When you’re evaluating health care options for a new job, the employer may offer some choices beyond the type of health insurance you choose. Choosing a plan that’s compatible with a health savings account (HSA) or a flexible spending account (FSA) is a great way to maximize your benefit plan. And with these accounts, you can reduce your tax liability while you save for expected medical expenses.
An HSA and an FSA are similar because funds from your paycheck or directly from your employer can be deposited into these accounts on a pretax basis. Using a debit card tied to the account, you can spend this money on qualified expenses like prescription medication and prescription eyewear, as well as out-of-pocket costs under your health coverage, like deductibles, copays, and coinsurance.
Choosing an HSA or FSA can be a great way to take charge of your medical expenses. In this article, we’ll explain and compare the following aspects of health savings accounts and flexible spending accounts:
An HSA is a financial account that you can fund with pretax contributions from your paycheck or after-tax contributions that are tax-deductible. You can use funds in your HSA to pay for qualified medical expenses now or in the future, even if you change jobs or retire. In other words, you own your HSA.
What are eligibility requirements for an HSA?
To be eligible for an HSA, you must have a high deductible health plan (HDHP), which has to be your only health insurance plan (the IRS states specific exceptions for this rule, including coverage for specific diseases or illnesses, accidents, and disabilities). You can’t be enrolled in Medicare, and you can’t be able to be claimed as a dependent on anyone’s tax return. For 2019, your health plan must have an out-of-pocket maximum of $6,750 (individual coverage) or $13,500 (family coverage) and a deductible of at least $1,350 (individual) or $2,700 (family). Not all plans with these deductibles are HSA-qualified, though, so be sure to check with your health plan or employer.
You don’t have to get your health plan from an employer in order to have an HSA. If you’re self-employed, you can buy an individual HDHP and contribute to an HSA too.
What are the advantages of an HSA?
HSA contribution limits can change yearly. Here are the annual limits for 2019:
What are qualified expenses?
The funds in an HSA can be spent only on certain expenses. The IRS provides a document with a detailed list, Publication 502, Medical and Dental Expenses, but here are some examples:
What is a Flexible spending account (FSA)?An FSA is a financial account that employees can fund with pretax contributions. You can use the funds in your FSA to pay for qualified medical or dependent-care expenses. An FSA is owned by your employer, and if you don’t spend the money by the end of the plan year, it remains with your employer, with certain limited exceptions.
What are eligibility requirements for an FSA?To open an FSA, your employer has to establish it for your workplace. Unlike an HSA, there are no health plan coverage requirements for an FSA, making it possible for employees to enroll in an FSA even if they don’t have health coverage through their employer. If you’re self-employed, you can’t open an FSA.
What are the advantages of an FSA?
What are the disadvantages of an FSA?
What happens with my FSA funds at the end of the year?
Your employer decides if you can keep some or all of your unused FSA funds at the end of the year. There are 3 options for the employer to choose from, and the employer makes their selection before the beginning of the plan year.
What are the annual contribution limits for an FSA?
FSA contribution limits can change yearly. For 2019, you can elect contributions of up to $2,700 to your FSA, which is lower than the maximum HSA contribution. You must choose the amount at the beginning of the year. However, if you have a family status change such as marriage, divorce, or the birth of a child, you can change your election at that time.
What are qualified expenses?
The funds in an FSA, like with an HSA, can be spent only on certain expenses.
The same goes for grown children on your insurance plan who will be 27 years of age or younger when the plan year ends, even if you don’t claim them as dependents.
Additional dependent care expenses can be covered by a dependent care FSA (DCFSA). This is another type of FSA, and it can be used to help pay for eligible dependent care services, including child and adult daycare, preschool, or summer day camp.
For additional details, see IRS Publication 503, Child and Dependent Care Expenses.
To receive reimbursements (or distributions) for qualified expenses from an FSA, you’ll need to provide a written statement detailing the expense from an independent third party plus an additional written statement stating that the expense isn’t being covered or reimbursed by another plan. You don’t need to report FSA distributions to the IRS.
If the end of the plan year approaches and you still have remaining funds left to use, there are online stores that exclusively sell FSA-eligible items.
What are the differences between HSA and FSA accounts?
