Friday, May 31, 2019

Agent behaving (VERY) badly

Some years ago, we blogged on a rather interesting (and illegal) sideline in which a Pine Tree State insurance agent was engaged:

"57-year-old Mark Strong Sr., pleaded not guilty to 59 counts of promotion of prostitution and violation of privacy."

Mr Strong being, of course, the proprietor of the "Strong (Insurance) Agency" of Thomaston, Maine.

We wondered at the time about whether or not his Errors and Omissions policy would provide much cover.

Fast forward a half-dozen years or so, and co-blogger Bob V tips us to this life-imitates-the-news story out of Portsmouth, Ohio:

"Regulators are trying to remove the license of an insurance salesman allegedly involved in a sex trafficking ring ... saying he committed insurance fraud on at least two separate instances."

Wait, is he in Dutch because of the sex thing, or the fraud thing?

Well, seems to be both, plus the odd HIPAA violation (one wonders how he missed out on the jaywalking).

Turns out, he's accused of trying to fool an insurance company into paying a fraudulent disability claim [ed: and look at that - it's still Disability Insurance Awareness Month! Go us!], so that covers the insurance part.

Aside from that, two women claim to have slept with him for money (wait, did he get that from the DI carrier?).

The article also mentions that he's "a long-time financial adviser;" given that at least two insurance carriers have fired him, and the DOI is apparently looking to suspend his license, seems like the SEC folks will soon be taking their bite, as well.

I lead such a sheltered life.

Thursday, May 30, 2019

Living Benefits: Is this something?

Recently, a friend of mine attended a post-retirement financial planning seminar, at which was touted a way to use one's life insurance as a "living benefit" (no, not that kind of living benefit).

The idea goes something like this (all numbers in this example are for illustrative purposes only):

One buys a single pay Whole Life (WL) insurance plan, depositing $100,000, which purchases s $200,000 death benefit. One then waits a few years for the surrender period to end, and then "withdraws" [ed: we'll circle back to this] $75,000, leaving $25,000 of the original premium in the plan. This reduces the death benefit to $125,000. When one's time comes to exit this mortal coil, one's beneficiary still gets $125,000 ($200,000 - $75,000). Nice return: $125,000 benefit check for $25,000 net deposit (5:1).

My friend wanted to understand why a carrier would agree to this, and I agreed to look into it, as a result of which I have some concerns.

Here’s what I think would actually happen:

As a single pay plan, it's automatically considered a Modified Endowment Contract (MEC).

And what the heck is that, you ask?

Well, a "modified endowment contract (commonly referred to as a MEC) is a tax qualification of a life insurance policy which has been funded with more money than allowed under federal tax laws ... Essentially a life insurance contract which becomes a MEC is treated like a non qualified annuity by the IRS for taxation purposes prior to the insured persons passing."

In other words, the money coming out of such a plan would be on a LIFO (last in, first out) basis, so when one pulls out that $75,000 at least some of that is taxable as income (and depending on age, may be subject to a 10% penalty). Also, that $75,00 is not a "withdrawal," it is a loan, and most companies charge 7% or 8% interest on outstanding loan balances (and that’s on the whole $75,000).

Ouch.

But what does that mean "in real life?"

I ran a Single Pay WL quote with our primary carrier (figuring it would be pretty industry average) as a baseline. 

The surrender charges went away by year 5, at which point cash value was $103,000, so about $3,000 growth, so maybe a $300 penalty. Not really hateful.

But: the whole $75,000 is a loan, and the interest on that is 8% (I presume that's fairly common). So the interest charged is $6,000.

Per year.

Every year.

Here's where it gets "fun:"

If one is smart, one is paying that $6,000 every year so that the loan doesn't snowball. In about 12 years (maybe less), one has just paid the carrier back the $75,000 (in $6,000 per year increments), and still has to keep paying. We call that "in the hole."

Or, perhaps one decides not to pay it, and the carrier deducts the $6,000 from the remaining cash value (remember: that's about $25,000). That's gonna go away pretty fast, no? And then one has nothing.

No, wait: one still has the $75,000 one took out
(and paid some taxes on) . After giving the carrier $100,000 of one's own money.

#Winning!

Now, why wouldn’t the carrier love this?


To be fair, we've seen (and debunked) this general idea before:


But this particular iteration has some novel twists, and I'm not so sure it's completely off the charts. A friend who's familiar with it suggested that I reach out to Lafayette Life, which apparently markets a plan that could (does?) serve as a platform. I have yet to hear back from them, but will update this post when (if) I do.

