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Understanding Health Insurance Claims Process

Health Insurance Explained

The number one complaint I receive about health insurance is how confusing it is.  Below are some tips to help explain the process.  I will start with a brief explanation of some of the key terms.

CO-INSURANCE is often confused with co-payment. A co-payment is typically a fixed dollar amount, while the co-insurance is a percentage that you pay after the deductible has been met. 

OUT OF POCKET MAXIMUM is the amount you pay before the carrier is responsible for 100% of your medical expenses.  The out-of-pocket maximum is a combination of your deductible, co-pays, and co-insurance.

DEDUCTIBLE is a fixed amount you are responsible for before the carrier begins to pay their share.  A higher deductible means lower health insurance premiums.

CO-PAYMENT is a fixed amount you are responsible for a particular service.  Typically, a visit with the primary care physician has a lower co-pay than a visit with a specialist. 


Tips to Filing a Claim

  1. Know Your Network. 

You should have an idea before needing to use the coverage of who is in network vs out of network.  While you can go out of network on a PPO plan, co-pays and deductibles are significantly higher for an out of network provider.  HMO plans do not allow coverage for out of network providers.  This means you are responsible for 100% of the charges.

You can keep this simple by sticking with the same medical group (i.e. Advocate, Duly Health, Northwestern Medicine, UIC, etc.).

*If treated for an emergency, ALL services are covered as in network regardless of the location*


  1. Know Your Plan Coverage Limits.  While I do not expect you to know everything, having a general idea of your co-pays and deductible is helpful.  This eliminates any surprises in the end and alleviates stress when something major occurs.


  1. Urgent Care vs Emergency Room. Pay attention to the location of the urgent care facilities in your area.  The wait is much shorter than the emergency room AND the cost is much less.  It is common to see a $1,000 copay for the emergency room vs a $40 copay for the urgent care.


  1. Wellness Visit vs Follow Up. While wellness visits are typically covered at no cost, if the doctor codes the visit as a follow-up, you will be responsible for the payment.  The service itself is typically shorter and less involved if it treated as a wellness visit.


  1. Additional Charges. As a reminder, each service renders a separate bill.  For example, if a service requires additional testing, it is common to receive a separate charge for each service (i.e. labs, x-rays, etc.).  This is the same for hospitalization or surgery.  You can expect to receive a bill for the location, the doctor’s time, and whatever additional testing was required at the time.


  1. Consult an agent with any questions or issues. Many assume we are alerted every time someone files a claim, but we are NOT.  Your agent can help set expectations, obtain answers, and fight if need be.  While we are not able to discuss your claim with the carrier (HIPAA requirement), we can help you through the process.

What to Consider When Filing a Claim

Whether we want to admit it or not, accidents do happen, and you should know what to do in the event of a claim. Many people react at the first site and immediately file the claim. Only to be aggravated later when the claim is not covered, or the claim does not outweigh the deductible. What you may not realize, once you file a claim (whether the carrier pays out or not), the claim will remain on your record for 5 years. While the impact is not huge for a $0 claim, it can affect your rate with a new carrier or the new carrier could deny coverage due to the number of $0 claims.

1. Assess the damage.
Home: Walk the property and take pictures of the damage.
Auto: Walk around the car, be sure to look underneath the vehicle and take pictures. It is important to take pictures of both vehicles, the location of the accident, etc. Often the police will not come out for a minor accident. You need to have evidence to determine which driver is at fault.
If the police do not indicate fault on a report, it is up to the insurance carrier to determine fault. This becomes your word against the other driver!

2. Swap information *This is only related to an auto claim*
Get the other driver’s name, phone number, and picture of their insurance card. This is helpful during the claims process. If the other driver is at fault, file the claim with their company. If you are not at fault and you file with your own, you will pay your deductible. You will get this back, however it can take MONTHS if the other driver has a substandard carrier.

3. Know your deductible!! It only adds more time to your repair if you file the claim, wait for the adjuster to come out and obtain your assessment only to find out the damage is less than your deductible. It also means the claim will be on your record for 5 years.

4. Contact service professionals for a bid to determine if the damage outweighs your deductible. Do your homework. If the claim is less than your deductible and the claim is filed with the carrier, it will be on your record for 5 years. I have had clients denied coverage by other carriers due to too many small claims.

5. Mitigate the damage. Once pictures have been taken it is safe to clean up the area. You want to do this so the damage does not become worse.

6. Consult your agent with any questions or issues. Many assume we are alerted every time someone files a claim, but we are NOT. Your agent can help set expectations, obtain answers, and fight if need be.

*Please note, this is only for small claims. If it is a large claim (i.e. fire, major roof damage, etc.) call immediately to get the process started. The carrier will provide you immediate relief funds to stay somewhere safe!

2022 Goals

“If you want to be happy, set a goal that commands your thoughts, liberates your energy and inspires your hopes.”-Andrew Carnegie

While setting my 2022 goals, I realized I have not shared them in the past and while my goals do not necessarily provide education about a certain insurance product it does provide insight to the type of office I have.  Making them public also puts a form of accountability on me, forcing me to accomplish these goals.