This chart provides a simple comparison between HSAs and FSAs, based on some of the key components of these accounts.
Other ways to save on health care expenses
In addition to saving money for medical expenses with an HSA or FSA, there are also smart ways to reduce those expenses.
The tax references in this article relate to federal income tax only. Consult with a qualified professional for tax, investment, or legal advice.
When you’re searching for jobs or considering a job offer, employer-provided health insurance is an important factor. You want to make sure there’s a plan available that meets your family’s health needs, allows you to see your preferred doctors or specialists, and works with your budget. The most common choice you’ll have is between a health maintenance organization (HMO) plan and a preferred provider organization (PPO) plan.
In this article, we’ll explain and compare the following aspects of HMO and PPO plans:
What’s an HMO plan?
An HMO plan is based on a network of hospitals, doctors, and other health care providers that agree to coordinate care within a network in return for a certain payment rate for their services. Many HMO providers are paid on a per-member basis, regardless of the number of times they see a member. This makes HMO plans a more economical choice than PPOs. An HMO generally only covers care received from the plan’s contracted providers, known as “in-network” providers. When you’re covered through an HMO, you may need to select a primary care doctor to manage your health care and refer you to specialists within the network. While you will typically need to stay within the network for care, HMO plans sometimes refer members to see outside specialists for care that can’t be provided within their HMO system. Members may also seek emergency care from the closest emergency room.
Advantages of HMO plans
The advantages of HMO plans compared with PPO plans make them a popular choice if you’re budget-conscious or if you don’t anticipate many doctor visits.
Disadvantages of HMO plans
What costs are associated with an HMO plan?
Typical costs associated with HMO plans include deductibles (the amount you must pay before insurance begins contributing to your medical bills) and monthly premiums (the amount taken out of your paycheck).
What is a PPO plan?
A PPO plan is designed to give you more flexibility in choosing which health care providers you see. Care is typically more affordable if you stay in-network. But if you have a doctor you prefer to see, it might be easier to visit him or her with a PPO plan.
Advantages of PPO plansA PPO plan can be a better choice compared with an HMO if you need flexibility in which health care providers you see.
Disadvantages of PPO plans
What costs are associated with a PPO plan?
The typical costs of a PPO plan can include higher monthly premiums and out-of-pocket costs. You may also need to pay a deductible before your coverage benefits begin. If you see an out-of-network doctor, you’ll typically have to pay in full for your copay during the visit, cover the cost of the medical bill, and then file a claim to be reimbursed by your PPO plan.
What are the differences between HMO and PPO plans?
This chart provides a simple comparison between an HMO and a PPO, based on some of the key components of health insurance plans.
Is an HMO or a PPO plan better?
A decision between an HMO and a PPO should be based on what’s most important to you: cost or flexibility. An HMO plan might be right for you if lower costs are important and you don’t mind choosing your doctors from within the HMO’s network. Think lower cost with less flexibility to choose health care providers. A PPO plan might be right for you if you already have a doctor or team of specialists you want to continue seeing but might not be in your employer’s HMO plan network. A PPO plan is also generally more expensive than an HMO plan. Think higher cost with greater flexibility.
Other types of health plansWhile HMO and PPO plans are the 2 most common plans, especially when it comes to employer-provided health insurance, there are other plan types you should know about, including EPO and POS plans.
An exclusive provider organization (EPO) plan is situated between an HMO and PPO in terms of flexibility and costs. With an EPO, you typically don’t need a referral to see a specialist, which makes it more flexible than an HMO. However, like an HMO, there are no out-of-network benefits.
A point of service (POS) plan also blends elements of HMO and PPO plans. Under a POS plan, like with an HMO plan, you usually need a primary care doctor referral to see a specialist. However, like with a PPO plan, you can see out-of-network health care providers but at a higher cost.
What to consider when choosing a health insurance plan
As you’re changing jobs and deciding between HMO, PPO, EPO, or POS health plans, your first step is to ask questions. Based on your health care needs and the information above, come up with a list of questions for the employer or their human resources representative. You should consider things like deductibles and out-of-pocket costs and whether you want to continue seeing your current doctor or team of specialists. Your potential employer’s HR team will often have a chart available that compares the details of the specific plans they offer, and that’s a great place to start.
