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Navigating the Health Claim Maze

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Introduction

The second half of getting sick is fussing with the health insurance claims process. I have some tips to pass-on from my own health claims experiences that might help you navigate this maze. Since I also sell health insurance, my understanding of the process and structure gives me an added perspective. This is not a rant on health insurance business or healthcare – just some techniques that can be helpful.

I am way too experienced in running the Health Claim Maze. Unfortunately, I lost my older brother to cancer last year and as his friend, and later executor, had the task of helping on the insurance issues.

First the Good News

I have always gotten the right answer eventually from every health insurance company on every health claim I have dealt with. Each and every insurance company honored their insurance policy and correctly paid what was due (or had a valid reason to decline a claim). Most claims were handled correctly and timely without any intervention.

This included the Kansas Health Insurance Association (the Kansas health insurance risk pool) which paid over $500,000 for my brother’s lymphoma treatments over his two year illness. It gave him access to any treatments that were appropriate. The final cost to him, in addition to his monthly premium, was his deductible and cost sharing of $3000 for each of the two years ($6000 total).

The core value of any health insurance plan is offsetting the huge financial risk of a major illness or injury and getting you access to the treatment you need.

Choosing the Right Insurance Company

Claims service matters. Unfortunately, most folks select insurance companies based on price and not value. An important value to consider is the ease of getting help if you have a claim.

Look for an insurance company that has kept their claims call center in the United States. Nothing will make the claims process more frustrating than trying to get help on a complex health claim over a bad phone connection with someone who is talking a different version of English. Avoid any insurance company that has chosen the cheap off-shore claims helpline strategy.

Second, ask around about the claims service reputation of an insurance company. This is a good question for your insurance agent. Some insurance companies focus on making the claims process easier while others only offer only adequate service. It is worth paying more and getting the quality service.

Organization Matters

Setup a filing system to keep all claim benefit paperwork. Since the annual insurance deductible follows the calendar year, it is helpful to sort any claims “Explanation of Benefits” by the year the healthcare service was rendered. At the very least, have a box or file to toss any health insurance paperwork – keep it all. You will need this paper trail if a major health claim problem erupts.

If you are dealing with a major illness with a high volume of claims documents you will need a more advanced filing concept. For my brother, I had three files for each year: 1. Paid Claims; 2. Claims in Process; 3. Claims being appealed. I also stapled any unpaid healthcare provider invoice or appeal letter with the claims documents. Within these files, all claims paperwork was sorted by date of service. With pounds of claim’s documents generated by my brother’s illness, organization of the paperwork was very important.

The Contract / Sales Booklet

Always keep in your file the actual health insurance contract and the detailed sales booklet. The sales booklet is much more accessible and a good starting point to understanding your benefits. I purposely send the detailed booklet to each of my clients when they apply for insurance. The contract is what the health insurance company is obligated to do in exchange for your premiums and is the final word on any dispute.

Troubleshooting the Maze

Most health insurance claims are automatically (particularly if you are “in network” with your healthcare providers) and correctly handled. With any organization, even if well intended and well run (I count most health insurance companies in this category), balls are still going to get dropped and mistakes will happen. Always treat the claims representatives politely (my wife’s very wise advice) and enlist them as allies.

Here are three primary claims problems with troubleshooting techniques that I have used:

Problem #1: Claim Denied

Health claims are often denied for minor technical reasons. Don’t panic. You have work to do.

First Action: Call the Insurance Company’s claims office and ask for an explanation. Why was the claim not paid? Often it is a simple problem that can be quickly corrected.

For example: a client that had a hospitalization ($45,000 three day hospital visit due to a heart rhythm problem), but had the claim initially declined by the insurance company. A phone call to the insurance company revealed they needed a detailed bill to process the claim but the hospital had only sent a summary bill. This was quickly resolved with a second call to the hospital. A payment for the claim (less policy deductible) was quickly sent.

Second Action: Appeal the Claim. You will see on any “Explanation of Benefits” a procedure to appeal any claim that has been denied. Follow this path (normally a mailed letter). Keep a copy of everything. You need to appeal within a limited time period. I made it a policy with my brother’s claims to appeal the same day I received any Explanation of Benefits that did not pay the claim. Always send an appeal by certified mail to establish the date the appeal was made and who it was sent to. An appeal forces a higher level of assessment and typically shifts the claim to a special claims appeal review department.

