Hedge Funds

I have been a health insurance broker for over a decade and every day I read more and more “horror” stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. Unfortunately, insurance companies are driven by profits, not people (albeit they need people to make profits). If the insurance company can find a legal reason not to pay a claim, chances are they will find it, and you the consumer will suffer. However, what most people fail to realize is that there are very few “loopholes” in an insurance policy that give the insurance company an unfair advantage over the consumer. In fact, insurance companies go to great lengths to detail the limitations of their coverage by giving the policy holders 10-days (a 10-day free look period) to review their policy. Unfortunately, most people put their insurance cards in their wallet and place their policy in a drawer or filing cabinet during their 10-day free look and it usually isn’t until they receive a “denial” letter from the insurance company that they take their policy out to really read through it.

The majority of people, who buy their own health insurance, rely heavily on the insurance agent selling the policy to explain the plan’s coverage and benefits. This being the case, many individuals who purchase their own health insurance plan can tell you very little about their plan, other than, what they pay in premiums and how much they have to pay to satisfy their deductible.

For many consumers, purchasing a health insurance policy on their own can be an enormous undertaking. Purchasing a health insurance policy is not like buying a car, in that, the buyer knows that the engine and transmission are standard, and that power windows are optional. A health insurance plan is much more ambiguous, and it is often very difficult for the consumer to determine what type of coverage is standard and what other benefits are optional. In my opinion, this is the primary reason that most policy holders don’t realize that they do not have coverage for a specific medical treatment until they receive a large bill from the hospital stating that “benefits were denied.”

Sure, we all complain about insurance companies, but we do know that they serve a “necessary evil.” And, even though purchasing health insurance may be a frustrating, daunting and time consuming task, there are certain things that you can do as a consumer to ensure that you are purchasing the type of health insurance coverage you really need at a fair price.

Dealing with small business owners and the self-employed market, I have come to the realization that it is extremely difficult for people to distinguish between the type of health insurance coverage that they “want” and the benefits they really “need.” Recently, I have read various comments on different Blogs advocating health plans that offer 100% coverage (no deductible and no-coinsurance) and, although I agree that those types of plans have a great “curb appeal,” I can tell you from personal experience that these plans are not for everyone. Do 100% health plans offer the policy holder greater peace of mind? Probably. But is a 100% health insurance plan something that most consumers really need? Probably not! In my professional opinion, when you purchase a health insurance plan, you must achieve a balance between four important variables; wants, needs, risk and price. Just like you would do if you were purchasing options for a new car, you have to weigh all these variables before you spend your money. If you are healthy, take no medications and rarely go to the doctor, do you really need a 100% plan with a $5 co-payment for prescription drugs if it costs you $300 dollars more a month?

Is it worth $200 more a month to have a $250 deductible and a $20 brand name/$10 generic Rx co-pay versus an 80/20 plan with a $2,500 deductible that also offers a $20 brand name/$10generic co-pay after you pay a once a year $100 Rx deductible? Wouldn’t the 80/20 plan still offer you adequate coverage? Don’t you think it would be better to put that extra $200 ($2,400 per year) in your bank account, just in case you may have to pay your $2,500 deductible or buy a $12 Amoxicillin prescription? Isn’t it wiser to keep your hard-earned money rather than pay higher premiums to an insurance company?

Yes, there are many ways you can keep more of the money that you would normally give to an insurance company in the form of higher monthly premiums. For example, the federal government encourages consumers to purchase H.S.A. (Health Savings Account) qualified H.D.H.P.’s (High Deductible Health Plans) so they have more control over how their health care dollars are spent. Consumers who purchase an HSA Qualified H.D.H.P. can put extra money aside each year in an interest bearing account so they can use that money to pay for out-of-pocket medical expenses. Even procedures that are not normally covered by insurance companies, like Lasik eye surgery, orthodontics, and alternative medicines become 100% tax deductible. If there are no claims that year the money that was deposited into the tax deferred H.S.A can be rolled over to the next year earning an even higher rate of interest. If there are no significant claims for several years (as is often the case) the insured ends up building a sizeable account that enjoys similar tax benefits as a traditional I.R.A. Most H.S.A. administrators now offer thousands of no load mutual funds to transfer your H.S.A. funds into so you can potentially earn an even higher rate of interest.

In my experience, I believe that individuals who purchase their health plan based on wants rather than needs feel the most defrauded or “ripped-off” by their insurance company and/or insurance agent. In fact, I hear almost identical comments from almost every business owner that I speak to. Comments, such as, “I have to run my business, I don’t have time to be sick! “I think I have gone to the doctor 2 times in the last 5 years” and “My insurance company keeps raising my rates and I don’t even use my insurance!” As a business owner myself, I can understand their frustration. So, is there a simple formula that everyone can follow to make health insurance buying easier? Yes! Become an INFORMED consumer.