A small but growing number of doctors are ditching insurance companies and working directly with patients.
When Dr. Heather Bartlett was working as an outpatient doctor for a hospital system in Seattle — right out of residency — her idealism ran headlong into the reality of much primary care medicine in the United States.
Too many patients. Too little time.
“It was a real eye-opening experience how many people you had to see,” said Bartlett, now a family medicine doctor at The Bartlett Medical Clinic & Wellness Center, a direct primary care practice in Ohio.
To make ends meet, many primary care practices squeeze more patient visits into their week.
As they do, the length of each visit shrinks, giving doctors barely enough time to assess a patient’s main concern, let alone connect with them “Patients become herded through the cattle gates and physicians become hamsters in the wheel,” Bartlett told Healthline. “And it doesn’t make for a good relationship for anybody.” So Bartlett did what a small but increasing number of physicians are doing — ditching insurance companies altogether. Instead they are setting up cash-only medical practices where doctors deal directly with patients on financial matters.This immediately shifts the doctor-patient relationship.“The main benefit of not billing through insurance is that you no longer work for the insurance company. You work directly for the patient,” Dr. Carmela Mancini, an internal medicine doctor who has a direct primary care practice in Massachusetts told Healthline.
What is ‘cash only?’
The cash only model is known as direct care or direct primary care. Patients pay an annual or monthly fee for access to their doctor. This covers most primary care procedures — things like physicals, tests for strep throat, EKGs, and stitches.
Patients also get 24/7 access to their doctors, longer office visits, and often same-day appointments.
Direct primary care differs from concierge medicine, which still bills insurance but uses the membership fees to provide patients with greater access and to pay for procedures not covered by insurance.
According to the John Locke Foundation, the average monthly payment for direct primary care is $25 to $85.Some practices also offer different membership levels. At Mancini’s practice, the fee ranges from $30 per month for 18- to 21-year olds, to $125 per month for people 65 years or older who often need more intensive care. With only 800 to 1,000 patients — or fewer — direct primary care practices are smaller than typical primary care practices, which may have 2,000 to 3,000 patients. This allows time during the day for longer office visits — and lets doctors maintain better work-life balance. Typical primary care doctors may spend no more than 10 to 15 minutes with each patient. A direct primary care doctor may spend at least 20 minutes with a patient. Or more. A follow-up visit with Mancini is 30 minutes. For people with multiple chronic conditions, she’ll book one-and-a-half hours. This hearkens back to your great-grandparents’ time. “This is how it used to be back in the day before you had back-to-back patients,” said Bartlett, “before insurance became the norm for outpatient care around the 1950s.”
Doctors connecting with patients.
Longer visits help doctors see the big picture when it comes to their patients’ health.
“To do good medicine, you need to know what’s going on with somebody,” said Bartlett. “If you tell somebody, ‘I only have time to hear your top two things,’ but their third thing was chest pain, you haven’t done your job.”
Direct primary care doctors also have more control over how they interact with patients. Phone consultations, text messages, and Skype are common. Most insurance companies will only reimburse a doctor when a patient comes into the office. “I don’t need to force people to come into my office for things that don’t need to be handled that way,” said Bartlett.
“Telemedicine is booming. There’s a reason for that.”
With telemedicine, patients can avoid unnecessary trips to the doctor — and hours away from work or having to pay for a babysitter — just to find out the results of a lab test or to ask a simple question about a rash or a cold.
And because doctors are accessible around-the-clock, patients may be less likely to put off seeking help. After talking to a patient on the phone or getting a text, a doctor can write a prescription, refer a patient to the emergency room, or just ease their concerns. “There are so many patients that have so much anxiety,” said Bartlett. “A lot of anxiety is triggered by a concern that there’s something wrong with them.” Quicker care can also keep small problems from turning into larger ones — like a cat scratch becoming a major infection or symptoms of a heart attack or stroke going untreated. People get urgent care when it’s needed and avoid it when it’s not. “With three of us in the office getting to know patients, we can save so many ER visits, so many unnecessary urgent care visits,” said Dr. Jeffrey Gold, a family practice doctor at Gold Direct Care, a direct primary care practice in Massachusetts. Cutting out insurance companiesMany advocates of direct primary care say these benefits result from no longer dealing with insurance companies. Part of this is that insurance companies don’t reimburse doctors enough to cover the cost of longer visits. And there are many hoops for doctors to jump through to get reimbursed, including the use of electronic medical records for billing purposes. “Most of us chose primary care to build relationships with people and take care of people,” said Gold. “How do you do that in an eight-minute visit, where 75 percent of it you’re standing at a computer checking boxes and typing stuff in?” Cutting out insurance billing also cuts costs. “[This model] definitely is sustainable, and what makes it sustainable is my overhead is really low,” said Mancini. “When you’re not billing through insurance, you don’t need 10 people doing coding and billing for you.”