Meantime, I would very much appreciate any thoughts our readers might have on this.

[Hat Tip: FoIB Chris v B]

Wednesday, May 29, 2019

Price Control FTW!

You may have seen the news that the Centennial State has become the first in the union to impose price controls on insulin:

"The state is capping co-payments for diabetics with private insurance at $100 per month"

The Tiffany Network also says that the average diabetic currently spends upwards of $500 a  month on insulin (although they offer no insight as to how they arrived at this figure, other than it was reported to them by the Health Care Cost Institute). They also don't say how much the average diabetic actually pays for the med (this is an important, and generally unremarked upon, distinction).

[ed: the Institute itself is apparently funded by 4 major carriers. FWIW]

While one's first reaction is likely applause, it should actually give one pause. As a longtime correspondent in Colorado notes in email:

"Recently our governor in Colorado signed a bill restricting copays on insulin to $100 monthly. Comments about this universally demagogue President Trump, blaming high prices on him. And a tv reporter did a completely uncritical segment on it. I wrote to him and told him that price controls create shortages, etc. But this won't work the usual way, because it is with an insurance company, not a retailer. I told the reporter that the insurance company may just raise premiums for everyone to make up the difference. Or they could pull out of the Colorado market."

I would quibble only with the "may" raise premiums: count on it.

It's also worth remembering that, while Colorado may be the first state to cap co-pays on insulin, they're far from the first to dabble in rx cost controls. From almost 4 years ago:

"Drug companies are facing a new campaign to contain treatment costs, this time with proposed rules in Massachusetts that would include a first-in-the-nation cap on some prices."

[ed: Which bill, by the way, "failed to emerge from a legislative committee." C'est la vie] 


Our correspondent also ponders:

"Why did Governor Polis choose diabetes as his target to reduce to costs? There are plenty of other chronic diseases out there that have attached meds to manage the disease. So why do diabetics get a break, but others don't? Does he want to buy the votes of diabetics?

Perhaps insulin is just a trial balloon to see how this flies and then move on to all meds."
 


This is an excellent point.

And it gets even better (for certain values of "better"):


"Let's play a game. What would happen if he capped the co-pay on all meds? And what if that co-pay was $1.00? It is easy to see that this would be so expensive, insurance companies would have to make it up in premiums. When premiums go up, the governor will have to create a new program to help subsidize them. So then he gets to buy the votes of those he is subsidizing, while calling the insurance companies evil."
Pitch. Perfect.

I responded that this echoes the minimum wage "debate:" why $15 an hour? Why not $25? Or $50? Or $1,000? Each is equally defensible, no?


In any event, will be interesting to see how the co-pay cap works out in Colorado.

Tuesday, May 28, 2019

Post-Tornado Heads' up

As I'm sure most have heard, our little corner of paradise was slammed with multiple tornadoes last night. Miraculously, there don't appear to have been any fatalities, but there is significant property damage (as one would expect).

We've been asked to pass along the following urgent suggestion from out primary carrier:

"Tell insured's not to sign any contracts with door to door contractors.  If you need to get in contact with [your adjuster] you can call her on her cell phone."

This is likely good advice no matter who your insurance is with....

Monday, May 27, 2019

Memorial Day 2019: A Tribute

Courtesy FoIB Dr Rob:

Friday, May 24, 2019

Outcomes vs Costs


Yup.

But: #NarrativeUberAlles

Gentlemen: Start your ... needles?

Courtesy FoB Holly R:

"Some fans attending Sunday's Indianapolis 500 can get measles vaccines at the track's infield medical center."

This comes as the CDC has issued a warning about the increasing incidence of the once-eradicated disease:

"From January 1 to April 26, 2019, 704 individual cases of measles have been confirmed in 22 states including Indiana. This is an increase of 78 cases from the previous week."

At least one fan's not worried though. Local Indy aficionado Mike Dean's theory is "I think if you drink enough beer, it kind of inhibits the measles virus, so that’s been my defense."

Heh.

Thursday, May 23, 2019

Gleaner Life: "Give and Grow" 2019

We've mentioned before how Gleaner Life gives back to its community of policyholders and their families:

"These "Give and Grow Grants" put real dollars directly into the hands of folks who want to help "to improve their communities through volunteer service projects."

