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.
------------------------------------ Health Insurance Agents: Training, Support, Discounts, E&O for $440 www.ihiaa.com
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?
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.
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.
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.
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.
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.
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.
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.
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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.
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.
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.
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Make sure that brain is in gear before operating mouth
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."
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.
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.
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.
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!
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 idiot 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.
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.
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.
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.
Re: Singular Pay Loophole
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