Although direct primary care physicians have fewer patients, the monthly membership fees plus lower overhead means that their practices can still be financially viable.
Direct primary care doctors can even do something else your great-grandparents might have been familiar with — the house call.
“I have quite a few patients that can’t get out of the house because they’re homebound for a variety of reasons,” said Mancini. “In the insurance-based model, it’s really hard to do a home visit.”
Putting consumers in chargeA big part of the direct primary care model is price transparency, which puts more control back in the hands of consumers.
“How do you become a consumer if you don’t have the right tools?” said Gold. “The biggest thing we’re bringing to light is transparency in pricing, which does not exist.”
Practices list membership fees on their website and clearly explain what patients get for their money — no surprise bills when an insurance company says a doctor’s visit wasn’t covered.
Direct primary care practices can also offer inexpensive medications to patients.
“You can have a small wholesale pharmacy in your office and dispense noncontrolled and non-compounded medications at amazing prices,” said Bartlett. And doctors negotiate prices with private companies for better rates on lab tests, imaging, and other medical services — some of these are even cash-only businesses.These rates are sometimes lower than what an insurance company would pay for the same service. Like their insurance-taking counterparts, direct primary care physicians can refer patients to a urologist, cardiologist, or other specialist.
But because direct primary care doctors spend more time getting to know patients’ medical histories and assessing their symptoms, they may be less likely to refer to a specialist just because they are in a hurry.
Many patients still carry some form of health insurance to cover these visits, hospital stays, and other nonprimary care services.
However, even some people with insurance that covers primary care visits find it worthwhile to pay a membership fee for 24/7 access to their doctor, longer visits, and a shorter wait for an appointment.
Not everyone is as enthusiastic about the promises made by direct primary care advocates, especially given the small amount of research available on these practices.
In 2016, only 6 percent of physicians participated in a cash only practice, according to Medscape's Physician Compensation Report. But interest is growing.
The Wall Street Journal sees direct primary care as an important piece of any replacement for the Affordable Care Act (ACA), largely because of its free market approach and focus on price transparency. Advocates say the direct primary care movement highlights the need to keep the doctor-patient relationship up front in any discussion of the future of the U.S. healthcare system. “Insurance does not equate to care,” said Gold. “It’s all well and good to have Medicaid or any other subsidized health plan, but if you can’t get access to a doctor who knows you and cares about you, a lot of good that [insurance] card does.” Downsides to cash onlyWhile advocates of direct primary care feel strongly about the ability of this approach to produce better care for patients, there are some downsides.
For doctors, switching to a direct primary care model is a big step. And like any business, they may have to invest heavily up front before their practices have enough patients to be sustainable.
They may also need to spend more time on the business side of their practices — marketing their practices, negotiating prices on lab tests and radiology services and medications.
They may even have to educate communities about the benefits of letting go of insurance for primary care.
“I knew this was the right thing for me, and I knew it was the right thing for patients,” said Gold. “But I also knew that 99 percent of the patients were also going to think it was bad for them.”
Many new primary care doctors are trained to assess quickly and refer to specialists. So they may not have a broad enough medical background to handle patient care with the intensity required for a direct primary care practice.
And when doctors switch to direct primary care, it can affect their current patients and their communities.
