Insurance Claim

The health insurance companies of America are lining up at the doors of Congress to commit legalized bribery like never before. In this time in which Congress and the President are trying to craft some type of health care legislation, insurers want to make certain that their feet are firmly under the table.

America’s Health Insurance Plans, the national association representing nearly 1,300 member companies providing health insurance coverage, reports that it spent $2.4 million just from July through September.

The non-partisan group Center for Responsive Politics reports that some drug companies are also outdoing previous efforts at buying influence. Pfizer has spent $16.3 million lobbying so far in 2009, and Amgen spent $9.2 million so far this year. Those amounts far outpace their 2008 bribes.

So, let’s run a total:

$ 2,400,000
$16,300,000
$ 9,200,000
$27,900,000

That doesn’t count individual companies like US Healthcare, Aetna, Kaiser Permanente, Humana, United Healthcare or any others. That also doesn’t count October and November.

But remember...there are 435 members of Congress and 100 Senators, one president and one vice president who is also president of the Senate. That totals 537 people. Divide the bribery total above by 537 and you see that each elected official could potentially have received $51,955.00 in contributions just from these lobbyists.

Remember also that the bribery is not done. Remember also that the opponents to this health care bill are also lobbying and bribing.

Even the AARP has spent a mind-boggling $15.1 million in lobbying bribes this year, which is less than they spent in the first three quarters of 2008.

Don’t worry about the insurance companies, though. Their profits are secure, and Congress will NEVER leave them out.

Why?

The insurance companies have vast investment portfolios. A big part of their portfolios are government bonds and other government securities. If the insurance companies sold off even 1 or 2 % of their holdings at once, they could cause the bond markets to collapse overnight. Washington knows this and won’t allow it to happen. So, insurers will get pretty much anything they desire.

As the old saying goes...“when money talks, all the bullshi* walks.” Don’t believe ANY headlines that tell you the insurance companies are dithering and worried. They have NO WORRIES.

It’s a typical health insurance scenario. You or a family member has some medical procedure done. It usually involves a hospital stay. Within a few days or weeks, all of the bills come to you from the doctors, the hospital, the anesthesiologist, the labs, the radiology department, the surgeon...everyone who had a part of your health care event.

If you have health insurance through your employer, you’re usually only concerned about the amount of the bills not covered by the insurance. That would be your deductible amount and any co-pays you might have.

But what if some medical procedures are denied? What if some are underpaid? How do you challenge the determinations of the insurance company examiners?

Those bills can be in the thousands of dollars. For more serious illness and treatment, the bills can be in the hundreds of thousands of dollars.

Unfortunately, many of the bills are incorrect...sometimes wildly incorrect. Billing miscommunication happens daily on all levels. Doctor to patient, doctor to coding staff or billing service, billing service to insurance company, and insurance company to patient. Many miscommunications are due to poor interpretation of the facts. The right hand doesn't know what the left hand is doing.

The patient is caught in the middle, doesn't know who to believe, and being the ultimate bearer of the financial obligation, many times just pays the bill out of frustration. There is no average case, all situations are different, and no two problems are the same.

But, what can be done? How can a regular person...an average American faced with giant medical bills...determine the correct medical charges and get correct medical bills?

Strategy #1: Remain calm.

When calling the insurance company to dispute a payment amount or challenge a denial, insist on obtaining the full name of the person you’re speaking to. If they refuse, ask for a supervisor. I also strongly recommend recording every call. When you call into the insurance company, you’ll regularly hear that “this call may be monitored or recorded for quality purposes.” Don’t you believe it. They are covering their butt in case the claim goes into litigation. Get a recording of your own. Make sure you know the law on recording conversations in your state. You can find that information at: www.insurance-claim-secrets.com/support-files/phonerecordinglaw.pdf

Strategy #2: Become aware of “hot spots” in the health insurance billing process that are the source of many errors.

A major source of errors is the “superbill” filled out by your doctor. It is a long form with row after row of medical procedures, types of tests, diagnoses, types of treatment and codes. If the doctor checks the wrong box it can lead to a claim denial. For instance, a woman may be covered for a mammogram for a typical “wellness checkup doctor visit.” But if the doctor checks a different reason for the visit, the insurer might not cover the mammogram.

