fixed amount with no Rx cap/yr.

You can punch holes in any plan including Assurant - Once again, if you are going to mention any business practices in an unfavorable light, you need to include Assurant in your presentation as well and not just as a hint. Do you explain the rate increase history with Assurant? They all take increases but Time is on a roll. I like Assurant but I like other carriers too, it depends on the individual situation. It is not a one policy fits all world, if you get to a point where you can offer more than one carrier, you will regret your current attitude.

 

[somarco]

If you get into the practice of telling a client how a claim will be paid by one carrier you are opening yourself up to some liability. Except for relatively minor details, I don't get into a lot of explanation on claims, contractual provisions, etc.

You can quickly cross the line between providing useful information and move into negative selling which almost never works. There are tales (tall & otherwise) about every carrier out there. I can tell you horror stories about BX, KP, Time, GR/UHC, Aetna . . . the list is endless.

When Aetna offered plans with $5k caps on Rx I told clients to avoid those plans and instead look at the PPO Value which did not have an Rx cap.

I am quick to point out the limitations of the Saver plans & Right Start plans. I also mention the Rx copay on Core Med & Max. But I don't get into the minutia of these plans.

I also tell folks the pre-ex cannot be waived with BX and if you have a p-x condition they will surcharge your rate and still not cover the condition for up to 3 years.

But I really see no point in beating up the competition on the intricacies of the contract.

Subway makes comparisons to McDonalds & Burger King in their ads & restaurants. They do so, not by telling you how bad the McD & BK sandwiches are but by telling you how much lower in fat their sandwich is.

You can compare a Copay Select to a Copay Saver without putting down the product. You can compare a "regular" HSA to the Save Right by pointing out how much more the regular HSA covers vs. the Save Right.

I don't see a need to go any further than that.