Well, they've just announced this year's recipients, all 100 of them (Wow!), will split almost a quarter of a million dollars to help with college (and/or other post-secondary) education expenses.

The competition is available to Gleaner life clients and their families, and:
Applicants are scored individually in six basic areas:

1. Academic record
2. Leadership
3. Quality of activities and community involvement
4. Letters of recommendation
5. Explanation of financial need
6. Overall quality and completion of the application
Sweet!

Wednesday, May 22, 2019

MedicaidForAll: A preview

Shot:
Chaser:

Tuesday, May 21, 2019

GoodRx for Healthcare?

A while back, our Jack Russell-mix puppy had knee surgery, and the doc prescribed 4 (yes, four - I told you she's a Jack Russell-mix) meds for her. Buying them from the vet got expensive pretty quickly, and they recommended the folks at GoodRx. This is a site (and an app) where you can procure coupons for various meds, often saving significant dollars.

This helped a lot with Maddie's meds, and we've since used it for our own. It's easy and efficient, and even better, it's free.

Well, seems like the basic idea is really taking off:

"Discount medical shopping site launches in Kansas City ... has gone live with the test version of sesamecare.com."

We've seen this model before, of course:

"Must See TV featured an interview with Dr. Keith Smith where he outlined the unique practice at the Surgery Center of Oklahoma.The hospital operates on a cash only basis."

The Sesamecare site takes the reduced-fee, cash only model and expands it to include primary care and dental visits, eye exams and MRIs, and other services. According to the site, over 100 providers offer over 600 services, from OB-GYN to dermatology, even cardiology services. Pretty expansive.

And of course, since patients know the price of services upfront, and there's no insurance involved, there's no worry about what they will ultimately cost.

Unlike Direct Primary Care or sharing ministries, these services will generally be HSA-eligible, which also helps to offset the fact that there's not going to be much (if any) insurance reimbursement (depending on whether your plan is a PPO or an HMO).

So far, the service is available only in Kansas City [ed: I've heard that everything's up to date there], but perhaps we'll eventually see it rolled out in other markets.

Kudos!

[Hat Tip: Dr Gina Reghetti]

Monday, May 20, 2019

Thursday, May 16, 2019

Evergreen State Long Term Care

So the great state of Washington has passed legislation implementing what appears to be the first "Social-Insurance Program for Long-Term Care" in the nation.

Cool.

But what, exactly, does that mean?

Well first, let's look at what this plan isn't:

It is not an individually owned, Partnership Compliant long term care insurance plan (it's not, in fact, 'long term care' coverage at all, but we'll circle back to that). That's not to say it's evil, fattening or carcinogenic, just noting its limitations.

On the other hand, it's also not the late, unlamented CLASS Act, so it actually seems to have some decent value, especially relative to cost.

Okay, that's nice, Henry, but what is it?

Pretty simple, really:

"All residents will pay 58 cents on every $100 of income into the state’s trust. After state residents have paid into the fund for ten years—three if they experience a catastrophic disabling event—they’ll be able to tap $100 a day up to a lifetime cap of $36,500 when they need help with daily activities such as eating, bathing, or dressing."

That is, they'll be eligible to receive up to a year of extra help with common tasks (assuming care costs $100 a day, and this amount increases each year). Which is, quite frankly, pretty remarkable. And at a tax rate of about 6/10th's of 1%, quite affordable. Given the state's average income of $70,000, that comes to about $400 a year per taxpayer.

So, is this a good deal?

Depends, no?

I'm ambivalent as to its likely result:

On the one hand, as it relates to encouraging folks to at least discuss the idea of long term care (and insuring it, obviously), raising awareness, I think that can be good.

What I'm afraid of, though, is that it will give folks a false sense of security as to the need to self-insure. I see this quite a bit with folks who think "oh, I don't need LTCi, Medicare will pay for it."

Uh, no, no it won't.

But a lot of folks believe that it does. And I'm concerned that folks will think that this is indeed Long Term Care insurance when it's not even really Short Term Care coverage.

On the gripping hand, it may well be all that many (most?) Washingtonians want, or need, or even qualify for.

Then here's this: proponents say that "[a]ll working people will pay into the fund through a payroll tax and then be able to claim a benefit when they need it."

Oh, really?

Then what happens if I pay into the plan for 20 years, and then decide to retire to Florida?

Time will tell, no?

[Hat Tip: Bill Comfort]

Wednesday, May 15, 2019

From the 'Be Careful What You Wish For' Files




A portent of MedicaidForAll.

