Small Business Benefit Solutions Blog

Archive for the ‘Insurance Carriers’ Category

The NH Department of Insurance has confirmed that the health insurance scam that’s robbed New Hampshire consumers out of thousands of dollars has been traced back to Pakistan, and now “Premier Health Care” is trying to continue the scam.

The NH DOI is now warning people that the American Trade Association (ATA) could still be drawing money from their bank accounts under a different company’s name.

The Department says they were warned that ATA was sending letters under the name “Premier Health Care” claiming they’re taking over the business.

The insurance department is urging people to call their banks and ask for a stop payment to keep a close watch on their accounts.

Anyone in New Hampshire who believes they could be a victim is urged to call the department at (603) 271-2261.

In any other state, please contact your states department of insurance.

Per the news story below, a woman who worked for a medical billing office “allegedly” helped herself to more than $60,000 of premium money paid into Oxford Health Plans.

She is accused of having filed claims for services she never had rendered to her by a physician.  This scam is partially responsible for the premium increase you received from Oxford this year. If you have a Oxford Health Plans ID card, that money was effectively stolen right out of your pocket.

Another man filed more than $200,000 in false claims and was only discovered when he made an mistake. A payment was sent directly to a provider whose name he had been forging. Fortunately, instead of cashing the check, the provider called and notified the insurance company that he was paid in error.  Both were surprised to learn that so many claims had been filed in his name.  Thanks to this doctor’s diligence and honesty, the thief was stopped, arrested, jailed and forced to pay the money back.

Many people have a false and overwhelming sense of entitlement when it comes to insurance.  ”If I pay my premiums, I should get something in return”.  This attitude is what has led to a multi-billion dollar crime spree to file false claims and reports in order to collect from insurance companies – not only health, but auto, theft , liability, etc.

Those billions of dollars have to be paid for by someone – and you may as well open your wallet right now, because that someone is each and every one of us.

As reported by Keith Martin of IFAwebnews.com:

A medical billing clerk for a Queens, N.Y., physician’s office faces charges of grand larceny and insurance fraud amid accusations she stole $61,500 through filing phony claims.

Magdalena Lubiejewska, 37, formerly of Rego Park, N.Y., allegedly filed 182 claims for medical treatments she never received, according to the New York State Insurance Department.

Officials with the department’s frauds bureau said Lubiejewska submitted the claims to an Oxford health insurance plan for payment to herself over a four-year period of employment at the doctor’s office.

Oxford became suspicious when it noticed the unusually large number of claims submitted under her name, sending as many as four of five claims a week for payment, officials said.

If convicted, Lubiejewska could be sentenced to 15 years in prison on the charges.

Anthem Blue Cross and Blue Shield has announced that the Bank of New York Mellon will replace ARCUS Bank for all High Deductible Health Plan members who are using Anthem to manage their Health Savings account bank accounts.

(This announcement will only effect clients of SBBS located in NH.)

Anthem Blue Cross and Blue Shield has decided to stop offering the ARCUS Bank health savings account (HSA) product. As a result, ARCUS is transferring clients’ Health Savings Accounts (HSA) with ARCUS to a The Bank of New York Mellon (BNY Mellon), as of July 01, 2010.

ARCUS and BNY Mellon will handle all of the details of this transfer.  You do not need to take any action yourself.  Accounts will be opened subject to the Terms and Conditions Statement of Mellon Bank and they will be contacted if additional information is needed.

Please be assured that you funds are safe and will continue to be insured by the FDIC up to the amounts allowed by law.

We expect there to be many questions about this transfer of your account to BNY Mellon, so we have included with this letter a comprehensive set of “frequently asked questions,” as well as a rate and fee schedule.  BNY Mellon will be sending additional details in the mail over the next few weeks to affected clients.

If you do not wish for your account to be transferred to BNY Mellon, you can contact ARCUS at 1-877-373-9859 no later than June 28, 2010, to receive additional assistance.

As always, you are free to select your own lending institution to manage your Health Savings Account.

No that’s not a joke, and stop looking for the punch line. I’m speaking about why you should consider supplemental insurance coverage.

