Insurance Agent Forum

[scrabble]

I am hoping to compile a list of gotcha moments that can commonly occur to new policy holders and any contributions are appreciated.

For example, I have heard of things like an anesthesiologist being out of network and therefore his services aren't covered.

Anyway, If anyone cares to share their experiences, I would love to hear from you.

Thanks

[CHUMPS FROM OXFORD]

Emergency room charges. Many customers (who don't talk to brokers) see a "$100" charge for ER on the policy description pages. They rarely realize that there is also a deductible (in most cases).

[healthagent]

Ambulance takes someone to the closest hospital since it's an emergency but that hospital's not in network - client gets slammed with bills.

[souldeux]

The anesthesiologist thing is a good one. Off the top of my head, there's also:

- The office visit copay covers a history, but not lab work or x-rays

- Generic prescriptions are covered, brand names aren't

- Check the caps (max Rx cap, max outpatient cap, max yearly cap)

- Per-confinement deductibles instead of per-year deductibles

- $250 deductible, $5000 out-of-pocket

- "What do you mean I only had six office visit copays? I'm not paying $500!"

[healthagent]

In-office lab is a biggie and most agents don't know how their plans handle in-office lab charges.

[leftsided]

% of surgery schedules ( reimbursement rates ), client gets billed for remainder all while they thought it was 100%* covered.

[healthagent]

Air ambulance either not covered or limited. Client gets medivac'ed and slammed with a 10K bill.

[CHUMPS FROM OXFORD]

Originally Posted by healthagent

Ambulance takes someone to the closest hospital since it's an emergency but that hospital's not in network - client gets slammed with bills.

I thought that in life-threatening situations...the closest hospital was considered "In-Network."

[healthagent]

"life-threating" would be the carrier's call, not the doctor or hospital's. Same thing with seeking OON care for a "medical emergency."

[CHUMPS FROM OXFORD]

""life-threating" would be the carrier's call, not the doctor or hospital's"


I think I would rather have the doctor or hospital make that call.

[DS4]

If you were selling Mega, every claim by an insured would be a "gotcha"

[emptyeternity]

John, you should post on IHIAA these gotchas and more!! Also show the agents how to find out the lab work etc. or what carriers this pertains to...

[somarco]

PARE claims are almost always non-par. Doesn't mean they aren't covered, just that the provider is free to bill whatever and you are obligated to pay the difference in what the carrier pays and the provider charges.

Pathology
Anesthesiology
Radiology
Emergency

PARE claims and other non-par claims are considered hidden providers. You may think they are in network, but they are not. The ER is full of hidden providers.

[alphawave2k]

Originally Posted by healthagent

In-office lab is a biggie and most agents don't know how their plans handle in-office lab charges.

I agree with this...however, it is difficult to figure this one out unless you ask the carrier....and you better hope you get the correct answer. Each carrier is different. Some will cover it if done within the confines of the Dr's office. Others will have you dip into your deductible and coinsurance whether in the office or having to go to a separate facility.
Same thing with ER charges...you have your access fee, which goes towards fulfilling your deductible..yipee!, but then everything else has to be covered based on whatever the policy stipulates, typically your deductible and coinsurance. Is it any wonder that people buying insurance are so easily confused? When agents...generally speaking... don't know the nuances in policy coverage, then how is an insured to know? That might explain why so few of us have so many different carriers to choose from, and end up with a pet few carriers that we know really well.
But then, the slighted carriers will drop your contract (BC/BS for instance) if you don't write a certain volume. Different topic for a different thread.
One of my pet peeves is the wellness care wait. Isn't it better to nip a problem in the bud at less expense than having get to a point where the patient might get worse and require more expensive treatment? Some will want you to wait for 3 mos, 6 mos, 9 mos, and some maybe longer....Duhhhh?
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Originally Posted by DS4

If you were selling Mega, every claim by an insured would be a "gotcha"

Well helll I could even sell that, specially if you say everything is covered...in fact, I know I can.......Hmmmmmm

[healthagent]

Originally Posted by emptyeternity

John, you should post on IHIAA these gotchas and more!! Also show the agents how to find out the lab work etc. or what carriers this pertains to...

so you don't listen to my chats and webinars

[souldeux]

Originally Posted by healthagent

so you don't listen to my chats and webinars

He taunts me on Facebook, too, about not joining the ILIAA.

He's a mean guy.

(Just kidding - I love you, buddy)

[WinoBlues]

Wow, every so offten I think about writing health insurance. Last one was about 20 years ago. This thread cures that itch for awhile. I have had only had one claim per life policy so far.

[djs]

Originally Posted by WinoBlues

Wow, every so offten I think about writing health insurance. Last one was about 20 years ago. This thread cures that itch for awhile. I have had only had one claim per life policy so far.

I hope you didn't insure this guy..
Brazilian makes surprise visit at own funeral - Weird news- msnbc.com=

He might collect a second time on his life policy, since he attended (alive) his own funeral.

Dan