Posts Tagged ‘insurance


Health claim denied? Here’s what you need to know.

Health Insurance denials can happen for a number of reasons.  A simple cause can be a billing error from the provider’s office.  If the claim is submitted using the wrong treatment or diagnostic code, the claim can be denied.  More serious reasons can involve treatments considered “experimental” or “pre-existing”.  Both of these reasons can be appealed if you feel the insurance company’s decision is wrong.

If your healthcare claim is denied, you have the right to appeal.  Health Insurance carriers are required to provide an appeals process.  Typically there are a few levels of appeal, each moving more ‘independent’ by involving impartial medical professionals.  Washington State also provides the Patient’s Bill of Rights which provides an independent third-party review of your appeal, if the standard appeals process is unsuccessful.

Washington Health Insurance Agency provides assistance through the appeals process, by walking their health insurance clients through the steps, carefully tracking the appeal deadlines, recommending the best supporting documents, and even participating in the appeal discussion board via conference call on behalf of their clients.

The most important thing to remember is that if you feel the denial is wrong, you have to appeal.  Many people just assume there is nothing they can do.  The New York Times recently reported a story about this very point.

Remember, if you have the right Health Insurance Agent, you don’t have to go through the appeal process alone.


Small Business owners pay too much for health insurance

There’s a huge misconception out there that if you own a business, you get a better deal on health insurance.  The fact is, many “group” health insurance plans come with higher price tags than individual health policies.

For the small business owner with 5-7 employees or less, offering to reimburse employees for their individual health insurance policies through an HRA (Health Reimbursement Arrangement) can prove a significant cost savings to the business, while giving more freedom of health insurance plan choice to their employees.

In addition, the employees ‘own’ their individual plans, which means there’s no need for COBRA coverage if they leave their current employer.  Since businesses smaller than 20 employees do not offer COBRA coverage anyway, individual plans become even more attractive.

The biggest advantage of individual health plans over small group plans is price.  Individual health plans typically offer lower premiums than similar group plans.   The reason is risk.  Individual health insurance in Washington State requires a health risk questionnaire be completed as part of the application process.  The purpose of the health questionnaire is to ‘weed out’ the higher risk applicants with significant health risks.

Most people pass the questionnaire with ease.  When they do, they fall into the same group as everyone else who also passed the same questionnaire, which represents a lower ‘risk’ to the insurance company, thus lowering rates.  (Those who do not pass the health questionnaire are provided the opportunity to sign up on the Washington State Health Insurance Pool, a high-risk pool with significantly higher premiums)  If a business has an employee who does not pass the health questionnaire, then it can still prove less expensive to cover the high risk pool premium for that individual employee versus paying higher group rates for all employees.

Group plans in Washington do not have a health questionnaire, so the insurance company has no way of ‘weeding out’ the unhealthy employees.  The rates have a ‘built in’ risk factor, whether warranted or not, because the insurer has no way of  separating the high risk groups from the low risk.  Groups of 2-50 employees are ‘community rated’ meaning they are in the same risk pool whether their employees have low utilization or high.   Therefore, the small business with healthy employees ends up paying a higher rate because of other businesses who may have employees with expensive high risk chronic health problems.

Offering individual health plans to employees comes with more advantages than just lower price.   They also come with less administration.   Unlike ‘group” plans, there are no ‘renewals’ each year to go through, no minimum participation requirements imposed by insurance carriers, and no minimum employer contribution requirements, either.   Employers still have the ability to define eligibility, probation periods, and can design their health benefit package with more options and flexibility.

The Washington Health Insurance Agency has been providing creative solutions like this to small business owners for years.  Give us a call at 360-464-1622 to find out if you’re paying too much for your health insurance coverage or fill out our business quote form for a free cost comparison at


Is Pregnancy a Pre-Existing Condition?

It happens from time to time that I get a call from a woman who is pregnant, and she has no health insurance.  In Washington State, there are programs available through DSHS for pregnant mothers that will pay for costs associated with a pregnancy, including the delivery.  However, many times applicants do not meet the low income requirements to qualify for the State assistance. 

Health Insurance carriers in Washington have 9 month waiting periods for most pre-existing conditions.  This 9 month waiting period is waived if proof of prior credible insurance is provided, but when there’s been a lapse in coverage of more than 2 months, then the new insurance plan will have a 9 month waiting period on ‘pre-existing’ conditions (conditions treated or that should have been treated in the past 6 months) 

Pregnancy has a different set of rules when it comes to the standard pre-existing condtion clause.

Coverage offered by an Employer (also called ‘Group’ insurance) typically DOES NOT consider pregnancy a pre-existing condition.  Maternity and Diabetes are often exempt from the 9 month waiting period and covered without any issue.

Individual health insurance carriers do consider pregnancy a pre-existing condition.  However, they will cover everything except the charges associated with the actual delivery.  All prenatal doctor visits and ultrasound costs leading up to the delivery will be covered, even if there is a 9 month waiting period on the plan. Additionally, these plans will often pay for hospital and physician charges surrounding complications for the mother or newborn, as well as postpartum costs.   

The cost of having a baby can range from as little as $4000 to as much as $20,000 or more if there are complications, premature birth, or an emergency c-section.   Having the right health plan will make sure those costs are covered.  For more information on the best health insurance to have when pregnant, give us a call 360-464-1622 or visit us at


How to avoid overpaying your doctor

For anyone who’s been to the hospital, you know the paperwork afterwards can be overwhelming.  Between the hospital bills, the surgeon, the anesthesiologist, the doctor you’ve never met before who must have come in while you were on the operating table…the bills start flying in.

Here’s a tip- WAIT to pay your provider bills until you’ve received confirmation from your insurance.

Since every claim must be submitted to your insurance first, you’ll receive a statement from your carrier for everything.  The statement is called an EOB (Explanation of Benefits)

One big problem is that some providers (not all) like to get paid right away, and don’t bother to wait for the insurance company.  So, they send the bill to you, the same time they send it to your insurance.  Since the billed amount is usually higher than the insurance company’s “allowed amount”, if you pay the bill, you will more than likely pay too much.

What’s worse, the provider may not refund you the overage, they may just give you a “credit” towards you next visit.

So, the solution?  Make a file that you drop every doctor invoice into.  As soon as your insurance company sends you an EOB, pull out the file and match the doctor’s invoice with the EOB.  If it matches, pay the doctor.  If it doesn’t, call the doctor’s office and request a corrected invoice.

This way, you can be sure to never over-pay for your patient responsibility costs.  *Note – be sure you don’t wait longer than 30 days to call your provider’s billing department, as some providers are quick to send you to collections.

For the best health insurance options in Washington State, visit us online at or give us a call for expert advice at 360-464-1622.

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