If the insurance company denies the claim in that instance, you need to get the doctor’s office visit file notes to see just what the doctor wrote in your file. Send the notes to the insurance company along with the explanation of the doctor visit. This one strategy could turn a claim denial into a claim paid.

Strategy #3: Ask for Credentials

Insurance companies use the term “not medically necessary” frequently in denial letters. This is another way of saying a claims processor is questioning your doctor’s judgment. If you get this denial message, call the insurance company and ask for the name and medical credentials of the person doing the second-guessing. Be cordial and polite, and take good notes. Record the conversation. If you find that the credentials of the claim processor are less than your doctor’s credentials, then send a letter to the insurance company, Certified Mail, requesting a medical review by a doctor with appropriate qualifications. For example, if you have a thyroid problem, ask for review by an endocrinologist, not just the insurance company’s medical director, who may have a completely different medical specialty.

Strategy #4: Separate Multiple Services

Multiple medical services that occur on the same day can also lead to a claim denial, especially if the doctor sends the insurance company two separate bills. So a bill from the doctor for reading an X-ray can get confused with the X-ray procedure that happened on the same day. The insurer may see them as duplicate bills and denies one of them...probably the larger of the two. So, get copies of the bills, highlight the separate charges, include a letter of explanation and send it all into the insurer. You might turn a denial into a payment.

Strategy #5: Retain a Patient Advocate

A Patient Advocate is a person or company that

• Organizes the endless bills, statements and claims forms
• Appeals denials of claims and incorrect payments
• Negotiates settlements with medical providers

The Patient Advocate gathers all the medical bills for a patient, analyzes them for accuracy, works with the insurer and medical provider to get the bills corrected, and negotiates settlement of the bills. They can cut thousands out of incorrect bills.

Finally, remember that everything about a medical bill is negotiable. Medical providers constantly accept negotiated amounts as payment in full. Don’t be the guy that “pays retail”...NEGOTIATE!

You can find out more about Patient Advocates at: www.insurancenightmare.com

The health insurance system in America is terminally ill. Americans have the highest health care costs on the planet. You’d think that expenditures like that would result in the healthiest population on the planet.

That is not the case.

For all our costs, the general health of Americans doesn’t stack up well against other Western nations. America has an intolerably high infant mortality rate, as well as a growing list of chronic diseases, including heart disease, diabetes and cancer.

To compound the problem, the economy is crashing, leaving millions more without health insurance. An estimated 48 million Americans are without health insurance. As businesses downsize and close, more Americans lose coverage. This crisis will give Congress and the Obama Administration the political cover to finally nationalize health care in the United States.

But is that the best way to solve the problem?

Some health care providers are innovating in a quest to provide higher quality care while controlling costs. One shining example is the Geisinger Health System in Pennsylvania.

Geisinger Health System serves 43 counties across Pennsylvania, accounting for over 2.6 million patients who are served by over 750 doctors.

Geisinger is perfecting a new method of health care that rewards doctors for taking better care of their patients, rather than the traditional way of paying them for the sheer number of patients they can see and the special treatments they get. So far, Geisinger is finding that quality improvement may actually reduce overall costs.

W. Edwards Deming, the father of Total Quality Improvement, would be proud.

Geisinger has developed a system that incorporates important strategies such as:

• Coordinated primary care - a team of doctors, nurses, technicians and a case manager coordinate all care for each patient, especially those with chronic conditions like heart disease, pulmonary disease or diabetes. They do what is best for the patient, not what is most convenient for the provider.
• Surgery with a warranty - typically, if you have to return for complications from surgery, you incur new health care costs. Not at Geisinger. Starting with cardiac surgery, they began offering a 90-day warranty at the same time they instituted checklists of best practices for surgical procedures. It has lowered readmission rates by44%.
• Electronic health records - the new records system allows doctors and patients to all access the same patient information with a mouse click. Patients and doctors can email each other, schedule appointments and patients can monitor their own progress.
• Patient involvement - encourages preventative health care, such as lifestyle changes.

