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The MD Benefits Mall-Advice for the Uncommon Man

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  • The MD Benefits Mall-Advice for the Uncommon Man

    This thread is designed for you as members to come forward with your benefits related questions for health insurance, dental, worker's comp, dealing with third party administrators, and the like. It is designed to give a basic understanding of some of the terminology that you might see ie. deductible, EOB, etc. and give you suggestions on where to turn if you are running into difficulties with your insurance carrier. This thread is intended to provide direction only, and should not be viewed as specific advice for any one carrier. Please feel free to post your questions, and those of us that have industry experience will do our best to provide you with the information you need.
    SnakeBite Racing

  • #2
    What is the difference between a participating and non participating provider. I want the one that pays more under my plan!!!
    I never lie because I don't fear anyone. You only lie when you're afraid - John Gotti

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    • #3
      Originally posted by GOODFELLAS View Post
      What is the difference between a participating and non participating provider. I want the one that pays more under my plan!!!
      A participating provider is held to the fee structure that has been agreed upon between the provider and the insurance company. The preferred, or network, providers are always covered at a much higher rate than those that are not preferred, or non-network providers. In cases where there are competing hospital systems, you'll find that the preferred providers are almost always aligned with one hospital system rather than the other. Here in Cleveland, you find this with the Cleveland Clinic and University Hospitals Health System. It does pay to check with your carrier though as there are cases when certain providers are still network providers.
      SnakeBite Racing

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      • #4
        I see you live in Cleveland. Suppose you go to Kansas and get sick. Will you still be covered under your medical plan. Even though you are in a different state?
        I never lie because I don't fear anyone. You only lie when you're afraid - John Gotti

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        • #5
          Originally posted by GOODFELLAS View Post
          I see you live in Cleveland. Suppose you go to Kansas and get sick. Will you still be covered under your medical plan. Even though you are in a different state?
          You can be if your insurance carrier has participating locations out of State, and they often do. I am with Medical Mutual, so I can use participating hospitals and doctors in the FirstHealthNetwork. To locate a doctor or hospital in the area I'll be traveling, I can either call the 800 for FirstHealth that is on the back of my benifits card, or call or go to my carrier's website to find that information. The rule always is in a life or death situation, go to the nearest hospital not necessarily one that is in network. For example, I'm going to Las Vegas to compete in July. I turned up 15 providers in the Las Vegas area that I can use In-Network.
          SnakeBite Racing

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          • #6
            This thread is a great idea! Good stuff already!
            http://forums.musculardevelopment.co...n?goto=newpost

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            • #7
              Originally posted by PTmuscle View Post
              This thread is a great idea! Good stuff already!
              Originally posted by GOODFELLAS
              Thanks Connstellation knows her stuff

              Hey thanks, guys! Just to answer a question if anyone is curious. I am licensed in the State of Ohio for Health, Life, Accident, and Variable Annuities. Currently I represent small employers dealing with State fund worker's compensation claims.

              Tip of the day. Go get your annual physical. These are covered by insurance, and if there is any out of pocket expense, it is typically a small co-pay. These physicals are vitally important and can save you tons of medical expense down the road. As we age, there are things that need to be checked and monitored and establishing a rapport with your physician is important to staying physically and mentally healthy. After all, none of us wants to be sidelined from the gym for long!
              SnakeBite Racing

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              • #8
                Tip of the Day

                Benefits of a high deductible health plan that is health savings account (HSA) compatible. These are a great way to save money on premiums! Preventative visits are covered at 100%, the rest of the visits, were you to need them, would be paid out of pocket until the deductible is met. Once this deductible is met, typically a high deductible plan will pay out at 100%. The reason why this lowers your premium is that you are absorbing greater risk for yourself rather than having the insurance company absorb the risk. For example, if your deductible is $2500 you would pay all costs that are NOT preventative treatment (like visit to specialists or prescriptions) out of pocket until your deductible has been met. For most people, all they need is their annual appointments and a few prescriptions. You never even approach the deductible limit. In addition each time you pay a co-pay on a traditional plan, that's money that is paid and lost with no return on investment. Here is the best part. With a qualifying high deductible health plan you can open a health savings account (HSA) at a participating bank. The money you put into this account goes in tax free and can be used to pay for your health expenses including not covered office visits, prescriptions, even band-aids if you wanted. The money is yours, and the amount will roll-over year to year collecting interest. You may even use this account when you are Medicare Eligible to pay prescriptions and the like. Take a look at high deductible health plans. It's an excellent way to maintain your insurance and save on premium costs in the long run.
                SnakeBite Racing