In the latter part of the 20th Century, finances were treated aggressively;  acquire as much as possible knowing that the value of assets would rise more than debt you’d take on to buy them. Leverage was both acceptable and advisable.

Today, however, you need to take a much more conservative approach to financial strategy; to protect what one has acquired so as to not lose it all.

Financial defense in the form of insurance has asserted its rightful place alongside financial offense.

Enter, the duck. I’m referring to the obnoxious, but lovable mascot of AFLAC, the largest supplemental insurance carrier in the world.  

In the 50′s, when three brothers saw the emotional and financial devastation that occurred in their family when their father died of cancer, they created the company to insure against such events.

Whenever someone becomes too sick to work or gets injured to a point they can’t go to work, there are two things happen:  your income goes down and your expenses go up.

With more than 60% of all personal bankruptcy filings coming as a result of medical expenses and nearly three quarters of those coming from someone with major medical health insurance, the losses from an accident or illness could be devastating, not only for individuals, but especially for someone with a spouse and children.

Major medical does an decent job of paying the doctor and hospital bills, but there are co-payments, deductibles, coinsurance, and, if you don’t use their approved doctors or hospitals, those expenses can double or triple.

Think about your expenses now. You get a paycheck, pay some bills, go to work, buy incidentals, fuel up your car, pay the rent, and so on. But what if your hurt or sick? What if it leads to a lengthy stay away from work?

There are 5 major things you aren’t thinking about right now, but they are exactly where that unexpected vacation from the job is going to hit you in the wallet:

Combined, these can add up to thousands of dollars overnight and funding for these expenses will have to come from either your savings, retirement funds, investments, your home’s equity, loans or a credit card. Recuperating from an accident or illness can take a long time. Recouping the finances you’ve lost can take even longer.

Supplemental insurance, like AFLAC, can provide a low cost safety net by offering cash payments when you need it the most.

Best of all, AFLAC coverage doesn’t coordinate with your major medical policy, so even if your medical plan paid for a procedure in full, you’ll still get an AFLAC check for eligible services to use as you choose – reimburse yourself for co-payments or deductibles, pay the rent, make a car payment, make a credit card payment, anything you choose.

But I’m pretty healthy and I don’t go to the doctor that often, so why should I bother buying supplements insurance?

Well, you need to first look at the numbers to answer that question. Consider this:

• More than 30% of all emergency room visits are because of an accident
• A disabling injury occurs in the home about every four seconds
• 13 accidental deaths and about 2,650 disabling injuries occur every hour on the average
• Accidental injuries are the 5th leading cause of death, and highest for people ages 1 to 44
• Despite spectacular advances in diagnostic tools and treatment techniques, cancer accounts for approximately 25% of all deaths
• The National Cancer Institute says 1 in 2 men, 1 in 3 women and 1 in 200 children will be diagnosed with cancer. Each year there are nearly 1.5 million new diagnoses of cancer and 85% of those will have no family history of that type of cancer
• Heart disease and strokes account for nearly half of US deaths
• The average hospital stay runs between 5 and 6 days. Co-payments, deductibles and coinsurance bills for such a stay can be from $500 to $7,500. Are you prepared to pay these expenses out of your pocket?

That’s where the duck can be of help. AFLAC policies are available, both to businesses and to individuals in most states, to supplement cash flow in times of need following an illness or injury, or like Yogi Berra says, ” They pay you cash, which is just as good as money.”

Better than that, most AFLAC plans can be funded with pre-tax dollars which lessens the impact on both an employee’s take home pay and the employer’s matching withholding tax payments and workers compensation insurance premiums.

If your employer isn’t presently offering supplemental insurance at group discounts, ask them if they would consider looking at the options available to them. The right agent will not only walk them through the process, but make it as painless as possible.

If your employers isn’t interested, then you should consider talking with an AFLAC approved agent like Small Business Benefit Solution, LLC who can provide you with information about purchasing coverage for yourself directly. It will be a little more expensive that a group policy would be, but when the worst happens, knowing your finances won’t need first aid as well is security worth paying for.

