While the earth around us still resembles a scene from “Winter Wonderland” I am hearing grumbling from many people who see winter as a time of captivity, and being confined to the indoors. If you have already cleaned out the closets, dusted the contents from the china cabinet, and watched enough movies to make you eligible to be a guest on Roger Ebert’s show, read on, we are here to help! Away with those mid-winter blues! We’ll keep your busy for days, leaving you with a feeling of satisfaction and gained knowledge!
Take advantage of the time indoors to tackle some of those things you will not want to do once the sun is out and gardening season begins. For starters, have you reviewed your medical claims for 2002 yet? Do you have a good system in place for keeping your claims up to date as you proceed though the year? If not, start a system now. Get a manila file folder for each member of your household. Or for some true excitement – go to staples and buy some purple or red ones! Next, start a sheet of paper for each family member and make heading at the top as follows: Date of Service, Provider, Procedure, Charge, Ins co 1, Ins co 2. When a family member has a medical experience, start recording the data on the sheet. Put a number next to each line item to indicate the claim number. Then when the bills and explanations of benefits start appearing, number them accordingly, and record the remainder of the information. This will help you to ensure that your claims are being processed correctly, and if you are balance billed any amounts from the doctor’s office, you will know how much you should pay. When the end of the year rolls around, you will know what your medical expenses were, and what your out of pocket expenses were. (This information comes in handy when you do your taxes and wonder if you can claim a medical expense deduction.)
DEDUCTIBLES AND THE STOP LOSS
Next, review the explanations of benefits and make sure that your deductible was satisfied only once. If you have a $250 deductible, check that only $250 has appeared in the column “deductible” for 2002. Keep in mind that deductibles run according to the calendar year, and start all over again on January 1. An easy error is for insurance companies to keep applying money to your deductible once it has been satisfied. Our office does not see this error as frequently now, as we did a few years ago. Perhaps the advancement of technology and better computer programs are preventing it from occurring, but it is always a good idea to keep an eye on it, nonetheless. If you do find that more money has been applied to your deductible than what should have been, simply call the company and advise them of the error. When you call, be sure to have the explanations of benefits in front of you that show money being applied to the deductible. If no errors were made, you will have the satisfaction of knowing that your claims have been processed correctly, and you are maximizing your insurance benefits and minimizing your unnecessary out of pocket expenses.
The Stop Loss is also referred to as Maximum Out of Pocket Expense. The dollar amount can vary from plan to plan, but the most common one we see right now is $10,000. That’s not when you spend $10,000 but rather when the total eligible charges for one person on the family reach $10,000 in any calendar year; the plan will pay 100% for the remainder of the calendar year. If you had a medically challenged year, did you reach the stop loss? Were the remainder of your claims paid at 100%? If not, call the insurance company and inquire. Again, be sure to know what the stop loss is on YOUR policy.
MEDICARE & SECONDARY
If you are on Medicare and have a Medigap policy, which is also known as a Medicare Supplement, have you matched the medical bills to the EOMB’s (Explanation of Medicare Benefits or Medicare Summary Notice) and made sure that your supplement has paid all your claims? Some companies will receive the information electronically from Medicare and you do not have to submit claims yourself. This scenario is often referred to as the claims “going automatically”, or “cross-over”, or “spin-over”. We find that this system of automatic processing is not airtight. Frequently claims fail to make it to the secondary carrier for some reason. If they have not gone automatically as planned, don’t sweat it. Submit it yourself. Many Medicare supplement carriers simply require the explanation of benefits from Medicare; others may wish to also have a copy of the medical bill. Find out what your Medicare supplement requires and submit those claims! Be sure to write your Medigap policy number on the Medicare Summary Notice. Always make a copy for your records.
For those of you who are really bored….. Get out those policies and read them! Whether it be your health insurance policy or a good Long Term Care plan (or the information your insurance agent or financial planner sent you six months ago that you simply have not had time to read yet!) Understanding your benefits is key. If you know how your plan works, you will make life much easier for yourself when you need it. For example, if you have a managed care plan, you may need a referral to see a specialist, or may need to pre-certify certain tests or medical procedures. What about if you need coverage in another state or country – will your plan cover your there? The responsibility of knowing how your insurance works belongs to you, not to anyone in your doctor’s office or the emergency room of the hospital.
As frequent readers of this column know, Long Term Care insurance is important coverage and continues to become more and more important as medical science advances, and the cost of medical care escalates. If you have been thinking about it, take advantage of the indoor time to do some research and investigate whether or not this is for you.
While we have given you some suggestions for maximizing your health insurance benefits and keeping yourself better organized, we recognize that there are people out there who are not concerned with such behavior. I’m sure you know the type; they never feel a need to balance their checking account. They don’t concern themselves with what type of insurance coverage they have because they will never get sick, never go to a hospital, and certainly never need care at home or in an advanced care facility. But we know no one reading this column will fall into that category – they left this column at the second sentence. They still have dust in the china cabinet, and are working their way though the “The Godfather” series for the third time!
Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance
Claims, Inc. a health insurance services company. If you have questions relative to this
column or other related topics, we invite you to call (973) 492-2828, browse our
past columns on our web
site at
www.micinsurance.com.
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All content copyright © 2002 Medical Insurance Claims, Inc. unless noted otherwise. All rights reserved.