Chapter 5 — YOU GOTTA LAUGH: Life in the Trenches of the Health Insurance Business

This month's health insurance nightmare: You submit your health insurance payments through a third party administrator but the administrator does not remit payments to the carrier, therefore all coverages for all employees are canceled.

The situation: The Alagassi Companies uses a broker for their insurance needs. The broker chooses where to submit the business — sometimes it is directly with the carrier, but many times there is a third party intermediary such as a wholesaler or a third party administrator.

Here's how that works: There is no difference in cost for the company purchasing the insurance. A broker chooses either a wholesaler or a Third Party Administrator (TPA) based on additional services that can be received from that organization. A wholesaler typically does not remit payment to the insurance company as the insurance carrier bills the customer directly. The organization processes renewals, runs quotes and handles problems on behalf of the client.

A TPA typically submits payment to the insurance carrier on behalf of the client thus creating another level between the client and the carrier. In fact, it would not be unusual for the TPA to do the billing, rather than the carrier.

The problem: In this case, the Alagassi Companies was using a TPA through their old broker thus submitting payment for their health insurance premiums to the TPA. The TPA unfortunately was not remitting payment to the carrier; thus the employees all received a notice that their coverage was canceled. The client was embarrassed — and furious — all at the same time.

The solution: If this is the process your company uses, make sure you ask your broker if they use a wholesaler or a TPA. It is always better to submit directly to the carrier to avoid these potential issues. With online technology, direct debit payment availability and other useful tools, there is no need to have an administrator collect the money. You want broker representation without multiple layers.

If we were the Health Insurance Ambassadors: We would not allow third party billing and collection of premiums. All insurance carriers should be paid directly from the customer thus alleviating cause for delay and loss of money.

The painful truth: If you are submitting your payments through a third party vendor, do not assume that your premium payment has reached the carrier — even though you have a canceled check. Yes, it's sad but true.

Share your stories: We encourage you to tell us about your insurance nightmares. Send an email to our newsletter editor, "hope@inkandescentpr.com.":mailto:hope@inkandescentpr.com

Chapter 2 — YOU GOTTA LAUGH: My Life in the Trenches of the Health Insurance Business = Continuity of Coverage

This month's health insurance nightmare: Continuity of Coverage

A new book by Stephanie Cohen and Scott Golden
With Hope Katz Gibbs
Coming: Fall 2010

When you leave a position and lose or change coverage, it's essential that you have proof of your previous coverage. You will be covered under the Health Insurance Portability and Accountability Act (HIPAA) that was enacted by Congress in 1996, but you must have proof – a letter from your previous insurance agency and a copy of your insurance card. If you don't keep track of this important information, frustration and complications can result. Consider this dilemma.

The situation

Our client, Ian, who worked for a nonprofit in DC from December 2007 through the end of June 2008, never thought about tracking the insurance he had from his employer and was surprised when he was required to provide his new insurer with proof of coverage. When he took another job in 2009 and applied for health insurance coverage, he called his old insurance company only to find there was no record of his previous coverage – and that's when he called us.

Ian is not alone. When we receive applications for new hires, most people fail to complete this section. Without proof of prior coverage, and if you are applying for coverage with a PPO, it is assumed you have a pre-existing condition. This usually results in a waiting period, which might become a barrier to getting insurance especially if you have a pre-existing limitation.

If you don't have proof of coverage and select an HMO, you are not subject to a waiting period – but only if you enroll in a timely fashion. Be aware that there are employers who do not offer an HMO – and again, you would be considered to have a pre-existing limitation.

Also, if you fail to complete the application in full and you have a "qualifying event," it could result in not being able get into the plan you desire.

A qualifying event includes death, divorce, legal separation of the employee, termination from employment for a reason other than gross misconduct, reduction in working hours, and the change in status of a child who ceases to be classified as a dependent under the terms of the plan. Of course, an employee is entitled to notice of the right to continuation after a qualifying event occurs.

In Ian's case, we called his previous employer who put us in touch with their broker. Eventually we got to the bottom of it and found Ian's original application. He now has coverage through his new employer.

Here's how you can take control

1. When you terminate coverage, save the HIPAA letter indicating you had credible coverage. It will help you save time and avoid frustration when you apply for health insurance later.

2. If you don't receive a letter within a month of termination, call your carrier or broker.

3. Make sure to keep a copy of your old insurance card. This paperwork should be kept until the new policy is secured and you have proof of your new coverage.

If we were the health insurance ambassadors

We'd make sure that all carriers were required to keep accurate records of all of their past customers for at least 3 years. I'd also be sure that all representatives working with customers be trained to handle situations where they would help find a solution and not be a barrier to the process.

In Ian's case, for example, the representative should have made a call to his previous employer and / or insurance broker to help him get the information he needed.