If current patients choose not to follow a doctor into the new direct primary care practice, they may lose a long-standing relationship with their physician. Not every community has enough primary care doctors to go around, which can be exacerbated when doctors cut their patient lists in half. Cost is also an issue. Even at the lower membership fees, not everyone will be able to pay this out-of-pocket expense, particularly those on Medicaid. Some practices offer “charity care” to those in need, but this may not meet the demand. Qliance, a larger direct primary care business shows that this may be less of a concern. The company has roughly 35,000 patients, about half are enrolled in Medicaid.
Some doctors have raised concerns about the lack of oversight offered by insurance companies, which monitor doctors to make sure they are following clinical care guidelines and practicing evidence-based medicine.
If you’ve been injured and it was someone else’s fault, odds are good you will hear from an adjuster for the at-fault party’s insurance company. Their interests are inherently opposed to yours as a person who was injured by their insured. You want – and deserve – fair compensation under the law for your injuries. The insurance adjuster for the other side, however, is not there to help you. They solely exist to protect and promote the interests of their employer – the insurance company. The insurance company’s ultimate goal is to pay out nothing or as little as possible on every claim – that is, to deny and devalue claims.
Every insurance adjuster is trained, and trained well, by the insurance company to promote this ultimate goal. The following list goes over 10 of the most common tactics insurance companies use to deny and devalue claims.
We refer throughout this article to these tactics as used in the context of a car accident. Keep in mind, however, that these tactics are used in car collisions, slip and fall, and other cases alike. They do not solely apply to car accidents.
1. CALLING YOU VERY SOON AFTER AN INJURY
This is done for a variety of reasons – mostly to catch you off guard
1) in a vulnerable spot soon after a traumatic event like a car collision;
2) before you’ve had time to determine the full extent of your injuries; and
3) before you’ve had an opportunity to hire a lawyer.
It is extremely common for an insurance adjuster for the at-fault party’s insurance company to call you the same day of a collision or shortly thereafter and act exceedingly friendly. He will ask you how you are doing, tell you he’s so sorry, tell you not worry, and generally give you the impression you can trust him. At this point, you’re probably feeling awful – both mentally and physically – and just hearing a friendly voice can be comforting. It can also be confusing if the insurance adjuster says he’s “admitting fault for the collision,” or if he agrees with you about how the collision occurred.
While it may be tempting to want to trust and engage with him, it is important to remember the insurance adjuster for the other side is not your friend. His interests are diametrically opposed to yours. Being nice is simply a tactic the insurance adjuster employs to get injury victims to let their guard down and provide information that can be used against them later.
2. ASKING YOU TO GIVE A RECORDED STATEMENT
It may seem very reasonable for an insurance adjuster to ask for your side of the story in how the collision occurred or ask you about your injuries. Insurance adjusters frequently try to ask you to provide this information via a recorded statement. You’re probably thinking, “Well of course – once I tell them my side of things and tell them about my injuries, they’ll know it’s not my fault; they’ll fairly compensate me for my injuries; they’ll pay all of my medical bills, lost wages, etc. After all, the other guy ran a red light and hit me. That’s reasonable, right?”
While an insurance company doing all those things is reasonable, insurance adjusters do not record statements as a tool to fairly compensate injury victims. They use recorded statements as a tool to deny and devalue claims by getting the information they can use against you later. This is true not just for information about how a collision occurred, but also applies to information on injuries. For example, they will ask you if you are injured shortly after a collision and ask you to provide an accounting of exactly how you are injured at a time when you may have not even seen a doctor yet and have no idea about the full extent of your injuries. The insurance adjuster may also ask pointed questions in a recorded statement in a manner that can be used against you later. For example, he may only ask you questions about a neck injury and then say later that because you never told them your back hurt, you must not have suffered a back injury.
Remember – the insurance adjuster’s ultimate goal is to pay out nothing or as little as possible for claims. He will do whatever he can to achieve this goal, and if this means catching you off guard an hour after a collision and getting your recorded statement, he will do it. Recorded statements are always used for this purpose whether he asks you for one five minutes, two weeks, or two months after a collision.
If you are asked to give a recorded statement, you should politely decline. Generally, you should not give an insurance company a recorded or written statement unless you are instructed to do so by a personal injury attorney.
3. ASKING YOU TO SIGN A MEDICAL AUTHORIZATION
Getting an injury victim to sign a blanket medical authorization, unlimited in time and scope, is another tactic employed by insurance companies. It is a frequently-used tactic because it is a powerful tool that allows the insurance company to obtain a host of private information about you that you would never even suspect.