#CanuckCareWinning

Tuesday, May 14, 2019

Bond, Dr James Bond

Just saw this report on the latest 007 outing:

"The difficult road to production on the latest James Bond film has hit another hurdle after shooting was reportedly suspended following an injury to star Daniel Craig."

The actor apparently suffered an unspecified leg-related injury during a stunt.

So what's that got to do with insurance?

Well:

"... the actor ... has been flown to the U.S. for X-rays." [emphasis added]

So apparently Her Majesty's Secret Service has no use for her Much Vaunted National Health Service©.

Hunh.

From the P&C Files: Active Shooter Insurance

So as one might imagine, this has become something of a hot topic of late. I knew we should blog on it (for all the obvious reasons), and since it's in the P&C world, I wanted to be sure that I had a firm grasp on as many of the issues as possible.

To that end, I turned to my colleague Teresa S, and we had a nice (long) chat trying to identify those issues (as best we could).

Beyond the obvious (wrongful death and medical and funeral expenses), there's counseling, biohazard cleanup, and destruction of property; in some cases, relocation and rebuilding expenses might also come into play. There's also business interruption and even Public Relations, and let's not forget off-site coverage (if the business or organization needs to rent temporary facilities).
This is not, of course, an exhaustive list.

Who and what, exactly, are being insured is also important: the institution/organization, of course, but also boards of directors, Elders, etc.

And who's eligible for coverage becomes an issue: members or students, of course, but what about guests or employees?

Generally speaking, commercial liability policies will have a list of exclusions; items not on this list are then usually covered. Typical exclusions might include acts of war and/or terror, or even more specifically mass casualty events. Which latter begs the question: what does mass casualty mean?

[ed: Turns out that, much like Tootsie Pops, the magic number is 3]

The folks at World Wide Facilities sent along a very helpful guide to their program, which includes some nice features. One thing that Teresa pointed out was that regardless of whether or not one's current commercial liability insurer even offers this coverage, it may be worth considering this kind of stand-alone plan in addition to or instead of adding coverage to the current plan. 

And, of course, what kinds of establishments might be looking for this coverage (or, maybe more critically, should be considering)? That would include:

Schools                                          Hotels
Religious Organizations                Restaurants and Bars
Hospitals                                       Sports/Recreation/Entertainment venues
Municipalities                                Events and Concerts
Retail  

Whew!

Coverage limits are generally measured in the millions (or even tens of millions). One thing I liked about World Wide's brochure was that the application itself provides a great deal of helpful hints about what to be considering:

■ Is there an on-site security detail?
■ How far away is the nearest police and/or fire department?
■ Is there an emergency preparedness plan in place, and who knows what it is (or even knows that it exists)?
■  Are there regular security drills?

And more.

The bottom line, of course, is that it's a lot easier (and more cost effective) to consider these issues and this coverage before an incident. As usual, we recommend speaking with your own agent to determine what coverage (if any) is already in place, and what's missing.

Monday, May 13, 2019

Options Denied

So got a call the other day from a couple looking for health insurance. Well, Karen was; Carl is on Medicare. Karen's 63, and a cancer survivor (Yay!!). Their current, grandfathered Anthem plan sports a $5,000 deductible, and runs about $540 a month, and that's become something of a budget burden for them. They reached out to me to see if they could get something cheaper.

After determining that they're not eligible for a Special Open Enrollment, I explained that there's not a lot that we can do for them. Yes, there are cheaper alternatives, but they're either underwritten, or exclude pre-existing conditions (or both), or offer much more limited benefits than their current plan.

Out of curiosity, I looked at the 404Care.gov site, and saw that the least expensive offering there featured a $7,900 deductible (almost 60% higher than their current plan), and cost almost $640 (about 20% higher than their current plan). They would almost certainly qualify for a subsidy, but that, too, is a moot point until the Fall.

I felt bad explaining to them that, as frustrating as it is, their current policy is the least bad alternative (at least until the next Open Enrollment period). I truly hate that, but I couldn't in good conscience recommend any other plan.

/sigh

Friday, May 10, 2019

It's a Holly Jolly Linkfest

All links courtesy of FoIB Holly R:

Scientists in Israel have discovered what appears to be a very promising treatment for epilepsy, and it comes from an unexpected source:

"Researchers at Tel Aviv University have discovered that a drug used to treat multiple sclerosis may help epilepsy patients."

Yasher koach!