Every time I contact a prospective client or call one of my client referrals, I ask a handful of specific questions that directly relate to the policy that particular individual currently has in their filing cabinet or dresser drawer. You know the policy that they bought to protect them from having to file bankruptcy due to medical debt. That policy they purchased to cover that $500,000 life-saving organ transplant or those 40 chemotherapy treatments that they may have to undergo if they are diagnosed with cancer.

So what do you think happens almost 100% of the time when I ask these individuals “BASIC” questions about their health insurance policy? They do not know the answers! The following is a list of 10 questions that I frequently ask a prospective health insurance client. Let’s see how many YOU can answer without looking at your policy.

1. What Insurance Company are you insured with and what is the name of your health insurance plan? (e.g. Blue Cross Blue Shield-”Basic Blue”)

2. What is your calendar year deductible and would you have to pay a separate deductible for each family member if everyone in your family became ill at the same time? (e.g. The majority of health plans have a per person yearly deductible, for example, $250, $500, $1,000, or $2,500. However, some plans will only require you to pay a 2 person maximum deductible each year, even if everyone in your family needed extensive medical care.)

3. What is your coinsurance percentage and what dollar amount (stop loss) it is based on? (e.g. A good plan with 80/20 coverage means you pay 20% of some dollar amount. This dollar amount is also known as a stop loss and can vary based on the type of policy you purchase. Stop losses can be as little as $5,000 or $10,000 or as much as $20,000 or there are some policies on the market that have NO stop loss dollar amount.)

4. What is your maximum out of pocket expense per year? (e.g. All deductibles plus all coinsurance percentages plus all applicable access fees or other fees)

5. What is the Lifetime maximum benefit the insurance company will pay if you become seriously ill and does your plan have any “per illness” maximums or caps? (e.g. Some plans may have a $5 million lifetime maximum, but may have a maximum benefit cap of $100,000 per illness. This means that you would have to develop many separate and unrelated life-threatening illnesses costing $100,000 or less to qualify for $5 million of lifetime coverage.)

6. Is your plan a schedule plan, in that it only pays a certain amount for a specific list of procedures? (e.g., Mega Life & Health & Midwest National Life, endorsed by the National Association of the Self-Employed, N.A.S.E. is known for endorsing schedule plans) 7. Does your plan have doctor co-pays and are you limited to a certain number of doctor co-pay visits per year? (e.g. Many plans have a limit of how many times you go to the doctor per year for a co-pay and, quite often the limit is 2-4 visits.)

8. Does your plan offer prescription drug coverage and if it does, do you pay a co-pay for your prescriptions or do you have to meet a separate drug deductible before you receive any benefits and/or do you just have a discount prescription card only? (e.g. Some plans offer you prescription benefits right away, other plans require that you pay a separate drug deductible before you can receive prescription medication for a co-pay. Today, many plans offer no co-pay options and only provide you with a discount prescription card that gives you a 10-20% discount on all prescription medications).

9. Does your plan have any reduction in benefits for organ transplants and if so, what is the maximum your plan will pay if you need an organ transplant? (e.g. Some plans only pay a $100,000 maximum benefit for organ transplants for a procedure that actually costs $350-$500K and this $100,000 maximum may also include reimbursement for expensive anti-rejection medications that must be taken after a transplant. If this is the case, you will often have to pay for all anti-rejection medications out of pocket).

10. Do you have to pay a separate deductible or “access fee” for each hospital admission or for each emergency room visit? (e.g. Some plans, like the Assurant Health’s “CoreMed” plan have a separate $750 hospital admission fee that you pay for the first 3 days you are in the hospital. This fee is in addition to your plan deductible. Also, many plans have benefit “caps” or “access fees” for out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit “caps” could be as little as $500 for each out-patient treatment, leaving you a bill for the remaining balance. Access fees are additional fees that you pay per treatment. For example, for each outpatient chemotherapy treatment, you may be required to pay a $250 “access fee” per treatment. So for 40 chemotherapy treatments, you would have to pay 40 x $250 = $10,000. Again, these fees would be charged in addition to your plan deductible).

Now that you’ve read through the list of questions that I ask a prospective health insurance client, ask yourself how many questions you were able to answer. If you couldn’t answer all ten questions don’t be discouraged. That doesn’t mean that you are not a smart consumer. It may just mean that you dealt with a “bad” insurance agent. So how could you tell if you dealt with a “bad” insurance agent? Because a “great” insurance agent would have taken the time to help you really understand your insurance benefits. A “great” agent spends time asking YOU questions so s/he can understand your insurance needs. A “great” agent recommends health plans based on all four variables; wants, needs, risk and price. A “great” agent gives you enough information to weigh all of your options so you can make an informed purchasing decision. And lastly, a “great” agent looks out for YOUR best interest and NOT the best interest of the insurance company.