Third Action: Follow up the appeal with a phone call. Normally, you will get an appeal response by mail within a specific time frame outlined in the appeals process. If you don’t receive a timely response or a response that you don’t understand, call the claims appeal office and ask for help. Request a supervisor if you don’t get an adequate answer.

Fourth Action: Ask for a copy of the contract clause that impacts the claims outcome and reread it. Have the claims representative or the supervisor explain the contract language and why the claim is ineligible for payment. You will eventually get the right answer (I always have). If the right answer is a denial, you are owned an explanation you understand.

Problem #2: Past Due Notice from Health care Provider.

This is a warning flag – something has gone astray in the claims communication or processing and you need to figure it out. Intervention will be needed.

First Action: Confirm with the healthcare provider that the claim was properly filed. Several times, I have found that the provider never got the policy information and was unable to file a claim.

Example: Both times that my brother was taken to the hospital, the ambulance service was never given any insurance policy information. The late notices alerted me to call them and provide what they need to file the claim.

Second Action: Call the insurance claims call center and confirm that they received the claim. Ask for an explanation on why claim payment has been delayed. Discuss when the claim payment will be handled.

Third Action: Repeat if necessary. If not resolved after calling the provider and health insurance claim office a second time, request the insurance company to contact the healthcare provider and resolve the communication issue directly. If this is refused, see: “Fourth Action.”

Fourth Action: The “Poor Man’s Conference Call” – my favorite technique to deal with communication barriers between healthcare providers and claims processors. Get access to two difference phone lines (I normal use a land line and my cell phone) and call both of them at the same time with a phone at each ear. Force them to dialogue with you as the conduit until the problem is resolved or until they accept your request to discuss the problem directly without you.

The “Poor Man’s Conference Call” has worked both times I had to use it. Reserve it for your stubborn communication problems when you need a “nuclear option” to force direct contact to resolve a claim problem. Because of HIPAA rules and legal risks, it is normal for healthcare providers and insurance claims processors to be reluctant to discuss any claims issues directly. Health care is a crazy world with privacy, legal barriers, office procedures and multiple layers of processors that limit cooperation and foster communication impediments.

Problem #3: Out-of-Network

The best way to avoid claims paid at the much lower “Out-of-Network” rate is to make an honest attempt to use “In-Network” vendors. If you choose to use providers that are not on the preferred list, you will pay more out-of-pocket and often have to meet a higher deductible.

Below are situations in which you are forced to use providers outside of the prefer ranks:

First Situation: Emergency Treatment. The health insurance contracts that I am familiar with and sell make an exception for any network issues if you are unable to choose a preferred provider due to bonified medical emergency. Your claim will likely be processed initially based on the “Out-of-Network” rates and then you will need to appeal for claim payment based on the emergency treatment exception and request adjustment to an “In-Network” settlement.

Second Situation: No Ability to Select an In-Network Provider. I have appealed and been successful based on the argument that there was no opportunity to select a preferred provider.

Example: My brother was transported by an ambulance service that was summoned by calling 9-1-1. He had no control over which ambulance was dispatched. The ambulance service was not a preferred provider and the initial claim was figured based on “Out-of-Network” rates which left a substantial balance. After an appeal, this balance was paid by the insurance company.

Another example: You select an “In-network” facility but are assigned an “out-of-network” doctor or provider. My brother’s pathology sample was sent to a lab that was not a preferred provider. He had no control of the transaction and no ability to select who got his lab work. I again was successful on appeal.

Third Situation: No network provider available. Any health insurance contract that I am familiar with has an exception for any network issues if no preferred provider is reasonably available. You may have a basis to appeal if you can show that no provider on the network will take you or that none of the preferred providers are within a reasonable travel range.

Example: My brother’s doctor that specialized in infections was not a preferred provider. All of the claims from this provider were initially process as “Out-of-Network.” I was able to prove that no “Infections Doctor” that was on the preferred provider list was available to treat my brother within 30 miles. An appeal, based on network provider availability, was then successful and the claim adjusted.