The painful truth

Many insurance companies are not friendly to customers who call in, and even fewer are willing to go the extra mile to help out a frustrated caller. Short of a total overhaul of the insurance company's corporate philosophy toward customer relations, consumers need to know they must be responsible for managing their benefits. Know what you are buying, ask a lot of questions, and hire a broker that you trust who will make those calls for you.

What's your health insurance nightmare? Send your tales of woe via email to Hope Katz Gibbs, our publicist and newsletter editor, at mailto:hope@inkandescentpr.com.

Chapter 1 — YOU GOTTA LAUGH: My Life in the Trenches of the Health Insurance Business = Think you have maternity coverage? Think again.

A new book by Stephanie Cohen, CEO
Golden & Cohen, www.golden-cohen.com

Welcome to the first entry of the book we’ll be publishing in 2010 entitled, "You gotta laugh: Life in the trenches of the health insurance business." The goal is to find a way to improve the U.S. healthcare system for everyone. We truly believe that by talking about this issue, and starting a conversation about what changes need to be made and how we can make them, we will be able to move mountains.

What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?

The situation:When our client Randy, a nurse, found out a few years ago that she was having her first baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits — the fundamental first step prior to having any major test, ongoing therapies or any surgery.

To Randy, making the call was merely a formality, because when she originally purchased the policy years before she was single and didn’t opt for the maternity rider. However, after she got married, she added maternity coverage because she knew she’d someday want to start a family.

Indeed, when she made the call to the insurance company, they confirmed that she had the insurance she needed. However, after her first check-up at the OB/GYN, she received a letter saying she was, in fact, not covered.

Panic ensued, followed by a slightly hysterical call to our office. We quickly phoned the carrier, and unfortunately it took two weeks of repeated calls to them to get the information we needed. At last, we received an email from a reliable supervisor confirming that the rider had been added and she was covered.

Fast forward to three years later. Randy once again is pregnant, and following proper health insurance protocol, she called the insurance company to notify them of her condition. Here's the shocker: The agent on the line tells her she has no coverage. Surely this was a mistake, Randy thinks, so she hung up, composed herself, and called back.

This time another agent told her that she herself had dropped her maternity coverage the day her first child was born. Who would drop coverage on the day they are in delivery, she asked? Most people in the throes of 27 hours of labor are not calling their insurance company.

Frustrated and confused, Randy called us and we remembered she received an email from the insurance company months earlier stating that she had maternity coverage. We both had saved the letter, and we promptly took it to the head of the claims department.

Still, despite the fact that the letter clearly stated that she had maternity coverage, it took three people making nine calls for four weeks to get a definitive answer that Randy did, in fact, have coverage and that the policy would pay for her delivery. What we never did discover was why the coverage was dropped in the first place. Who authorized the change? And why did it take so long to resolve the matter?

You gotta laugh.

Here’s how you can take control

1. When you are thinking about getting pregnant, call your broker or insurance carrier to confirm that you are covered.
2. Make sure to get the name and telephone number of the person you spoke with, the department and supervisor’s name and telephone number, and the reference number for the call.
3. Always write down the date and time that you placed the call.
4. When buying a policy, if you are of childbearing age, be certain that you are covered for maternity.
5. Get a copy of your contract and review it carefully to be sure you are covered for all the potential situations that you may need the insurance for in the future.

If I were the health insurance ambassador

If I were in charge of health insurance policy, I would require every carrier to clearly outline and explain what is covered in the policy. When amendments are made, the policy needs to be updated and the customer needs to be notified. I would also post these changes on the insurance company’s website using easy-to-understand language.

Too often, this information is buried in the policy and is difficult — if not impossible — for consumers to understand. I’d also make sure that carriers were required to respond to issues like Randy’s within 48 hours, so as not to leave paying customers hanging. This is their health we’re talking about, and they are spending large sums of money and trusting that the insurance firms will fulfill their end of the bargain.

I often ask myself, why is this such a big problem. Is it corporate greed? Or are health insurance companies so big and bloated that no one knows what is going on? Either way, there obviously needs to be a change in the system.

The painful truth

The reality is that for now consumers are stuck having to fight for their rights and too often their calls are not returned in a timely manner. This serves to frustrate them more, and makes the insurance industry seem like an even greater villain. For now, there’s little that can be done to change the system. The best solution for the consumer is to know what you are buying, ask a lot of questions, and have a great broker that you can trust.

We encourage you to share your insurance nightmares with us, too. Send an email to our newsletter editor, hope@inkandescentpr.com.

Scott Golden weighs in on latest health care vote

THIS JUST IN: The Senate cleared a crucial procedural hurdle to bring its health-care bill to the brink of final passage by Christmas Eve.

The partisan vote of 60 to 40 shut down a Republican filibuster of the $871 billion package and followed days of tough negotiations with Democratic holdouts. "Read more here": http://www.washingtonpost.com/wp-dyn/content/article/2009/12/20/AR2009122002872.html?hpid=topnews.