Common misconception: The other side’s insurance company will use the signed medical authorization as they have represented to me – to get my medical bills related to the collision so they can pay them in my claim.
Wrong. Once turned over, the insurance company will use the medical authorization to obtain your medical records from any and every medical provider you have ever seen in your entire life – both before and after the collision. It will do this to try to find any evidence of prior injuries, prior pain, prior anything to try to argue your injuries, pain, treatment, etc. after the collision were not related to the collision. The argument will then be – you had these injuries before; your issues were caused by those prior things, not our insured running a red light and hitting you. The insurance company will try to argue this even if you did have some level of pre-existing pain or injuries that were asymptomatic by the time of the collision and were reactivated or made much worse because of an accident.
If you are asked to sign a medical authorization, you should politely decline. Generally, you should not give an insurance company a signed medical authorization unless you are instructed to do so by an attorney.
4. OFFERING A QUICK SETTLEMENT IN RETURN FOR A SIGNED OR VERBAL RELEASE OF YOUR CLAIM
At a vulnerable time, it may be tempting to take money – any money – for settlement of a claim. This can be especially true if it’s very soon after a collision, before you know the full extent of your injuries or before you’ve seen a doctor or gotten any treatment.
This is the perfect time the insurance company wants you to settle. If an insurance company could get every injured victim to settle for $1,000 or less in every case a day after the collision, it would do it. After all, it would save a lot of money.
If the insurance company does employ this tactic, it will, of course, want you to sign a full release or give a full verbal release in return for the money. The insurance company does this to say your claim is over, and you cannot pursue anything for your injuries ever again in the future, even if your injuries get worse, you receive more medical treatment, etc.
5. DENYING LIABILITY, EITHER COMPLETELY OR PARTIALLY
Even if a collision is the fault of its insured, an insurance company may simply deny liability on the claim. If it does this when a collision is clearly the other side’s fault – for example, if the other party rear-ended you in a collision – it is because the insurance company is arguing you couldn’t possibly have been injured as a result of what happened. This routinely occurs when a collision involves what the insurance company deems to be minimal or minor property damage to the vehicles involved.
Another tactic is denying liability in part by saying you were partially at fault for the collision, whether this was true and whether there were other witnesses who say it was the other side’s fault. The other side is hoping those witnesses will disappear or not want to get involved later should you have to fight your case. If there is any room to argue the collision was partially your fault, insurance companies routinely do it. Minimally, they will do it to devalue the claim. Other times it is done to avoid paying altogether, such as in Kansas where an injury victim is not allowed to recover anything if he is found to be 50% or more at fault for an injury event like a car collision.
This is truly a tactic to call your bluff and see how far you’re willing to go to pursue a claim. Insurance companies know many people will give up, confused and frustrated by the situation.
6. DISPUTING A PORTION OF YOUR MEDICAL BILLS OR MEDICAL TREATMENT, OR TELLING YOU THAT YOU SHOULDN’T GET TREATMENT BEYOND A CERTAIN POINT BECAUSE IT WON’T BE COVERED
Similarly related, insurance companies routinely fight a portion of an injured person’s medical bills or treatment to devalue claims. They may say, well you may have been injured by the collision, but we don’t believe you could have been that injured. They will try to say you treated too long, you should have recovered sooner, or the treatment you did receive was unreasonable.
An insurance adjuster may also urge you or convince you to stop treatment at a certain point because the insurance company won’t pay for it for these reasons. Beyond being bad for you from a physical and treatment standpoint, this is bad for your case and is done in an effort to create a bad record in your treatment course or cut off your damages. If you do stop treatment because of such urging, but you are not better and are still in pain thereafter, the insurance company will then use that failure to seek treatment as a tool to argue you must not have really been injured, you were making it up, or you were, at least, not injured badly enough to warrant getting any recovery for it.
Keep in mind again, they are trying to save money and pay out less on a claim – however much they can get away with. The insurance companies frequently have computer systems that spit out red flag alarms to adjusters on when to fight people on these issues, such as if treatment lasts longer than a certain amount of time, costs over a certain figure, or if you had what they will argue are “delays in treatment over a certain period,” even as little as a week – no matter what the reason.