So how do you know if you have a “great” agent? Easy, if you were able to answer all 10 questions without looking at your health insurance policy, you have a “great” agent. If you were able to answer the majority of questions, you may have a “good” agent. However, if you were only able to answer a few questions, chances are you have a “bad” agent. Insurance agents are no different than any other professional. There are some insurance agents that really care about the clients they work with, and there are other agents that avoid answering questions and duck client phone calls when a message is left about unpaid claims or skyrocketing health insurance rates.

Remember, your health insurance purchase is just as important as purchasing a house or a car, if not more important. So don’t be afraid to ask your insurance agent a lot of questions to make sure that you understand what your health plan does and does not cover. If you don’t feel comfortable with the type of coverage that your agent suggests or if you think the price is too high, ask your agent if s/he can select a comparable plan so you can make a side by side comparison before you purchase. And, most importantly, read all of the “fine print” in your health plan brochure and when you receive your policy, take the time to read through your policy during your 10-day free look period.

If you can’t understand something, or aren’t quite sure what the asterisk (*) next to the benefit description really means in terms of your coverage, call your agent or contact the insurance company to ask for further clarification.

Furthermore, take the time to perform your own due diligence. For example, if you research MEGA Life and Health or the Midwest National Life insurance company, endorsed by the National Association for the Self Employed (NASE), you will find that there have been 14 class action lawsuits brought against these companies since 1995. So ask yourself, “Is this a company that I would trust to pay my health insurance claims?

Additionally, find out if your agent is a “captive” agent or an insurance “broker.” “Captive” agents can only offer ONE insurance company’s products.” Independent” agents or insurance “brokers” can offer you a variety of different insurance plans from many different insurance companies. A “captive” agent may recommend a health plan that doesn’t exactly meet your needs because that is the only plan s/he can sell. An “independent” agent or insurance “broker” can usually offer you a variety of different insurance products from many quality carriers and can often customize a plan to meet your specific insurance needs and budget.

Over the years, I have developed strong, trusting relationships with my clients because of my insurance expertise and the level of personal service that I provide. This is one of the primary reasons that I do not recommend buying health insurance on the Internet. In my opinion, there are too many variables that Internet insurance buyers do not often take into consideration. I am a firm believer that a health insurance purchase requires the level of expertise and personal attention that only an insurance professional can provide. And, since it does not cost a penny more to purchase your health insurance through an agent or broker, my advice would be to use eBay and Amazon for your less important purchases and to use a knowledgeable, ethical and reputable independent agent or broker for one of the most important purchases you will ever make….your health insurance policy.

Lastly, if you have any concerns about an insurance company, contact your state’s Department of Insurance BEFORE you buy your policy. Your state’s Department of Insurance can tell you if the insurance company is registered in your state and can also tell you if there have been any complaints against that company that have been filed by policy holders. If you suspect that your agent is trying to sell you a fraudulent insurance policy, (e.g. you have to become a member of a union to qualify for coverage) or isn’t being honest with you, your state’s Department of Insurance can also check to see if your agent is licensed and whether or not there has ever been any disciplinary action previously taken against that agent.

In closing, I hope I have given you enough information so you can become an INFORMED insurance consumer. However, I remain convinced that the following words of wisdom still go along way: “If it sounds too good to be true, it probably is!” and “If you only buy on price, you get what you pay for!”

OHA’s can contribute by helping managers to manage sickness absence more effectively. The nurse may be involved in helping to train line managers and supervisors in how to best use the OH service, in how to refer staff, what type of information will be required, what to expect from occupational health. By developing transparent referral procedures, ensuring that medical confidentiality is maintained and that the workers’ rights are respected the OHA can do much to ensure that employees referred for assessment due to sickness absence are comfortable with the process.

OH nurses, with their close relationship with workers, knowledge of the working environment and trends in ill-health in the company are often in a good position to advise management on preventing sickness absence. In my experience referral to General Practitioners have a limited use for work related issues, and gain best results by as well as keeping the GP aware, referring to a specialist occupational physician.

Planned rehabilitation strategies, can help to ensure safe return to work for employees who have been absent from work due to ill-health or injury. The nurse is often the key person in the rehabilitation programme who will, with the manager and individual employee, complete a risk assessment, devise the rehabilitation programme, monitor progress and communicate with the individual, the OH physician and the line manager. Nurses have also become involved in introducing proactive rehabilitation strategies that aim to detect early changes in health before such conditions result in absence from work. Improving and sustaining working ability benefits many groups, the individual, the organization and society, as costly absence and other health care costs are avoided.