Summary

While most health insurance claims are processed correctly, you still need to be prepared for the few that aren’t. Always follow-up with phone calls, ask for help and appeal an unfavorable outcome, if necessary. Be polite and enlist the claims representatives to be your allies. Remember, you deserve explanations that you can understand and help resolving any claims processing problems. I hope my organizational and troubleshooting tips are helpful.

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Food Business Ideas

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Promising and Trending Food Business EatanceApp

Today’s food market is in flux, and no single food company can predict how or when it will achieve long-term success. While certain things never change, such as ordering takeout from a neighboring restaurant or having your favorite cuisine delivered to your door, there are a few options accessible today.

 

During the epidemic, the abundance of local goods, services, restaurants, and other food enterprises struggled to stay afloat. Additionally, during the Covid-19 stay-at-home orders, consumers’ shopping and eating habits improved.

 

People are looking for processed foods since fresh foods are difficult to come by. They want to eat better and safer foods. The majority of eateries do not encourage it.

 

So, where do we go from here?

According to surveys, 53% of customers will wait at least three months, 38% will wait at least five months, and 38% will wait even longer before regulations and health improvements are implemented in restaurants. As a result, some may be concerned about how long tendencies like cooking from scratch and looking for healthier options will continue to grow in popularity as more people become aware of them.

 

Products like immune support tablets and supplements for increased sleep and stress reduction will become more prevalent if individuals want to stay at home and have fewer opportunities to go out and enjoy life.

 

Post-COVID Trends: Shaping the Food Industry

The food market is being shaped by the following notable trends. This year, the food sector is being impacted by the coronavirus epidemic, changing consumer patterns, and the growing use of technology.

 

Eat organic and healthy food

A huge shift toward vegan, healthful, and organic cuisine is expected by 2020. With Covid19 sweeping the globe, however, this trend will quickly become the norm for many. People would be more conscious of what they eat, leading in a rise in the number of vegan-only items available.

 

Across the country, a slew of tiny enterprises has sprung up to promote plant-based foods, meats, and other products.

 

Highest priority on food safety

Despite the fact that COVID-19 is spread by airborne respiratory droplets and the danger of infection via food is negligible, people all around the world are concerned. Furthermore, many individuals are cleaning unpackaged fruits and vegetables more thoroughly now than they were before the outbreak.

 

The pandemic has also prompted certain communities to rethink long-held beliefs, including the use of wet markets and the consumption of wild animals. New policies, such as formalizing small and micro food enterprises, enabling producers to sell directly to customers, employing technology to verify safety, and investing in a more robust food system, could be implemented as a result of the epidemic.

 

A New Approach to Dining

Although the restaurant business was one of the first to be hit by the pandemic, it has showed amazing adaptability in dealing with the situation. Many merchants have added delivery and take-out options, as well as pop-up food shops, to their menus.

 

Any of these ideas is so effective that it will continue to work even after the pandemic is finished. However, there remains a significant impediment to significant expansion. Many clients have discovered a new passion for eating.

 

According to a new poll, 54% of individuals are cooking more today than before the outbreak, with 35% saying they “like cooking more than before.” Customers, on the other hand, claim to be ordering more.

Click here to read more.

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React Native App Development Services

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How React native app development technology is quick and cost effective 1024x536 1
React Native App Development

The new age of technology is witnessing the burgeoning usage of smartphones worldwide. If we take a closer look at the data, there are over 2.87 billion smartphone users & 1.26 billion tablet users globally. One can easily foresee how bright the future of the mobile application industry is. With high potential, the industry also holds great competition. To ace in the market & be profitable, one has to be dynamic and geared with the latest technology unequivocally.

 

Let’s dive in to learn what is React Native

Facebook’s invention React Native, is an open-source mobile application development framework that is used for iOS, Android, and Web applications. The technology came into existence in 2013, and in just a couple of years, it was ranked the fastest-growing open-source platform with over 30,000 stars on GitHub. Also a year later, Facebook and Microsoft established a partnership, thereby adding Windows support to the React Native platform.