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                • #9
                  Thanks I knew it was my turn. Been fishing since 6 am going to bed now lol.
                  I never lie because I don't fear anyone. You only lie when you're afraid - John Gotti

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                  • #10
                    Originally posted by GOODFELLAS View Post
                    Thanks I knew it was my turn. Been fishing since 6 am going to bed now lol.
                    No problem. I figured that one was a good subject for today.
                    SnakeBite Racing

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                    • #11
                      That is kinda like what my wife does. She puts says 1000 on credit card at the beginning of the year and we use it for copays, drugs, most things you pick up health related in a drug store. Contact solution, stomach aides etc.Doesnt roll ove though that is nice....

                      People have tried to buy washing machines, vacuums, etc. There is always someone out there
                      I never lie because I don't fear anyone. You only lie when you're afraid - John Gotti

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                      • #12
                        Tip of the Day

                        If you do not agree or understand how your recent claims was paid by your insurance company call customer service. Customer service phone numbers are normally located on the back of your insurance cards.

                        After service explains the the payment to you and you are not satisfied with the explanation do not settle for the answer you were given!!!

                        Ask to speak to a Supervisor.

                        I have seen subscribers ask to speak to the President of the company if they are still not satisfied.

                        Sometimes it does not end with the President. Subscribers contact the department of insurance and get the attorney general involved. This course of action will definitely get the insurance companies atttention. The AG demands an answer in so many days. If he/she is not satisfied with your claim they will demand your claim be paid by the insurance company and they may levy a fine against the company for thousands/millions of dollars if a large problem is discovered due to your one claim!! Also they may demand all of your claims in your history be reviewed so you may get paid even more money.

                        Never give up when you are not satisifed with an answer. Stand up for yourself and good things may happen
                        I never lie because I don't fear anyone. You only lie when you're afraid - John Gotti

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                        • #13
                          Tip of the Day (Coordination of Benefits and EOBS )

                          For example your insurance company is Aetna and your spouse has MVP. This means if you have each other covered under your contracts all claims will be paid twice. First Aetna will make a payment. Next the remaining balanace will go to MVP and they may also make a payment on the claim. And vice versa.

                          Coordination of Benefits is one of the most difficult tasks for a claim examiner. The reason is every insurance company has a different looking EOB. So not only may you be confused by the EOB the examiner may be too. Ask questions about your EOBS. LEarn to understand them. You may be getting shorted of money owed to you.
                          I never lie because I don't fear anyone. You only lie when you're afraid - John Gotti

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                          • #14
                            Tip of the Day
                            Generic and Mail Order Incentive for Prescriptions

                            Often insurance companies will offer incentives for using generic drugs where available and mail order prescription service for any maintenance medications (medications taken constantly, for example the Pill for women). Typically these incentives are in place to help both you, and your insuruer save money. Generic drugs have the same chemical content as the brand name, but can be much, much cheaper. A mail order prescription service will mail you a 3 month supply of your medication each time you order which saves you the trouble of having to run to the pharmacy. In some cases if your insurance company has these incentives in place and you CHOOSE NOT TO take advantage of them, you will be billed an extra amount. See if your plan has this type of incentive available to help you save both time and money.
                            SnakeBite Racing

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                            • #15
                              Tip of the Day
                              Don't be afraid to question your provider.

                              You know your body best. If you are at your doctor's office, chiropractor, dentist, podiatrist, gastroenterologist, whatever, and you think that you aren't being "heard" on a concern or that something is being glazed over, you are entitled to not only question, but receive a second opinion. Trust me on this. There are PLENTY of idiot physicians and I see a lot of them in my line of work.
                              SnakeBite Racing

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