In many cases the OH nurse has to work within the organization as the clients advocate in order ensuring that managers appreciate fully the value of improving the health of the workforce. OH nurses have the skills necessary to undertake this work and may develop areas of special interest.

The occupational health nurse may develop pro-active strategies to help the workforce maintain or restore their work ability. New workers, older workers, women returning to work following pregnancy or workers who have been unemployed for a prolonged period of time may all benefit from health advice or a planned programme of work hardening exercises to help maintain or restore their work ability even before any health problems arise. Increasingly the problems faced by industry are of a psychosocial nature and these can be even more complex and costly to deal with. OH nurses, working at the company level, are in a good position to give advice to management on strategies that can be adopted to improve the psycho-social health and wellbeing of workers.

Health and safety

The OHA can have a role to play in developing health and safety strategies. Where large, or high risk, organizations have their own in-house health and safety specialists the OHA can work closely with these specialists to ensure that the nurses expertise in health, risk assessment, health surveillance and environmental health management is fully utilized into the health and safety strategy. Occupational health nurses are trained in health and safety legislation, risk management and the control of workplace health hazards and can therefore make a useful contribution to the overall management of health and safety at work, with particular emphasis on ‘health’ risk assessment.

Hazard identification

The nurse often has close contact with the workers and is aware of changes to the working environment. Because of the nurses expertise in the effects of work on health they are in a good position to be involved in hazard identification. Hazards may arise due to new processes or working practices or may arise out of informal changes to existing processes and working practices that the nurse can readily identify and assess the likely risk from. This activity requires and pre-supposed regular and frequent work place visits by the occupational health nurse to maintain an up to date knowledge and awareness of working processes and practices.

Risk assessment

Legislation in Europe is increasingly being driven by a risk management approach. OHA’s are trained in risk assessment and risk management strategies and, depending upon their level of expertise and the level of complexity involved in the risk assessment, the nurse can undertake risk assessments or contribute towards the risk assessment working closely with other specialists.

Advice on control strategies

Having been involved in the hazard identification and risk assessment the occupational health nurse can, within the limits of their education and training, provide advice and information on appropriate control strategies, including health surveillance, risk communication, monitoring and on the evaluation of control strategies.

Research and the use of evidence based practice

Specialist OHA’s utilize research findings from a wide range of disciplines, including nursing, toxicology, psychology, environmental health and public health in their daily practice. The principal requirement for an occupational health nurse in practice is that they have the skills to read and critically assess research findings from these different disciplines and to be able to incorporate the findings into evidence based approach to their practice. Research in nursing is already well established and there is a small, but growing, body of evidence being created by occupational health nursing researchers who investigate occupational health nursing practices. OHA’s should ensure that they have access to and the skills necessary to base their practice on the best available evidence. At the company level occupational health nurses may be involved in producing management reports on for example sickness absence trends, accident statistics, assessment of health promotion needs and in evaluating the delivery of services, the effectiveness of occupational health interventions. Research skills and the ability to transfer knowledge and information from published research to practice is an important aspect of the role.

Ethics

OHA’s, along with other health, environment and safety professionals in the workplace health team, are in a privileged position in society. They have access to personal and medical information relating to employees in the company that would not be available to any other group. Society has imposed, by law, additional responsibilities on clinical professionals to protect and safeguard the interest of patients. The ethical standards for each discipline are set and enforced by each of the professional bodies. Breaches of these codes of conduct can result in the professional being removed from the register and prevented for practicing. Nurses have a long and well-respected tradition in society of upholding the trust placed in them by patients. This level of trust in the occupational health nurse’s professional integrity means that employees feel that they can be open, honest and share information with the nurse in the confidence that the information will not be used for other purposes. This allows the nurse to practice much more effectively than would ever be possible if that trust was not there. The protection of personal information enables a trusted relationship between employees and the nurse to be developed and facilitates optimum working relationships and partnership. The International Commission on Occupational Health (ICOH) has published useful guidance on ethics for occupational health professionals’. This guidance is summarized below “Occupational Health Practice must be performed according to the highest professional standards and ethical principles. Occupational health professionals must serve the health and social wellbeing of the workers, individually and collectively. They also contribute to environmental and community health the obligations of occupational health professionals include protecting the life and the health of the worker, respecting human dignity and promoting the highest ethical principles in occupational health policies and programs. Integrity in professional conduct, impartiality and the protection of confidentiality of health data and the privacy of workers are part of these obligations. Occupational health professionals are experts who must enjoy full professional independence in the execution of their functions. They must acquire and maintain the competence necessary for their duties and require conditions which allow them to carry out their tasks according to good practice and professional ethics.”