 

Popular Apps built using React Native

Multiple business giants use this modern-day technology, including Uber eats, Myntra, Airbnb, Instagram, Bloomberg, Facebook Messenger, Discord, etc. What makes this technology stand apart is the feature to share codes between two different operating systems to develop an application without compromising the performance and being cost-effective at the same time.

 

Major differences between React Native and other traditional technologies

React native is written using Javascript, and it is known as a hybrid framework. This quality of React Native separates it from conventional apps written in Native languages such as Java or Kotin for Android apps and swift or objective – C for apps on iOS. Using a hybrid app technology allows the developer to write code once that can run on both Android and iOS devices. While most hybrid frameworks such as Ionic, Cordova, Phonegap entirely rely upon web view to achieve cross-compatible capabilities, React Native works differently. Instead of using a web view, React operates through a system that allows it to render Native components from base Javascript code.

As React Native runs on both Android and iOS, it allows both target platforms to receive an outcome from a single team of developers and codebase, which results in quicker and easier development and testing of the app.

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Restaurant Online Ordering System

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Top 10 Restaurant Online Ordering System 1
Top 10 Restaurant Online Ordering System in 2021

The pandemic has affected the restaurant business severely. Experts warn that full-service restaurants may not recover until 2025 so businesses need to offer additional services like online delivery to survive and thrive.

However, to allow customers to order online, you should have an online ordering system. It lets consumers add foods of their choice, calculates the bill (including delivery charges and tax), and enables you to accept payments.

 

Here are some more online ordering statistics that prove how beneficial it could be for restaurants:

  • About 42% of the total food orders are now being placed online. 
  • 9 in 10 US food delivery service users say it makes their lives easier. 31% say they use these services at least twice a week. 
  • 34% of consumers spend at least $50 per order when ordering food online. 
  • In large suburbs, online ordering went as high as 3,868% between February and April 2020. 

What is the Best Online Food Ordering Software?

The best online food ordering software is the one that helps you manage your orders seamlessly. It should work on any internet-connected device and shouldn’t require you to purchase any new electronic gadget (phone, tablet, or laptop).

Additionally, your online ordering system should integrate with multiple payment gateways. This will give your customers an option to pay from their preferred payment method, enhancing the overall experience.

 

1. EatanceApp

Eatance is an on-demand app marketplace that provides you with custom apps to accept orders online.  You can get a tailor-made app and website for your restaurant that will help you build a professional image.

For large restaurants, Eatance offers multiple promotions, engagements, and unique features. It also includes a blog/food recipe section, combo deals, contactless dine-in, and table booking.

2. 9Fold

Just like EatanceApp, 9Fold offers a customized solution for restaurants, making online ordering a seamless process. As soon as you partner with 9Fold, they’ll integrate their software into your website so you can start accepting orders online.

9Fold allows you to upload high-resolution food images that can be used beside the names to increase sales. It also allows you to create and share promotional campaigns to drive repeat sales

3. ChowNow

ChowNow enables you to accept orders via your website. If you don’t have a website, ChowNow can help you build it. They can also create a custom mobile app for your restaurant.

They provide you complete access to your customer database. This enables you to create custom campaigns for your customers to build loyalty and drive repeat purchases.

4. CloudWaitress

CloudWaitress is an online ordering and reservation system that helps restaurants boost sales. Its easy-to-use platform allows you to manage all types of orders: pickup, delivery, dine-in, and reservation.

CloudWaitress also helps you create a website, allowing your customers to order food from you directly. In addition, it offers a real-time order management interface so your staff can get a birds-eye view of every pending order.

5. GloriaFood

GloriaFood is one of the popular online food ordering systems that aims to provide low-cost solutions to independent restaurants. It even allows you to accept orders via Facebook.

To accept orders on your website, all you need to do is add the GloriaFood widget. It will display your menu and allow customers to place orders directly.

6. iMenu360

iMenu360 offers a complete ordering solution to restaurants. Its services include apps, web-based ordering, contactless transactions with QR, and POS integrations. iMenu360 allows you to create an interactive menu to integrate into your website.

Perfect for large restaurants and restaurant chains, iMenu360 shuttles your online orders directly to the POS. It also helps you build your restaurant’s mobile app. You can then send push notifications to encourage repeat orders and increase your sales.

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