Recently I had the opportunity to switch health insurance carriers.

Why switch? First, my existing carrier increased my premiums regularly. This was interesting, because I didn’t make one claim in over 3 years and only used 1 doctor visit a year towards my deductible. I certainly wasn’t a strain on their program, in fact, they made out quite well from my premiums. Second, they didn’t have a flexible payment plan. Either I had to pay annually by check, or monthly by ACH debit from a bank account. Neither plan fit my needs.

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Look out, you may be asked to pay more for your company’s health insurance plan if you’re out of shape.

That’s right, more and more companies are taking a controversial approach by ‘encouraging’ employees to get fit by lowering their insurance premium deductibles if they pass a yearly physical fitness test. If they don’t, they pay a much larger deductible.

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With healthcare, medications and insurance costs rising, it isn’t surprising that people are trying to figure out ways to avoid getting sick and choosing a better lifestyle to lower health insurance costs. There is actually quite a bit you can do to help save some cash. Mostly, it’s just a matter of tweaking ones lifestyle choices and preventing health issues from arising and keeping the immune system strong so you don’t get sick often. For those who are seriously sick of high medical premiums and paying skyrocketing costs year-round for doctor’s visits and prescriptions, this should be a great thing. Little things make a big difference when it comes to your health.

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Are you having trouble getting your insurance company to pay your medical expenses? It’s not uncommon. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate. The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don’t even realize these review boards exist.

Another issue is that too many people just give up when their insurance claim is initially denied. The appeals process can be frustrating and long and most people don’t have the patience or time to pursue a claim no matter how legitimate it is. People must be persistent and they can win. Especially if there is a substantial amount of money involved, the time you dedicate to appealing insurance company decisions can usually pay off faster than you think. A Kaiser Family Foundation study recently found that 52% of patients won their first appeal for each claim made. The insurance companies aren’t getting away without paying anymore.

If your first appeal gets turned down, continue to press on. The study found that those who appealed a second time won 44% of the time. Those who appealed a third time won in 45% of cases. This means the odds are in your favor no matter how long it take. Remember that every time you appeal it costs the insurance company more money and they are not only going to lose money to you, but also in court costs. Medical health benefits are particularly tricky because insurance companies usually have a cap on the amount of money they’ll spend in a given year, or on the amount of visits they’ll pay for. But there’s often flexibility when you can document that you or your child’s health warrants more care than your policy normally covers.

Here’s how to get started:

Do Your Homework

Read your Policy Thoroughly: What are the benefits? Which kinds of services are included? Inpatient or outpatient care? Is it a serious or “non-serious” diagnosis?

Know the law: Contact your local Health Association to determine your states legal requirements regarding insurance payments for an illness. Does your state require full or partial parity? Are parity benefits available only to patients with “Serious Illness” or is a so-called non-serious illness also included?

Provide written documentation: Some insurance companies may not consider some diagnosis serious. In this case, you will need documentation to validate the required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.

Keep good records: Remember, you’ll be dealing with a bureaucracy. Keep the contact names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.

Start early: If you can, start the appeals process prior to initiating treatment. For example, if the doctor states your child will need to be seen once a week for a year, begin immediately to appeal your insurance company’s policy of reimbursing only 20 visits a year.

Call and ask the insurance company:

• What are the pre-requisites for receiving health benefits?
• Which services must be pre-certified — and by whom?
• How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?

Be polite, positive and patient with the customer service representative. Remember that they are only the messenger, not the decision-maker. They are the gatekeepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.

Be persistent. There are no magic bullets. Be like a dog with a bone and don’t give up until you get the answer you want. If you don’t get anywhere after several calls, ask for a supervisor or a nurse in the pre-certification department.

Remember that you do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what justifiably belongs to you.

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Recently a woman from Las Vegas sought out to buy health insurance. She searched around and found something that looked and sounded just like health insurance. The Las Vegas woman wasn’t 65 yet, which means she doesn’t qualify for Medicare, so she went online looking for health insurance. She ended up finding something called Healthcare Advantage, and signed up after paying $100.

Come to find out, this was not medical insurance at all and the sales representative never told this poor lady. She found that out after her cards arrived in the mail. In tiny writing at the bottom, it read, “not an HMO, PPO insurance or managed care company”. It was basically a discount plan. These plans do not have the same coverage as a full medical health insurance policy. Before making a commitment, make sure you know what you are getting and if it fits your needs.

So what is a discount plan? The plans claims to save people money by offering discounts on physician visits, prescription drugs, dental work, eye care and other treatments for a monthly fee. Unlike normal health insurance, which is very costly and very selective about who it covers, a discount health plan accepts everyone, no matter what health conditions they may have. You will use a list of doctors that are willing to charge discounted rates to the subscriber. The discount plan is not the same as health insurance coverage, so you will pay more for visits and other services that you wouldn’t with a regular medical plan. The average savings is approximately 25% and that could be very expensive if you have to see a specialist or require surgery. These networks claim to have as many as 400,000 doctors and 50,000 hospitals available to choose from, but what if none of them are near you? You can get a savings of up to 30% on both generic and brand name drugs which could also be costly if your prescriptions are expensive or if you have multiple prescriptions. If you have an existing health plan but have a high deductible, this extra plan may help save you some money. But to use the savings plan as a complete health plan isn’t recommended. It really isn’t designed for that and will cost you more than a competitive HMO.