Last week’s news that Wellpoint targeted breast cancer patients for insurance cancellation had both pro and anti-big insurance supporters reeling.  The article was so controversial that it reached all the way to the top of  the Administration when Health and Human Services Secretary, Kathleen Sebelius, issued a terse rebuke of the Blues calling on WellPoint to “stop ‘unconscionable’ coverage cancellations“.

But Wellpoint quickly turned around to fight off the attacks. They issued an equally terse response claiming that national news wire service Reuters’ issued an article filled with shoddy journalism claiming that the facts were wrong, mis-interpreted and misrepresented. They even claim that one of the women mentioned in the article was never cancelled because she was not  enrolled in of their plans.

WellPoint, as well as many other insurance carriers, scrutinize medical applications and paperwork, especially when a large claim occurs early on in the policy.  They are trying to determine if a patient knew about the condition before applying for the coverage, or if there are fraudulent claims being submitted under the members name.  Medical insurance fraud makes up only 3% of claims expenses to medical insurers each year, but that small percentage adds up to an enormous $68 billion according to 2008 studies by the National Health Care Anti-Fraud Association.  It makes sense that insurers are keeping a close eye on potential fraud, as should doctors and patients who are paying 3% more in their premiums to fund these expenses.

The Reuters Breast Cancer article suggests that insurers are taking that watchdog approach too far and using it to keep from paying for expensive treatments.  Wellpoint strenuously denies this charge.

Many states don’t permit termination of a person’s policy unless they have committed fraud in the enrollment process.  They call it “guaranteed renewable” coverage.  Carriers say this leaves them exposed to fraud that they can’t correct if they can’t prove the fraud exists, so they are forced to examine all applications more closely with specially designed software that flags common fraud transactions and medical codes.

We’ll let you decide what’s true and what not.

HOWEVER, SBBS believes it is so very important to be as close to 100% factual on insurance applications as possible.  If you’re unsure about the answer to a question on your medical insurance application, don’t guess!  Find the answer in your files or records, or don’t answer the question.  Making up an answer or guessing exposes you to the possibility of your application being scrutinized more closely, and if your answers are proved to be incorrect, your policy could be cancelled or your coverage could be reduced on the basis of misrepresented facts.

In the present medical insurance environment, take the utmost caution to answer questions accurately on your medical policy.  Your coverage could depend on it.

Whether you believe them or not, UnitedHealthcare’s PR folks have put together an Insurance_Cost_Fact_Sheet.  This document tells their story of why UHC has increased rates for it’s medical plans. 

Now the Scarecrow points his fingers in differing directions and so do insurance companies and medical providers and this document will not clear that up for you, but if you look at the arguments from both sides, you’ll have to admit that they each makes the case that the other plays a pretty significant role in the spiraling upward trend of health insurance premiums.

One of the claims that UnitedHealthcare is making in this document is that contracts and reimbursement demands from providers are unreasonably high.

Conversely, medical provider groups say that administrative hassles and insurance company red-tape are causing the increase in their costs.

And the national argument is forgetting about the patients who want the best doctor or facility, the most advanced technology, the best medicines and more research to cure illnesses and relieve injuries. They want all this for the cheapest possible price, but medicine is not a product suited for the big-box chain store mentality.  It’s not logical to see an ad announcing a “sale on colonoscopies this week only” or “15% of your blood work until teh end of the month”.

So can you lay blame for these increased costs in any one place?  Is it logical for the federal government to cap profits of the insurance carriers without also doing so to medical providers?  (Is it logical or even legal for the federal government to cap profits of any American is an argument for another’s blog.  The political implications of these decisions are a matter of vast and passionate debate.)

This is one of the most complex policy issues of our time, but we’re very interested in your opinions on this matter. Please comment.  If you had a magic wand and could fix health care costs, in which direction would you wave it?  Be respectful, but we’re very interested in posting your comments on this issue.

UPDATE:

Continuum Hospitals have reached agreement with Aetna on a new 3 year agreement that will be backdated to April 1, 2010. This means that all services that Aetna members received at the Continuum Hospitals after the termination date, will be reprocessed by Aetna and paid as “in network”.