On the other hand, Israel's universal health insurance system (a hybrid of public and private) isn't faring so well:

"Israel’s health expenditure is way below its OECD peers’. This leaves Startup Nation lacking beds, doctors, nurses, MRIs and CT scanners"

The country has begin a major effort on tech solutions to the problem but, well:

"... if you are in need of hospital care in Israel, you may end up, like 94-year-old Mr. Dabah or Fiasl’s mother, parked for days in a ward corridor, or waiting for hours in an emergency room."

Oy.

As we've noted before, the major benefit to Direct Primary Care (DPC) is that it "guarantees quick access to care." And  that access also means more quality time with the doc.

Which, as it turns out (unsurprisingly), is a very good thing:

"Trojanovich spent more than an hour with patient Andrew Buttrell, who says that time spent with the doctor makes a difference with his health needs."

Hunh.

Bonus Link: When is a clump of dirt *more* than what it seems?

When it holds the key to a life-saving medicine:

"In 2010, when Lilli Holst scraped a lump of soil from the underside of a rotting eggplant, she had no idea that this act would help to save the life of a British teenager, eight years later and 6,000 miles away."

This is a fascinating true medical detective story. Very cool.

Thanks, Holly!

Thursday, May 09, 2019

Don't Bogart That Ointment

So I recently had a life case go south in a weird way:

Did my usual pre-screen, which includes height, weight, any meds, any tobacco use, and the like; based on his answers (including no tobacco use), gentleman seemed to qualify for a preferred non-smoker rate. And so we submitted the application and arranged for the paramed exam. All very cut-and-dry.

Until I got back the approval .... at Preferred Smoker class.

Hunh?

So I thought "oh, he vapes or maybe had a cigar the day before." But when I called, he said no, had quit smoking years ago, but when he gets anxious he sometimes pops some nicotine gum.

Hunh.

So I called the underwriter, who said, based on the lab result, my guy's "popping that gum" a lot; enough, in fact, to kick him into tobacco use territory.

But Henry, you object, he's not using tobacco, he's just chewing some nicotine-laced gum.

Um:

"Nicotiana tabacum, the type of nicotine found in tobacco plants."

Oh.

Thing is, most folks don't make that connection: they (reasonably) believe that nicotine ≠ tobacco, because they're not smoking or chawin' it.

Which brings me forward a few weeks, to CBD oil:

"Cannabidiol (CBD) is one of more than 100 unique “cannabinoid” compounds that are found in the oily resin of the cannabis plant ... To make CBD oil, one must start with CBD-rich plant material."

Are you beginning to see a connection?

This past weekend, I had an interesting conversation with a doc who specializes in pain management and is a big fan of CBD oil and its pain-reducing abilities. He also claimed that taken topically (ointment) or even orally, one would likely not get flagged on a drug test.

I questioned this, in part because of my client's recent tobacco/nicotine experience. One of the questions on life applications is about marijuana (among other drugs) and/or extracts thereof. So I again reached out to my primary carrier's underwriter to see what he had to say, and he graciously replied:

"If the applicant is taking CBD oil, it should be noted on the application as we ask if they are taking any medication, prescribed or not. The drug testing results should be negative if they are using CDB oil.

Our concern certainly is if they have chronic pain and we would rate for this impairment
."

Which, to be fair, I hadn't even considered. So it turns out that my doc friend was right about red flags for the oil itself, but the underlying impetus for its use would be a concern. And, of course, it is a med, so needs to be noted on the application.

Interesting (at least to geeky me).


[Thanks to FoIB Rob P for the assist]

Wednesday, May 08, 2019

That was then...

I'm with Bernie:

[click to embiggen]

[Hat Tip: FoIB Sam B]

The Best/Worst Part

I've noted before that the death claim process marks the final part of the promise I made to my client when I sold him (or, of course, her) a life insurance policy:

"There is really nothing remarkable about this process; after all, everything went as it should ... And yet, there is everything remarkable about it: over the years, George paid in several thousand dollars in premiums, a mere fraction of what his widow will receive ... And in a week or so, I will be the only person in his widow's life who will be giving her money."

This was the culmination of the process, wherein I got to keep my promise to George. It is at once the worst part of my job (losing a client) and the best (bringing a check).