HMOs and other medical plans can offer full medical coverage at great rates. Managed care plans are recommended for those who are limited on funds. They offer the best policies for the least amount of money. Most of these plans are available to anyone and can save you considerably. You can make the plan even more affordable by asking for a higher deductible, which will lower your monthly expense. Most HMO’s do not have one at all but, you can request one, and most basic PPO’s and POS’s only have a small one, usually $200 to $500 per year, which you can also asked to raised to lower your monthly payments. The co-pays are also very reasonable with these types of plans. If you choose to purchase an HMO, expect to pay about $5-$10 per office visit and per prescription. With PPO’s and POS’s you will have a 20% co-pay with both visits and medications. The differences are how strict they are and you pay more of a co-pay to have extra flexibility. Usually a PPO or POS plan is less expensive and you have more freedom to see whom you want so the insurer makes you more responsible for payment. HMO’s tend to be the least expensive and best policies for people with fixed incomes.

Review your needs and double-check what you are getting. If you need full medical coverage with low co-pay then a discount plan will not work for you. If you are already covered by a medical group but have a large deductible then you might benefit from the extra savings a discount plan can offer. Also, ask whether the plan is health insurance that covers your treatment, or is a discount plan that still requires you to pay all medical bills yourself less the discount. Beware of slippery sales pitches. Make sure you know what’s being offered. Discount health plans may only sell you access to a large mailing list of medical providers that it purchased commercially. Don’t assume you’re getting access to a large provider network just because your discount card displays the network’s name and logo. If you plan to use a specific listed doctor, hospital, pharmacy or other provider, ask a few questions before you sign up. The more details and information you get, the better decision you can make for your health insurance needs.

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Supplemental insurance benefits, like heart/stroke insurance or cancer insurance are paid directly to the insured, unless otherwise required by Medicare supplemental insurance. Hospital and major medical insurance benefits are paid directly to the provider, where you would normally have to pay a small co-payment, if anything. But if an emergency were to happen or you had a specific disease or condition that was going to cost you out of pocket expenses, investing in a supplemental plan is an idea to consider. As a policyholder, you can use those benefits to help with your out-of-pocket expenses or loss of income. Supplemental insurance products such as cancer and accidental injury insurance are not a replacement for major medical insurance. These types of policies help to cover expenses that are not covered by major medical insurance and reduce the money paid out by the insured. These policies can also pay for lost income in the case of missing work.

Supplemental medical insurance only provides coverage after your regular medical insurance has been exhausted. Supplemental medical insurance is normally used to pick up where basic medical insurance leaves off. You will have to have a regular health insurance plan to be able to use the supplemental insurance. When this coverage is exhausted, your supplemental medical coverage would begin paying. Supplemental medical coverage is written in a separate policy, and does not include coverage for basic doctor visits. Supplemental insurance can definitely be a lifesaver for many people. The only downside is that they can be expensive and useless if you never need them. You have to pay for your regular medical coverage and then add an extra policy or two which can get pretty expensive. If you try to purchase a policy after you have become ill or injured it won’t cover a pre-existing condition, so you will pay out and not receive any benefits for the condition you already have. The idea is that you have to buy into a supplemental plan prior to the incident or condition so they can prove you are healthy. There are some plans for supplementing your health insurance that can be used at any age as well.

Cancer insurance provides benefits to help cover costs for cancer treatment and other related expenses associated with the disease. Most policies provide direct-to-policyholder cash benefits for daily hospitalization and intensive care unit confinement, as well as for surgery, anesthesia, chemotherapy, radiation, and preventative care. This is a good plan to have if you have a family history of cancer, it could save your life and your wallet.

Critical Condition/Critical Illness Insurance is a policy designed to provide you with a lump sum benefit to help pay out-of-pocket expenses if you suffer a heart attack, stroke, have heart surgery, cancer (except skin cancer) or several other conditions. It covers illnesses and diseases that cause you to be hospitalized for critical conditions and picks up where you regular benefits leave off.

Disability Income Protection supplements lost income by paying a monthly benefit to you if you become partially or totally disabled due to a covered illness. This also provides a daily benefit for in-patient hospitalization for a covered illness. This policy has a reduction in benefits after age 65.

Hospital Emergency Recovery and Outpatient Insurance (Supplemental Medical) provides benefits for treatment due to a covered illness including daily benefits for in-patient hospitalization, intensive care and recovery care following hospital confinement due to a covered illness. It also provides a benefit for outpatient surgery and emergency room treatment for each covered illness.

Some of the plans geared toward the elderly and retiring persons are actually very smart to have. They can help pay for things that Medicare won’t or can’t. They also offer assistance if you ever need to be cared for at home, move to an assisted living home, or need to go to a nursing home. These types of expenses can leave other family members in debt after you are gone. Funeral and burial are normally covered as well. This gives many folks the ability to leave their families something other than bills. Also with assistance for medication there is more money to enjoy while you are st