All Continuum physicians that currently participate with Aetna will continue to remain in network.

Aetna apologized for the stress and anxiety this may have caused it’s employees/clients.

ORIGINAL ARTICLE:

Aetna and Continuum Hospitals are drifting towards a June 5th contract termination if the 2 sides can’t agree on reimbursements for medical services provided to Aetna members by these Manhattan and Brooklyn/Kings County based hospitals .

Aetna claims the hospitals request for a 40% increase over a 3 year period far outweighs the consumer price index, but Continuum claims that the CPI cannot adequately reflect medical cost trends.

Aetna members stand to lose key network participating hospitals including:

• Beth Israel Medical Center, Petrie Division
• Beth Israel Medical Center-Kings Highway Division
• Long Island College Hospital
• NY Eye & Ear Infirmary
• St. Luke’s Roosevelt Hospital Center – Roosevelt Division and St. Luke’s Division

Right now, Continuum Hospitals will at least remain participating until the end of the contract cooling off period which is June 5, 2010.

Small Business Benefit Solutions, LLC  will stay on top of this matter and post updates as they become available.

Some of the largest health insurance companies offering medical plans covering students at school – including Aetna and United Healthcare – were recently subpoenaed, along with several insurance brokers, agencies and consultants, in an ongoing investigation into what the New York Attorney General’s Office says is inferior health coverage at colleges in and around the state.   

 NY Attorney General Andrew Cuomo said that an investigation by his office has revealed “troubling practices” of school-sponsored student health insurance including extremely low coverage limits, excessive costs for coverage provided and inconsistencies with federal protections recently made law, “which leave students at risk”.

Cuomo has written directly to more than 300 colleges, universities and professional and trade schools both in New York and out-of-state suggesting they review plans offered to their students through the major insurance companies.  

Parents often find that their college bound son or daughter is forced to buy a school-endorsed policy from their college or university unless they can prove their child has comparable coverage elsewhere.  

But according to a statement released by Cuomo’s office, many of these school-sponsored plans “leave students at risk while providing massive profits for insurance companies”, because, as his office’s investigation found, the amount of claims paid out by the insurer, in many cases, is only a fraction of the unusually high premiums charged to students and their families.

For example, the investigation found some plans have maximum benefit caps lower than $25,000, while others place a cap on individual illnesses as low as $700. Additionally, many plans either don’t offer prescription-drug coverage or severely limit such coverage, Cuomo said.

“It is important for students to have adequate health care coverage to protect themselves during times of illness or injury, but a bad health insurance plan can have catastrophic and long-lasting effects on a young person’s life,” the attorney general said. “By being informed of the problematic practices that currently exist in the industry, schools can negotiate for better health plans, and students and their families can be better equipped to select the coverage that is best for them.”   

Details of the investigation also suggest that “troubling, conflicted relationships” exist between agents and health insurance companies that involve undisclosed incentives for agents to  persuade schools to take and maintain overly costly plans.  

This kind of practice flies in the face of the ethical and moral obligations agents agree to maintain through the licensing process.  The Independent Agents and Brokers of America, a trade organization for the insurance brokerage industry also encourages members to take that obligation one step further by taking the “Pledge of Performance” oath.  Every member of the Small Business Benefit Solutions, LLC team has taken this pledge* and, as a “Trusted Choice Agency” strives to exceed these requirements* within the context of being solely a health insurance brokerage agency.  

While SBBS doesn’t market student policies, we would be happy to discuss your particular situation.  With many legal changes, your student may already have the coverage he or she needs without having to buy an extra policy from their school.

*Unlike property and casualty policies, where claims require immediate attention in the case of a fire, storm, natural disaster or accident, health coverage is provided in a medical setting around the clock on an as needed basis.  Claims are then filed after the services have been rendered, in some cases many days weeks or even months later.  Health insurance carriers also only operate on a limited schedule with no service available on evenings and weekends.  Our agency is exempt from the 24/7 service clause.