Yesterday, I learned of the recent death of another client: Bob had some medical issues, and was far from a spring chicken, but he was a patient, kind and friendly gent, with a ready smile and a quick wit. When we met back in '15, he said that he wanted to take care of his (much younger) wife should he pass away. His health precluded a "regular" underwritten plan, so we chose a Guaranteed Issue one from the wonderful folks at Gleaner Life. This underwriting process asked only for a pulse and a check, but had very limited death benefits for the first two years.

Since it's now 4 years later, no such restrictions apply, and so Beth will soon be receiving a check for $25,000.

Out of the blue.

Hunh?

Well, it turns out that Bob had chosen not to tell her about his purchase, and she only figured it out going through some of his paperwork and finding the policy and my card. So I was fortunate to provide a substantial, and welcome, surprise.

Feelin' pretty good 'bout that.

Monday, May 06, 2019

DIAM: How much is enough?

May is Disability Insurance Awareness Month, and as usual we'll be featuring posts about this important coverage throughout it. Here, for instance, is an online calculator, courtesy of MassMutual, to help folks try to get a handle on how much coverage they really need:

Online DI Calculator

Friday, May 03, 2019

Friday LinkFest: International Edition

As we see the effort to implement Medicaid For All (M4A) continue ramping up, it may be instructive to see how well the concept works in the real world. Case in point: Singapore. As Ari Armstrong explains:

"Singapore has a mixed system, with both public and private components. But “the government holds the cards” ... the government strictly regulates what technology is available in the country and where."

It's the ultimate exemplar of "who pays the piper calls the tune."

#BeCarefulWhatYouWishFor

Meanwhile, Sally Pipes reports on Our Neighbors To the North, specifically the folks n Nova Scotia:

"A mother in Nova Scotia living with cancer is challenging Premier Stephen McNeil to meet with her after a years-long battle with the province's health-care system."

*This* is the face of government-run health "care:"



Finally, some good news on the health/culinary front, courtesy of FoIB Holly R:

"When restaurants across America put signs in their windows vowing never to use your company's flagship product, you might have a problem."

For many years now, we've been been warned to stay away from MSG.  But that may have been a mistake:

"[X]enophobia, not science, explains the initial anti-MSG push a half-century ago that lingers today despite no definitive evidence that MSG causes sickness in humans."

Bon appetit!

Thursday, May 02, 2019

#Clawback FTW!

One more satisfied ACA victim customer:

Springtime Heads' Up

From our friends at Cincinnati Insurance:

Wednesday, May 01, 2019

Coincidence?

Shot*:
Chaser:

"May is Disability Insurance Awareness Month"

Just sayin'.

*Hat Tip: Erie Insurance

Transparency is the Word


Gotta love this headline in today’s readings: Doctors: Don’t blame me for high healthcare costs.

Lots of factors are at play when it comes to high healthcare costs. But doctors are sure of one thing: They aren’t to blame.

Physicians instead point to pharmaceutical and insurance companies as the source of high costs, according to a new survey from the University of Utah Health.”

This seems counter-intuitive: of course Doctor’s are to blame because that is who the patient pays for medical care. Yes you, the patient, pay the Doctor for your portion of the appointment, but the Insurance Company determines what is the patient’s portion.

There has been much discussion lately about making the cost of health care transparent. Most of that discussion revolves around the physician appointment and the physician charges but very little revolves around the part Insurance Companies play in determining the cost of healthcare.

To understand how vital a role Insurance Companies plays in healthcare costs, one must understand the relationship between the Provider and the Insurance Company. The Provider agrees to see all the patients in the Insurance Company’s Panel for a certain reimbursement for each Procedure Code that is billed. The Insurance Company agrees to list the Provider as an “in network” Provider and promote that Provider to their panel.

The Provider is given a list of select Codes and the reimbursement for each. Usually, the provider does not know what the reimbursement will be until the payment comes in. Since the provider does not know the exact amount he/she will be paid, charges are set high enough to ensure full payment from the various insurance companies with which the Provider is contracted. The standard charge is set at 150% or more of the Medicare Fee Schedule.

So, a Provider sets a charge high enough to get full payment and the Insurance Company pays the Provider, then why doesn’t the Provider know what the patient will pay. There are two factors:1) The reimbursement from the Insurance Company is always less than the charge (this is known as the write off) and 2) In the Insurance Contract between the Insurance Company and the Patient is defined Patient Responsibility of the cost. This includes a Deductible, Co Payment, Co-Insurance, Out of Pocket, Cost Share and a plethora of other terms to break up the Patient’s Responsibility. Based on all these breakouts, it is impossible for the doctor to know what the patient will end up paying.