Life & Health Insurance/how insurance works

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QUESTION: I have a special needs daughter. Well, Starting in late August she had to have her gallbladder out and physical therapy came to us. Once she got well enough, they transferred her to another Physical Therapy place that could help her with laser therapy. After about 8 visits her Podiatrist wanted her to go to another place. So she did about 12 visits there. Then the first place told me 'sorry. we don't take her insurance and never did. you have an account with us.' To this date I still haven't gotten a bill.
So I'm wondering how would a company sign up for 'such and such' insurance.
How does a Physical Therapy or anyone decide what insurance to take? And then how do they do it? Would they simply sign their name to a contract? Does the insurance pay the practice or do the practice pay the insurance?

Thank you for your attention. This insurance stuff is so frustrating.

ANSWER: Joyce,

Thank you for reaching  and thank you for your patience. Busy week in my world both professionally and personally. However, your question deserves some answers and here we go...

First, my prayers for you and your daughter. Special needs are special indeed and your heart is precious for all you do for her.

Now, I will try to address the questions you have without adding to your frustrations:

1 - Every physician, specialist, etc. decides who they accept and who they don't. They are not governed by anyone but their own decisions. As an example, I have a client whose son went into the emergency room a few months back and received a bill after the fact for over $800 because that doctor within that facility did not take the coverage he had. It is an oddity indeed and because it was an ER and that doctor was the only one on duty the day they went in, it's just what happened.

2 - Most companies will call on doctors and facilities to accept their payment plans and such. Many times if a doctor is NOT on the list, the individual can nominate them to be visited by the insurance company and see about adding them to their network. That's the insurance term you need to know...NETWORK. The network doctors are the ones that have said YES and are being paid by the carrier. (This should answer 2 of your questions above).

3 - The insurance pays the doctor. Now, if the doctor owns the practice and that is where the doctor wants the funds to  go, he can assign it to the practice, but that's how the doc gets paid. He gets paid through co-pays, fees, and through the insurance company for services rendered.

I hope this answers your questions. You situation is one of many I run into. Health coverage requires people to have to ask these days. The first question people should always ask is if the coverage they have is covered there or if they need to use a different doctor. ER visits for true emergencies are different in that most times they can't stop and ask. They deal with that after the fact. In your case, you would assume that the physician would have asked and inquired and been able to tell you they did not take the coverage you had. That's why I train all my clients to ask.

My best to you and your daughter.

Sincerely and professionally,

Gene Ramsay

---------- FOLLOW-UP ----------

QUESTION: The question I have this time is WHY.
Why did the PT decide to treat her and then approx. a month later say 'sorry, we don't take her insurance' They knew in the beginning what insurance she had as they asked for her cards. I think that may be the part that bothers me most. Is this common? Do they make MORE money by self pay than they do if the insurance pays?

ANSWER: Joyce,

I wish I could answer why people do things the way they do. It seems like common sense to me that doctors and hospitals ask about insurance up front and advise people. In an emergency situation I can see not doing that. You have a an insurance case here, I think. If you can show where they got the insurance information up front and can prove this was not an "emergency" situation then they will need to chalk it up to their fault and have to swallow it.

To answer your second question...a bill is a bill. They may adjust it some depending on the insurance situation but again...this is why they check on insurance before services are rendered. I can see where self pay MIGHT pay them better as those funds they don't have to wait on.

Your situation is not uncommon, and that is unfortunate. The best thing I can tell people is to always be proactive and never assume that the person or office you are talking to has the right processes in place for you.


Sincerely and professionally,

Gene Ramsay

---------- FOLLOW-UP ----------

QUESTION: Ok. One more question and I'm not sure you know the answer to this one. Approx a year ago, (Sept 2013) we moved to Fl. When we lived in Maine, I never EVER thought about who took what insurance. I guess it was all assumed. We never had a bill. So is there some difference in the law or something? I'm just kind of confused on that.

Answer
Joyce,

What I can tell you is that different states and different carriers in those states equals differences in claims processing. What you had may have been more prevalent in that state. Take Alabama, for instance. BCBS has a 95% market share. You'd be hard pressed to find anyone who did not accept it. However, there are some doctors who would rather charge per treatment or occurence and not be affiliated with insurances. Nothing is in stone but the answer to your question is that differences in any one area can mean differences across the board.

As I stated before, the key is to inquire and get verification from your carrier on what they cover, who uses them, and what to expect to pay. At least that way you have all the knowledge you need going in and can refer back to that if anything shows up differently.

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Gene Ramsay

Expertise

I can answer questions from people regarding health, life, and voluntary insurance. I can also answer certain annuity questions, long-term care, medicare, vision, dental, group products, individual products, and certain carriers. Another area would be general discussion on an individual basis to determine need and help individuals make the right decisions for them. I can also field questions from other insurance providers about carriers I represent so we can do some business together and I am also willing to offer my thoughts on certain issues they may be having with clients/customers, etc.

Experience

My experience comes from helping many people every day handle tough situations in the health, life, and voluntary insurance markets. I do not claim to know it all, but I will always be direct and professional.

Organizations
National Association of Health Underwriters, Alabama Association of Health Underwriters, Birmingham Association of Health Underwriters

Publications
Self Funding Magazine, ezines.com, Birmingham Business Journal, North Jefferson News

Education/Credentials
My educational credentials are holding a health and life insurance license in multiple states.

Awards and Honors
Colonial Life Rookie Sales Award of the Year (2006), Treasurer - Birmingham Association of Health Underwriters (2010), NAHU Region 5 & 6 Leadership Conference Participant (2011), "Benefits Selling" Magazine Reader Council Advisory Board (2011), President Elect - Birmingham Association of Health Underwriters (2011), President (2012-2014), VP of Technology - Alabama Association of Health Underwriters, (2011-Present), NAHU LPRT Soaring Eagle Award Recipient (2013)

Past/Present Clients
I would prefer not to divulge clients without their consent to do so.

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