  •  Create written process for quoting and maintaining the database
  • Create activities to promote team growth
  • Analyze technology to increase productivity
  • Implement initiatives for employees
  • Focus on account rounding
  • Social Media Marketing
    • *Analyze activity (website, FB, LI)
    • *Create educational videos
    • *Ask for reviews/testimonials (Jan and June)
  • Set time to focus on the business/administrative responsibilities.
    • *Analyze productivity
    • *Reconcile commission
    • *Send Thinking of You cards

Tips to Reducing your Medicare/Health Insurance Premium

REMINDER: Medicare Open Enrollment ends December 7th and Health Insurance Open Enrollment ends January 15th.


TIPS to Reducing your Medicare Premium…

*Consider a Medicare Advantage Plan.  If you are already in one, you may want to consider another carrier.  Be sure to pick a plan with a low maximum out of pocket and confirm that your doctors accept the plan before switching.

*Consider switching the type of Supplemental Plan you are in currently (i.e. Plan N is less expensive than a Plan G).  I will caution, that changing your plan may require you to pay for services that you have not paid for in the past. 

*Consider switching carriers for your Supplemental Plan.  Plan coverages are the same regardless of who the carrier is.   Please note, you may be medically underwritten which means the new carrier can charge a higher rate or deny you based on your medical history.

*Review your drug lists with other carriers. is a great source for reviewing rates with other carriers.  Simply plug in your drug information, select your pharmacy, and review the different plans available (based on the drugs you have been prescribed).

*Consider switching pharmacies.  First, make sure your pharmacy is still in the Preferred Network with your prescription drug plan.  Second, find out what the different pharmacies charge for your drugs.  You may see a difference that can save you some time in reaching the donut hole.


TIPS to Reducing your Health Insurance Premium…

*Be prepared to discuss your household, estimated adjusted gross income for 2022.  This will be used to determine if you qualify for assistance.   Thanks to the American Rescue Plan, the threshold has increased.  Some families making $250,000 per year can qualify for assistance!

*Those without pre-existing conditions should consider a short-term medical plan.  These plans do not provide coverage for pre-existing conditions, maternity, and limited wellness visits. However, these plans are a fraction of the cost of plans offered through the Marketplace and they have a PPO network.

*If you are going to opt to self-insure, protect yourself with an accident or critical illness plan.  The plan works separate from health insurance and pays you in the event of an accident (slip, fall, and break an ankle) as well as a diagnosis of a critical illness (cancer, heart attack, or stroke).  The purpose is to use the funds to pay towards the unexpected treatment.

Consider splitting your household.  If one of you need to be on a plan that covers pre-existing conditions the other can look into the short term medical plan.  You can also split plans through the Marketplace. 



Health Insurance Open Enrollment

During this time, individual policy holders can enroll in a health plan or make changes to their existing plan.


What to Expect in 2022

  • Open Enrollment has been extended to January 15th! Please note, changes made AFTER December 15th will take effect February 1st.


  • NEW CARRIERS: Molina Healthcare, Oscar Health Plan, and United Healthcare will offer plans for 2022.  Blue Cross Blue Shield continues to be the only carrier offering a PPO network.


  • OFF EXCHANGE Plans: While the network is the same on exchange or off exchange, Blue Cross Blue Shield, Bright Health, and Cigna will offer off exchange plans.  This means if you do not qualify for assistance you do not have to go through the Marketplace.  Blue Cross Blue Shield is the only carrier offering a PPO network.


  • NO penalty continues! This means you will not receive a penalty for not having coverage or for obtaining a plan that does meet the minimum standards of the Affordable Care Act.
  • Blue Cross Blue Shield, Bright Health, Cigna, and United Healthcare will offer virtual visits.  While Blue Cross Blue Shield only offers this service with their PPO network, Cigna, Bright Health, and United Healthcare will offer the same service on all of their plans. Policy holders can call or chat online with a nurse practitioner to obtain a diagnosis and prescription for medication.


  • Out of pocket maximum will increase to $8,700 per person.  You can offset this by purchasing an accident or critical illness rider.  The rider starts at $25 per month and provides coverage to you in the event of an accident or diagnosis of a critical illness (heart attack, cancer, or stroke). 


  • Group plans are still an option for small employers. Blue Cross Blue Shield continues to offer relaxed guidelines during this time to allow for a 1-person group. The employer must have at least 2 full time employees that are not husband and wife.  The employees can be 1099’d.


  • Carriers are offering Visa gift cards for participating in their rewards program.  Some are offering up to $500!  Rewards are given for signing up for an account online, obtaining an annual physical, signing up for text message reminders, selecting a primary care physician, etc.


  • Cigna is offering plans tailored to those with asthma, COPD, and diabetes.  This means lower drug costs, $0 cost for labs, pulmonary rehab, and supplies (including certain brands of insulin pumps)


I am now license in Florida!!  Insurance Counts can service plans in Illinois, Indiana, Wisconsin, Texas, and Florida.


Feel free to email or call me with any questions or comments about my services or if you have any insurance related inquires.


Phone: 708.444.0050


Monday - Friday: 10am - 5pm
Evening and weekends
available upon request