These are the kinds of innovation that will always be found in the free enterprise system. Geisinger Health System is a for-profit company with revenues over $3 Billion per year. The profit motive is notably absent in all government activity, innovation and efficiency are seldom found there.

I don’t believe that government control of the health care of the nation is a good solution to the myriad problems. For the best example of government-run health care, look at the failures of the Veterans Administration. The Federal government has botched a system that affects only a few million people. We can only dread the day when Washington takes over health care for the entire nation.

Think about the depression that we’re entering in America. Millions of people are losing their jobs, and thousands of companies are either laying off workers, closing their doors or dropping employee benefits. Many of those now-unemployed people are also losing their health insurance. There are presently about 48 million uninsured people in the US. This gives Congress the political cover to do what they’ve wanted to do since the Clintons were in the White House...nationalize health care.

I just read an Associated Press report about the health insurance industry. The insurance companies are terrified of the future, which looks like it’s going to include some kind of Federal takeover of health insurance.

America’s Health Insurance Plans and the Blue Cross/Blue Shield Association (BCBS), two giant health industry interest groups, issued a letter to key senators on March 24th. In the letter, they stated that their member insurance companies were willing for the first time to curb the controversial practice of charging higher premiums to people with a history of medical problems.

Although the proposal left open certain loopholes, it’s a pretty big change of the old policy of “risk rating.” In today’s insurance market, insurers charge higher premiums to people with previous medical problems and who are trying to purchase individual coverage. If such a person even gets an offer of coverage from an insurer, many times they cannot afford the premium. However, in group coverage through employers, past medical history is not usually considered.

Last year, the insurance companies offered to forego the practice of denying coverage to sick people.

The conciliatory offers did not extend to small businesses, though. Small businesses with even one sick worker can see their premiums jump up significantly year to year.

It’s somewhat comical to see what the insurance companies will do to save their own skin. For decades, they have been sticking it to individuals on health insurance premiums. But now that it looks like Washington is going to set up national health care that will either be in direct competition with them, or might just put them out of business, they have had a “come to Jesus” experience.

Please don’t misunderstand the tenor of this article. I believe that the free market should dictate health care policy, not government. I believe that nationalizing health care is an unconstitutional usurpation of power. I’m just amused to observe that the bullies in the health insurance industry have met a bigger bully, and instead of fighting, they’re cowering.

If the insurance companies wanted to play hardball with Washington, they could win. All they would have to do is to begin systematically selling off their government securities, such as Treasury Bills and other Federal debt instruments. A small sell-off would shake the very foundations of the Federal Government and threaten to crash the entire financial system.

That would put Congress and the President on the defensive, and stop health care nationalization.

Aetna, the health insurance giant, may soon be insuring Fluffy the kitty or Fido your pooch.

Pets Best Insurance is the new pet insurance company under the Aetna banner. They began underwriting policies last week in six states, and plan to sell in all 50 states before long.

Pets Best intends to trade on the market visibility of Aetna and sell its policies through the 40,000-plus veterinarians in the United States. The policies will also be offered through the company website. Policy premiums will range between $300 and $500 per year per pet, based upon the chosen coverage.

Should you buy Pet Insurance?

About 60 percent of American households have a pet and spend over $10 billion a year on veterinary care.

The policies will pay 80% of costs, subject to a deductible, for each illness. Routine checkups, lab tests, prescriptions emergency room visits and other services are covered.

Pet Best’s policies are comparable to those that have been on the market since about 1998. Some insurers exclude hereditary and chronic conditions, others don’t.

If a pet lives an average of ten years, you could shell out between $3,000 and $5,000 on premiums for each pet. Without insurance, you might not ever spend that much on medical treatment. But if you are the kind of person who will do anything to take care of your pet, then medical insurance for your pet might make sense.

One of the things you might consider next time you’re shopping for a pet...remember that dogs are in veterinary offices twice as often as cats. So, if you’re a person on a budget who can’t stand the thought of life without a pet, consider a cat. Also, do some reading about the health problems inherent in the cat or dog breed you want to own.