Healthcare Insurance

Losing your medical insurance – 60 days

60 DAYS – that is how much time you have to get insurance after you lose your current insurance without any medical questions asked.  SIXTY DAYS. If you miss this window, your choices become very limited and, in some cases, no insurance at all.

Losing your medical insurance

Losing your medical insurance provided by a previous employer or even your company, you qualify for either COBRA or State Continuation.  Both are the same plan you had.  The difference, COBRA lasts longer.  You pay the premium price your company paid for you plus a 2% administration fee.  That is the law.

Most of you will get sticker shock because you had no idea how much your insurance premium costs your employer every month.  There is a better alternative.

The Federal Facilitated Marketplace

The alternative – The Federal Facilitated Marketplace or in some States, their State Exchange.  A family of four making $70,000 this year [2020], could end up with similar if not better insurance than your employer provided, and you could end up paying $150 per month or less.  In some cases, it could be free for you.

Why?  The government picks up the tab for your insurance, especially as you are losing your medical insurance.

How? Call an agent.  It costs nothing to use an insurance agent.  The insurance company pays them, and the price is the same with or without an agent.  Also, the price is the same no matter which agent you use.  Why would you want to go at it alone?

You can see this BLOG post in other places, including DSV Consulting LLC post on the same subject wherein VersaClaim Inc. is a guest BLOG participant.

Healthcare Insurance Uncategorized

What you can expect to pay on your healthcare claims

Recently, we’ve received numerous calls from everyday folks, just like you, who have had medical treatment and aren’t sure what to expect as it relates to their claims.  More to the point, they want to know how much are they going to owe.   The answer to this question is based on which category of patient you fall into financially.  The answer varies depending on the answer to these questions.  Do you have insurance?  Do you have any other third-party who might take responsibility for your claim?  Other third-parties are Medicaid, Medicare, TriCare, Worker’s Compensation or the “Healthshare Ministries”.  If you have no insurance or one of the other third-party companies, then you are considered, “Self-Pay”.

In this post, I will deal with patients who have insurance.  I will cover the others in later posts.  So you need medical care?  If you need emergency treatment, don’t worry about the finances, in-network or out-of-network, go to the nearest Emergency Room that can handle your condition.  By law, your insurance company must treat all emergency visits to an Emergency Room as in-network.

When you walk into your provider’s office, any provider, they should ask you the same question I did.  Do you have insurance?  If so, they will have you sign an “Assignment of Benefits”.  You may not recognize it, but buried in all the paperwork somewhere is a statement that says, you are giving them the right to bill your insurance company directly.  Many years ago, it was typical to see a provider, pay that provider, get a receipt of payment and then send that receipt into your insurance company for reimbursement.  This process can still be done, but not recommended.

If a provider doesn’t collect an Assignment of Benefits from you and expects you to pay for their services up front, it is usually because they know, insurance doesn’t cover their services.  Chances are good they have tried in the past to get paid, and the insurance companies have decided the services they provide aren’t medically necessary or follow the standard treatment of care.  Tread carefully with these providers.

So here are the steps with comment:

1.) Once you have received the care you went in for, the provider will generate a bill and send it to your insurance company.

2.) The insurance company will process the claim.  In most states, there are “Prompt Pay” laws, which require the insurance company to process or adjudicate a “clean” claim within a specified period of time.  In Texas, it is 45 days.

3.) To process the claim, the benefits you have paid for via your premium will be applied to the bill.  This is where your deductible and co-insurance come into play.

4.) Once the claim has been processed according to YOUR benefits, an E.O.P. (Explanation of Payment) is sent to the provider along with payment (if applicable).

5.) At the same time, an E.O.B. (Explanation of Benefits) will be sent to you explaining how the insurance company applied your benefits to that claim.  THIS IS NOT A BILL.

6.) Each claim is handled separately, therefore there should only be ONE E.O.B. for each bill sent by a provider.  A provider can send multiple bills for multiple dates of service.  Therefore, you may receive multiple E.O.B.s.

At this point in the process is where the providers and the patients get into trouble.  Just because your insurance company has processed a claim, doesn’t mean it is correct.  If you or the Provider don’t feel the insurance company should pay something they didn’t, you can appeal it.  Your insurance claims department has a lot of goodhearted people who want to do the right thing, but the insurance companies put such pressure on them to move claims out the door, many things get overlooked.  In some cases, they didn’t pay because they need more information, which the provider must respond too.  

7.) If you and your provider feel the insurance company has adjudicated your claim correctly, then expect a bill from the provider.  You will be expected to pay the amount on the bill.  By law, providers must make three (3) attempts at collections.  What does that mean?  There isn’t a hard and fast definition.  For many providers, they simply mail out three bills and that is the end of it.  Some, turn you over to collections after the three “attempts” and some actually call before turning you over to collections.  It just varies by provider.

The billing process is now complete.  I welcome any questions or comments.  I can be reached at 512-417-6058.


Insurance is like a flashlight

Just like a flashlight, don’t really care if it works or not when there is plenty of light.  That changes when it gets dark.  When you turn it on, you count on it working.

Healthcare Insurance

It makes me MAD

During the Open Enrollment, I’ve talked to hundreds of people.  Some are getting conned by bad insurance agents.  I call them bad because they either don’t know, don’t care, or are just plain crooked.  If you bought a Short-Term plan or an Individual PPO (Preferred Provider Organization) and the Agent didn’t explain the difference between a Qualified Health Plan and the one you bought, then you’ve dealt with a bad insurance agent.  You will have to pay the penalty next year for not having a Qualified Health Plan.

A Qualified Health Plan has 10 Essential benefits included in them.  The others do not.  Be sure to ask before you buy!