The insurance company’s computer system is not right. If you were injured because of someone else’s negligence, you should consult with an attorney about your rights and what you may be entitled to for your injuries.
7. EMPLOYING DELAY TACTICS TO GET YOU TO SETTLE FOR A LOWER AMOUNT – OR WORSE – GIVE UP ENTIRELY
Insurance companies know that many people will be facing financial difficulties after suffering an injury. You may be facing medical bills, losing time from work, losing your car because it was totaled or has to be fixed, and generally dealing with stress from all angles in your personal life, family life, and work life.
Insurance companies use this vulnerability to their advantage. They will routinely delay processing a claim until you’ve reached the point where you’re desperate enough to settle for just about anything. Even worse, many people eventually start viewing the process as so exhausting, stressful, and not worth it that they give up entirely and never receive any recovery.
Stand firm in demanding what you are rightfully owed under the law for your injuries. If you were injured because of someone else’s negligence, you should consult with an attorney about your rights and what you may be entitled to for your injuries.
8. MISREPRESENTING THE LAW ON WHAT YOU ARE LEGALLY ENTITLED TO SEEK FOR DAMAGES, OR LOW-BALLING YOU ON SETTLEMENT OFFERS
Some insurance adjusters may try to tell you that you’re not entitled to seek damages for pain and suffering for injuries, or that you can only recover a certain amount. They may also try to tell you there is no recovery for lost wages. They may try to tell you a certain low-ball amount is fair considering the law or what you could seek in your claim, knowing that is not true. Insurance companies use your unfamiliarity with the situation in order to devalue and diminish claims.
Do not accept legal advice from an insurance company for the at-fault party. You should consult a personal injury attorney to advise you of your rights in what you may seek in your injury claim under the law.
9. MISREPRESENTING THE AMOUNT OF INSURANCE COVERAGE AVAILABLE FOR YOUR CLAIM
Insurance adjusters may try to say there’s only a certain amount available to be paid on a claim when that amount may not accurately reflect what is truly available to compensate you from the at-fault party. An attorney can help you find out what insurance policy limits are available for any potentially at-fault party and advise you of the issues at play with available insurance coverage.
10. TELLING YOU THAT YOU’LL BE BETTER OFF NOT HIRING AN ATTORNEY
If all insurance companies were fair in every instance, truly on your side, and really cared about fully and fairly compensating people who are injured because of their insureds’ actions, then people might be fine with not hiring an attorney to represent them in an injury claim. Of course, this is not the case.
People do not fly across the country without a pilot, conduct surgery on themselves, or climb Mount Everest without a guide. People like pilots, doctors, guides – and yes, even lawyers – exist for a reason. Lawyers have experience and knowledge that the insurance companies don’t want you to know about. They do not want you to hire an advocate to look out for your best interests – someone who stands in the way of their goal of denying and devaluing claims.
We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.
As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a “peer-to-peer.”
Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few key words to make sure the denial is reversed.
Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.
The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.
I’ve dealt with this system from the patient side, as well. My daughter has a rare genetic disorder called Phelan-McDermid Syndrome, which causes developmental delay, seizures, heart defects, kidney defects, autism and a laundry list of other problems. She receives applied behavior analysis therapy, an approach often used for autism, and which has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.
While I know what levers to pull from the physician side, a patient’s options are completely unclear. I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective.
My daughter can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life gets smaller.
Consumers have a right to appeal denials for health-care services, but regulations still largely focus on the process, not the content. For instance, insurers are required to notify you in writing of a denial, and patients have the right to an internal appeal; if that fails, some states also allow for an external review.
This sounds good, as most denials are related to specific provider choice or contractual issues, which are relatively easy to remedy (but a problem nonetheless). But other denials are a judgment of some test or treatment as “not medically necessary.”
Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction ask for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.
Some might argue that it makes sense to have two doctors discuss a case and then come to a consensus on the most cost-effective approach for an individual. That’s not what is happening. This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.
We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.
When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.
We don’t have to put up with this. Health care in the United States is shockingly opaque; it’s time to take insurance companies out of our decision-making process.
Source: Insurance companies aren't doctors