Frequently Asked Questions (FAQs)

In this space, we will post those questions, queries, and concerns that come to our offices most frequently. These will not be "policy holder or carrier" specific but will, rather, be generalized questions that may be of interest to everyone.  Please feel free to go to Contact link on the Tool Bar, use the drop down menu to access EMail link and send your question or concern to us.  We will plan to post those that are applicable to a number of people. 

Frequently Asked Questions From Employers:

"Why are my premiums going up so much?"

As a whole, your premiums are "pooled" with all the other small groups of your size within your state (typically under 500 insured employee lives) and the collective total amount of claims paid in the past year, versus the premiums paid in that same timeframe, determines the premiums for the following year. A heavy year of claims for that "pooled" group may mean an increase in your premiums even though you, personally, have not utilized the insurance heavily.

"What is considered when insurance companies use the term "treatment"?

The word "treatment" can mean a wide variety of services, if provided by a health care professional.  This will include but not be limited to such things as: prescription medication, office or ER visits, any procedure performed by a health care professional (doctor, nurse, NP, PA, Physical, Occupational or other Therapy, etc) and includes consultations or advice provided to the individual by a professional health care provider.

"Can I keep my present insurance agent and still utilize BeneScope's services?"

That is a great question and the answer is absolutely you can!  BeneScope, Inc. is not in the business of insurance sales and so we are not in competition with your insurance agent or broker in any way.  In fact, if you are considering having a discussion with BeneScope about our services, we would welcome the opportunity to also speak with your agent at that time.

"What about pre-existing conditions?"

Any treatment (including medication, professional health care provider advise or consultation, therapy, etc) that a person has received in the six (6) months prior to the effective date of the new health insurance policy is determined to be a "pre-existing condition".  If you are subject to the pre-existing clause, you will not be covered for that specific condition for twelve (12) months.  If you have prior "creditable coverage" without a break in coverage of over 62 days, then you can reduce or eliminate that waiting period.  This would be the type of issue where your BeneScope Liaison would work with the member to establish the "creditable coverage" and work with the new insurance carrier to negotiate a reduction or elimination of that waiting period.

"What do you mean by  "creditable coverage"?

The most obvious "creditable coverage" would be if the member had been covered by a major medical policy without a break of over 62 days since that coverage ended.  However, there are a number of other types of care coverage that meet the standard for "creditable coverage".  They include but are not limited to such things as:

  • Coverage while in the active duty military
  • VA coverage after or during active duty
  • Medicaid
  • Indian Health Care Coverage
  • Dept of Social Services coverage (will be called different things in different states)
  • As well as a number of other possibilities.
"How does a carrier determine what is a "covered service" and how much it is worth?"

The insurance carrier submits, to the state insurance commission, the list of services and scope of payment for which they will pay.  After the state insurance commission reviews the actual list of services and potential payment  to be provided, the insurance carrier's actuaries determine what premiums would be necessary to cover those planned expenses. The actuaries work with rather complex data, analyzing cost histories VS current costs, demographics in given areas and a wide range of other data points to come to the premium determination.


Frequently Asked Questions From Employees/Policy Holders:

"What is the difference between "in-network" and "out of network" providers?"

An "in-network" provider is someone who has signed an agreement with the carrier concerning their fee schedule.  They, in exchange for the volume and direct payment from the carrier, agree to accept what are often significant discounts for their services.  This designation is not merely a financial decision on the part of the carrier; it is an examination and validation of the provider's credentials to deliver health care services of the type being described in their carrier/provider agreement.  "Out-of-network" simply refers to a health care provider who has no prior agreement with the carrier and is under no obligation to provide the discounts as an "in-network" provider.


"What is an EOB"?

An EOB (Explanation of Benefits) is a document sent to a policy holder by the insurance carrier and is a documentation of a medical insurance claim.  It lists various types of information such as: the date of service, the name and location of provider, the type of service/procedure performed, etc.  It also may list the status of the claim (paid and the amount paid, etc).  If the claim has not been paid or the amount paid does not seem appropriate to you, and especially if you did not receive this treatment or service,  now is the time for contact with your insurance carrier.  If you have BeneScope Claims Advocacy working for you, a simple call to our Liaison will set this discussion in motion. 


"The bill for my son being seen in the Emergency Room seems really high.  Why isn't my insurance covering more of it?"

Since emergency room treatment is one of the most expensive form of health care, it should be noted that most insurances (with a few exceptions) do "charge" a penalty for emergency room visits that could just as easily and safely have been performed in a doctors office or urgent care setting.  Typically that "penalty" runs around Five Hundred Dollars ($500.00).  That means that the first $500.00 of the ER charges will not be covered by your policy if the incident was not deemed "an emergency" by the doctor when he/she placed a diagnosis on the chart  and/or the individual coding the visit for submission to your insurance.  We all know that sometimes non-emergency patients are taken to the ER  but there may also have been an error made in the coding of what was a genuine emergency at the time the patient arrived in the ER.    This is a place where you or (if you have BeneScope Advocacy services) your Liaison will contact the insurance and/or the billing agent and work toward a resolution. 


"I received a bill from a provider I did not see.  Can you help?"

Actually, this is a very good example of how BeneScope can assist you.  First, we need to discuss the bill that you received.  Who is it from and  for what services are they billing you ?  Two things could be at play here and it is important that we determine which we dealing with and then seek our solution. 

Did you have any type of health care on or around the "date of service" noted on the bill?  If so, it may simply be that this care provider is what we might term an "invisible provider".  If you had an X-ray taken, this may be a bill from a radiologist who read the films.  If you had lab work done in the ER or in your doctors office, this may be a lab cost.  If you had surgery on that date, it is possible that this is the billing of an assistant surgeon, an anesthesiologist, lab or radiology, or even from the hospital pharmacy for medications used.  Invisible providers are those separate entities that do not necessarily bill for their services within the hospital or office costs and, although you may not have met them (while awake!) or know their name, they may have been an integral part of your care provision at a specific time in an office, ER, or hospital visit.

However, we said two things were possible.  It is also possible that this is NOT your bill.  There could have been a clerical error and your billing info was utilized incorrectly.  And, last but not least, there is the possibility (not great but possible) of billing fraud.  So always read your EOB and carefully review any medical bill you might receive.  When in doubt, contact your BeneScope liaison and discuss your concern with them.  Together we can find the truth and resolve the issue.


"My spouse's claim has been denied.  She is still on my insurance plan.  How can I get them to pay this claim?"

First, we need to say that it may not have been a claim denied but, rather, a claim working its way through the system and that system includes the annual disclosure form that allows you to tell your insurance company whether your spouse is employed (at present) and if so, whether she/he is covered by any other insurance policy.   Most carriers will query their members annually or at least periodically to determine whether this status has changed. 

Often we find that members, knowing that they have given this info to the carrier in the past and feeling that nothing has changed, will not respond to the query.  By discarding that form or ignoring that email request, you may slow down the processing of your spouse's medical care claims.  So, the first thing that the BeneScope Liaison will do is establish whether or not this is the problem.  If it is, that is a simple fix; submit the form stating that your spouse is not covered by another policy and that your insurance is primary.  If, however, that is not the problem, then the Liaison will be working with the carrier to determine where the problem lies so that resolution and payment can occur.