Healthcare Insurance

Open Enrollment is Almost Over!

You have until this Friday, the 15th to select a health insurance plan, without answering any health questions.  According to Forbes and the Motley Fool, “medical debt is the No. 1 source of personal bankruptcy filings in the U.S.”  Having health insurance can help you avoid this.  Don’t delay.

Call us with any questions, 512-417-6058.

Healthcare Insurance

Don’t Get Scammed this Enrollment

Many people are being lured into Short-Term insurance policies with the thought or hope they will be covered.  It isn’t that simple.  People are looking at the cost of Qualified Health Plans and thinking there must be a cheaper option.  There is.  Going without insurance altogether and hoping nothing happens.  Short of that, there are short-term policies (pun intended).  A short-term policy is only good for 3 months.  And yes, they are cheaper.  Some insurance carriers are offering back-to-back insurance policies, so you can have six-months of uninterrupted coverage.  So what happens when that runs out?

You must do this all over again.  Only now you have no choices.  You can either get a short-term policy or have nothing.  During the process of getting the short-term policy, you will notice they ask health-related questions because they can.  If they choose not to ensure you, they can.  When you come up for renewal, they don’t need to ask any questions because they know your health status.  You’ve been with them for six months.  If they decide not to renew you, they can.  Now what?

You have to wait for the next Open Enrollment and your insurance won’t be effective until January 1, 2019.  Other insurance companies won’t touch you because you’ve been declined due to medical reasons.  Did I mention you will also have to pay the penalty?

People who buy these plans tell me they are “covered” not knowing they are just barely covered, if at all.  I am working on two cases right now, whereby they had short-term coverage that isn’t paying their claims.  The insurance company claims it wasn’t disclosed during the application process so they are denying it.

Short-term policies are designed to provide stopgap coverage, not be major medical coverage.  To know more, please don’t hesitate calling me at 512-417-6058.


How to get a PPO!

If you’ve been trying to get insurance during the Open Enrollment, which ends December 15th, you have probably noticed you can’t get a PPO or Preferred Provider Organizations.  PPOs are only offered in the Small and Large Group markets.  The reason why is a topic for a future blog.  This topic is about how to get one if you are looking for insurance.

A small group in the State of Texas is defined as 2 to 50 employee lives.  It can’t be husband and wife, and it can’t be formed for the purposes of getting insurance.  The husband-wife thing has to do with participation.  Insurance Carriers in Texas require that 75% of eligible employees participate in the health plan, or they won’t insure you.  Having said that, a couple of insurance companies will waive the participation rates and allow a husband and wife to apply for insurance as a small group.

First, you must have a company.  A company would be an LLC, C-Corp, S-Corp or any other legal entity recognized by the State.  The company must be registered with the Secretary of State’s office.  A DBA (Doing Business As) doesn’t count.

The advantages are:  You have access to about 5 times as many plan choices including PPOs, the premiums paid are 100% deductible from the company, sometimes they premiums are cheaper and providers are more willing to take a group plan versus an individual plan.  Why providers don’t want individual insurance is a topic for a future blog.

If you think you might qualify and want to see how it might look for you, give me a call  I can answer all your insurance questions.

Ken Stephenson, MBA, FHIAS – 512-417-6058


Another Healthcare Law that Sounds Good but does No Good

In 1986, Congress enacted the Emergency Medical Treatment and Labor Act or EMTALA.  In 1994 they revised the Act to include the “prudent layperson” definition as a standard for evaluating whether a patient has an emergency condition.  Boiled down, it says if you think it is an emergency, then it is to be classified as an emergency.  It goes on to stipulate that payment is to be made for the initial evaluation and examination based upon the nature of the patient’s presenting complaint.

This federal law supersedes state law as it pertains to emergency healthcare and insurance companies.  So if you present to an Emergency Room (free standing or connected to a hospital), it doesn’t matter if it is in-network or out-of-network.  It is supposed to be paid for by your insurance company as though it were an in-network provider.

In Texas, we passed a law this year, Sponsored by State Representative Dr. Tom Oliverson (R-Cypress), HB 3276, that requires ERs to post notice of what, if any, insurance networks they are in.

Here is my question.  If ER visits are supposed to be treated as in-network, regardless of their network status.  Then why do we need a law requiring them to post a notice of what, if any, insurance networks they are in?

Healthcare Insurance

What is an “Oscar”?


There is a new entrant into Travis County for insurance.  It is called, Oscar.  Those of you looking for health insurance are very limited in your choices.  For years, Blue Cross Blue Shield has really been the only viable choice.  Now that Oscar has emerged, Blue Cross Blue Shield has some competition.  Let me briefly explain what they do differently.  Blue Cross Blue Shield only offers an HMO or Health Maintenence Organization.  What most people don’t like about HMOs is having to get a referral to see a specialist.  Oscar offers an EPO (Exclusive Provider Organization) which doesn’t require referrals to specialists.  Blue Cross Blue Shield offers Telemedicine, but charges you a PCP (Primary Care Physician) copay everytime you call.  That could range from $30 to $60 depending on the plan you chose.  Oscar does not charge a copay for Telemedicine phone calls.  Call every 5 minutes if you want.  Additionally, Oscar offers a concierge team responsible for answering your questions.  It is the same 4 people that you deal with and they know who you are and your history.  Blue Cross Blue Shield would ask that you call Customer Service and repeat your story multiple times to different people.  If you would like to see what Oscar might cost you and your family, drop me an email at or call me at 512-417-6058.



Reminder! Medicare Open Enrollment began October 15th

It will run until December 7, 2017.  If you are Medicare-eligible, and you know who you are, you can look at different options for your health insurance for 2018.  Now is the time to do this!!!

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