*SCOTT GOLDEN SAYS:* The Senate bill will be approved by the end of week. That is not the most interesting event that will occur before we leave 2009, however.

When the House and Senate attempt to create a bill that both will accept, there will be fireworks.

Why? The Public Option. The House has one. The Senate does not.

Liberal groups are putting pressure on Democrats to vote NO if there is no Public Option. The public, in general, has become more skeptical about proposed changes. The process seems to be a race against time. The longer the process goes on, the more of a chance of the entire bill coming apart.

This is why there is such a sense of urgency. It is now or never.

Stay tuned for more in our "January newsletter":http://www.golden-cohen.com/newsletter.

A letter from Senator Barbara A. Mikulski

Dear Ms. Cohen:

Thank you for getting in touch with me about health care reform. It's great to hear from you.

Health care is one of the most important issues facing families and our economy. We need to pass comprehensive health reform that:

• reduces costs for families, business and government
•protects people's choice of doctors, hospitals and health plans
• assures affordable, quality health care for all Americans

As a member of the Health, Education, Labor and Pensions (HELP) Committee, I helped write the Affordable Health Choices Act, which was passed by our committee on July 15, 2009. This bill takes a giant step forward in providing health care that is available, undeniable and affordable for all Americans. It allows you to keep what you have if you like your current coverage. It prohibits insurance companies from denying coverage to those with preexisting conditions. It enables people to keep their health insurance if they lose their jobs.

Families and business are facing staggering health care costs. Premiums have doubled over the last 10 years. Without reform, these costs will continue to rise. The HELP bill reduces costs by:

• reducing administrative costs
• reducing medical and medication errors
• preventing hospital readmissions
• better managing chronic diseases
• reducing fraud and abuse in the health care system
• eliminating waste through promoting effective, evidence based medicine

I understand your concerns regarding the creation of public health care option. You should know that the HELP legislation is very clear: if you like the insurance you have today, you can keep it. The creation of the public option simply offers additional choice and competition to the current system. The public option is voluntary for patients and providers, it will be self-supporting, and will compete on a level playing field because it must abide by the same rules as private health insurance plans.

This is a historic moment. Forty years ago, the United States of America landed a man on the moon. I think that's a wonderful achievement. But if we can send people into space and be able to afford to do it, we can also help people get to a doctor and be able to afford to do it.

Thanks once again for writing. Please let me know if I can be of assistance in the future.

Sincerely,

Barbara A. Mikulski
United States Senator

My letter to Senator Barbara A. Mikulski

Dear Senator Mikulski,

As a health insurance broker who owns a firm employing 15 employees and insures more than 1500 groups in Maryland, the District of Columbia, and Virginia, it is very upsetting to me that the issues pertaining to te costs of care have not been properly addressed.

Has anyone mentioned the costs of prescriptions and reform within the pharmaceutical companies? What about the issue of tort reform, or the fact that many of the uninsured are illegal immigrants who do not pay into the system?

Until we look at the real cost of care, any reform that Congress initiates will do us no good. Arguably, the bills proposed and or passed will cost us more money than what's being spent thus far. In our experience, each year the average American has a physical, mammogram, Pap Smear, two sick visits, an X-ray, and a prescription such as Lipitor. How can a $200 per month benefit cover the cost of all of that?

Furthermore, why should some be able to walk in a hospital with no insurance and be provided with free healthcare when others pay for it? Wouldn't it be better to incentivize those on Medicaid to get off, and buy a useful, affordable health insurance policy healthcare after a certain tme period?

I firmly believe there are many ways to cut costs and keep premiums down. We believe it is a sad state of affairs that the real issues are not being addressed to heal or health insurance issues.

My partners and I would love to sit down with you to show you what the real problems are in healthcare as we sell, service and provide the products that the consumers are purchasing.

I will look forward to hearing from you.

Stephanie Cohen, CEO
Golden & Cohen www.golden-cohen.com

Q&A with Scott Golden was posted today on OurBlook.com

A website that offers innovative solutions to todays problems, "OurBlook":http://www.ourblook.com, today posted an "interview with Scott Golden":http://www.ourblook.com/Heathcare/Scott-Golden-on-Healthcare-Reform.html, chief financial officer of Golden & Cohen, a health benefits consulting company in the Washington, D.C. area.

Here's a sample:

*Question:* President Obama has made it clear he isn’t working to set up a precursor to a single-payer health care system. Meanwhile, the insurance industry says that any version of a public plan will kill private industry. Is there any precedent for a public/private partnership in health insurance?

*Scott Golden:* The way the proposal is being described, there are no partnerships, so the public plan would compete against private plans. There is nothing on point with this scenario to date, which is why there is great speculation as to what might happen.

Click here to read the entire interview.