Category: Health


Repricing on Health Insurance Claims

July 19, 2018

Health

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We have all heard the stories of the emergency room claim that cost $10,000 for a broken thumb, or the person who had to file bankruptcy from the huge bill while using a network outside of their HMO. These stories have been the fuel for arguments on what should be done with our Nation’s healthcare system. The truth is these stories occur more than most people realize, and many have misconceptions on how this happens. This is why it is crucial to have the right billing network to take advantage of most favorable, predetermined pricing available.

Lets take a look at a couple of scenarios where one person is stuck with a high medical bill and the other is protected. Suppose that two people walk into an emergency room for the same injury, one having adequate health insurance and the other having none. The emergency room is going to immediately know that each patient will be billed differently. The person with the right network billing plan will be able to take advantage of a nationwide network, allowing predetermined pricing for most any medical condition you can name. The other will be at the mercy of what the emergency room decides to charge. Depending on the medical condition, the difference of what is paid out could be upwards of tens of thousands of dollars. The catch is, in order to receive this predetermined billing you must have access to the participating billing network.

When you take a closer look at how these billing networks work it becomes clear where you may be exposed, especially on smaller networks. No one knows this better than the self employed and those who do not get insurance offered through work. When an individual purchases health insurance on the exchange (Healthcare.gov), the only network options available in Texas are HMO, or restricted networks. These networks are formed for the insurance company and the medical institution to share losses, while hoping to bring in excess volume of patients to offset the claims. Even these smaller type of HMO networks can have big holes in their billing networks. For example, if an individual has a surgery within their HMO network they may still have an unpleasant surprise when the final bill comes. Although their surgeon is likely covered, both the anesthesiologist and the surgical tools rented for the surgery might fall out of the billing HMO network, causing thousands of dollars to be paid by the patient. You guessed it, not a word of warning, just a bill that the health insurance will not cover well after the surgery.

The only way to avoid a small HMO network pricing trap is to take advantage of much larger billing networks, allowing you to avoid the uncovered pitfalls. These larger networks, or providers, can have hundreds of thousands of doctors and medical institutions participating coast to coast. Many of these nationwide networks make it mandatory for their preferred discount to be the primary, or front runner, method of billing, protecting the patient’s financial interests from any threat of overpricing. In fact, these predetermined pricing modules are so accurate some insurance companies form their coverage to mirror the preferred billing, therefore limiting the out of pocket expense by thousands of dollars. Those who utilize this service can rest easy knowing that their interests will be protected moving forward from the right billing network with unrestricted networks nationwide.

Although these billing network giants are elusive in today’s ACA health insurance environment, they do exist across the nation, Texas included. In fact, I have helped dozens and dozens of clients take advantage of these unrestricted networks over the last few months alone, at much more reasonable premiums than ACA policies. It is important to consider the network billing plans when choosing the right heath insurance plan for your family, especially for those who do not qualify for a subsidy (Federal income credit given to those with limited financial means). It is extremely important to speak to a health insurance professional who has access to these unrestricted billing networks, in order to protect your financial interests.

Overusing Your Health Insurance

July 19, 2018

Health

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When reviewing health plans and evaluating cost, keep in mind health insurance wasn’t designed to cover every penny related to health care.

Everything under the sun on an open credit card is nice, but not when you are paying the bill. But you are.

The purpose of insurance is to cover sudden very expensive losses. It’s about making you whole again and not have the financial responsibility of a ton of money to do it. Somehow we all decided over the last 60 years that the traditional plan should pay for everything.

Health insurance is the only insurance product, for the most part, that pays for first dollar coverage like doctor visits and prescription drugs. The healthcare system gamed the system on the bigger bank account paying the bill, not the small guy. The tables have turned…

Employees are more responsible for their healthcare in paying more for premium dollars out of their check and higher costs. Employers should engage their employees in being more proactive in their healthcare. Here are a few ideas:

  1. Don’t run to the ER or the doctor visit for every little thing. What happened to home remedies or waiting to see the doctor instead of running to the ER? This will save you thousands in a year if you have kids.
  2. Try saving money on medication by finding alternatives. Sometimes skipping the drug may not have an impact on your health, but keeps you coming back to the doctor. The other thing you can do is shop around. Just because they are convenient doesn’t mean it is the most cost-effective.
  3. Just because your doctor recommends a test, it doesn’t mean you have to jump to it and have it done. The doctor went through many years of school, but they are also trying to run tests to protect them and get paid. Ask more questions to see if you feel it’s the right thing. Just like you would if your mechanic suggested items. It’s your money.
  4. If you are scheduling a procedure, take a look around. Many new facilities are popping up to help reduce cost from outpatient testing to outpatient surgical facilities. The hospital isn’t the cheapest. Far from it. This ends up driving the price up for you and the insurance company.
  5. You do not need to go to a state of the art teaching hospital, for most thing. There are a time and place for the advanced care that some of the predominant teaching hospitals bring to the table. However, for most things people go through its overkill and overcharged.

In the end, it will end up costing you more money, either in out-of-pocket expenses or premium. There is no free lunch.