The health insurance system in America is terminally ill. Americans have the highest health care costs on the planet. You’d think that expenditures like that would result in the healthiest population on the planet.
That is not the case.
For all our costs, the general health of Americans doesn’t stack up well against other Western nations. America has an intolerably high infant mortality rate, as well as a growing list of chronic diseases, including heart disease, diabetes and cancer.
To compound the problem, the economy is crashing, leaving millions more without health insurance. An estimated 48 million Americans are without health insurance. As businesses downsize and close, more Americans lose coverage. This crisis will give Congress and the Obama Administration the political cover to finally nationalize health care in the United States.
But is that the best way to solve the problem?
Some health care providers are innovating in a quest to provide higher quality care while controlling costs. One shining example is the Geisinger Health System in Pennsylvania.
Geisinger Health System serves 43 counties across Pennsylvania, accounting for over 2.6 million patients who are served by over 750 doctors.
Geisinger is perfecting a new method of health care that rewards doctors for taking better care of their patients, rather than the traditional way of paying them for the sheer number of patients they can see and the special treatments they get. So far, Geisinger is finding that quality improvement may actually reduce overall costs.
W. Edwards Deming, the father of Total Quality Improvement, would be proud.
Geisinger has developed a system that incorporates important strategies such as:
• Coordinated primary care - a team of doctors, nurses, technicians and a case manager coordinate all care for each patient, especially those with chronic conditions like heart disease, pulmonary disease or diabetes. They do what is best for the patient, not what is most convenient for the provider.
• Surgery with a warranty - typically, if you have to return for complications from surgery, you incur new health care costs. Not at Geisinger. Starting with cardiac surgery, they began offering a 90-day warranty at the same time they instituted checklists of best practices for surgical procedures. It has lowered readmission rates by44%.
• Electronic health records - the new records system allows doctors and patients to all access the same patient information with a mouse click. Patients and doctors can email each other, schedule appointments and patients can monitor their own progress.
• Patient involvement - encourages preventative health care, such as lifestyle changes.
These are the kinds of innovation that will always be found in the free enterprise system. Geisinger Health System is a for-profit company with revenues over $3 Billion per year. The profit motive is notably absent in all government activity, innovation and efficiency are seldom found there.
I don’t believe that government control of the health care of the nation is a good solution to the myriad problems. For the best example of government-run health care, look at the failures of the Veterans Administration. The Federal government has botched a system that affects only a few million people. We can only dread the day when Washington takes over health care for the entire nation.
Sunday, April 12, 2009
Tuesday, April 7, 2009
Insurance Claims: Hire The Right Restoration Contractor
This article is Chapter Nineteen of my new book, "Commercial Insurance Claim Secrets REVEALED!" The book is presently in manuscript form, and we anticipate a publishing date of June 1, 2009.
* * * *
A restoration contractor is very different than a general contractor. Most general contractors who do remodeling or new construction do not have the skills and knowledge that a restoration contractor has.
For one thing, the restoration contractor is very familiar with the insurance claims process, and how insurance companies pay for repairs. The restoration contractors use similar estimating software to that used by the adjusters and insurance companies. A general contractor who submits an estimate in an unacceptable form to the insurance company or adjuster just annoys them, and slows down your claim.
Another reason to find restoration contractor is that they are usually full service contractors. They will be able to do temporary or emergency cleanup and board up. They will own the equipment for drying and water damage remediation. They are familiar with the kinds of damage that fires, wind and water do to commercial building. Finally, they are experts at writing accurate estimates for these specific kinds of damages.
General contractors who do not make their living in insurance restoration do not have this kind of equipment and experience. Period.
Do a search online for restoration contractors in your area. You can also look in your local Yellow Pages under “Disaster Restoration,” or “Fire Restoration,” or “Water Damage Restoration.” Look for logos in the ads that say “DKI,” or “RIA” These are professional organizations for restoration contractors. You can also go to the following websites to identify restoration contractors in your area.
DKI - Disaster Kleen-up International. Headquartered in Chicago, IL, is a network of the leading independent property damage restoration contractors across North America. You can ask for a referral at 888-735-0800, and also find them at: www.disasterkleenup.com
RIA - The Restoration Industry Association is the leading trade association for cleaning and restoration professionals worldwide, and the foremost authority, trainer and educator in the industry. You can ask for a referral in your area at 800-272-7012, or the website: www.restorationindustry.org
Call at least two restoration contractors, if possible. Ask them to meet you at your business location to inspect the damage within 24 hours of the loss.
Remember this important point…there is NOTHING in your policy that requires you to get two or three estimates. Meeting two contractors is just a smart way to find one that you like best and want to work with. Interview them about their experience and expertise. Check out their references, and ask them for a list of satisfied customer that you can call by phone. Get a copy of their insurance certificate to be sure they have liability and Workers Compensation coverage. Call the insurance companies to confirm coverage. ONLY AFTER THE CONTRACTOR CHECKS OUT should you hire him.
You might see many restoration contractors drop by after a loss to see if they can help you with temporary repairs, like tarps on roofs, board-up, and contents removal. Don’t be annoyed...they are trying to get some new business. Appreciate their effort for what it is. Get written estimates from them BEFORE you sign ANYTHING. They will sometimes tell you that they were sent by the insurance company (maybe true, maybe not), and that it is your responsibility to protect your property from further damage (which is true). They may tell you that they will “direct bill” the insurance company (which they may do).
WARNING!!
Be very careful on contents removal, sometimes known as “pack out.” The more contents they clean, the more money they make. The cost to clean something is usually a fraction of the cost to replace it. However, I have seen restoration contractors charge more to clean an item than it costs to replace it. So, when the restoration contractors are involved, the claim value may be reduced, which benefits the insurance company. That is why many adjusters will bring a restoration contractor with them to the loss location. Remember that many policies pay REPLACEMENT COST, and following major fires, large windstorm and water losses, your damaged possessions could be replaced instead of being cleaned. Every penny that goes for cleaning your contents comes from the contents limit of liability shown on your policy declarations page. So, theoretically, a substantial amount of your insurance money to replace your items could go to the restoration company to only clean the items!! If the restoration contractor cleans a bunch of your property, and you reject it as unusable, there will be less money for replacement of your property.
So, if the adjuster and restoration contractor are all gung-ho to pack-out your property, that’s probably a good idea. Getting your property off the loss site will at least prevent it from further damage. But you should be the person that controls which contractor packs out your property. You should also bet the person that controls what gets cleaned and what gets thrown away. This may take you a significant amount of time to sort through, but that time investment will mean a much larger settlement amount.
Under no circumstances allow the adjuster or restoration contractor to make the determination about what business personal property is repairable or replaceable. The adjuster will typically want to clean items and give them back to you. You own the property...it’s your call. Fight hard about this issue!
ANOTHER WARNING!!
Sometimes, adjusters and insurance companies will tell you that you must use their “approved contractor.” Unless you can find that requirement written into the terms and conditions of your insurance policy, don’t believe it. It’s your property. YOU be the person that makes the decision on which contractor or other vendor to use.
The contract for cleaning and restoration of your property will be between you and the contractor...not the contractor and the insurance company. MAKE SURE YOU ARE IN CONTROL!!
* * * *
A restoration contractor is very different than a general contractor. Most general contractors who do remodeling or new construction do not have the skills and knowledge that a restoration contractor has.
For one thing, the restoration contractor is very familiar with the insurance claims process, and how insurance companies pay for repairs. The restoration contractors use similar estimating software to that used by the adjusters and insurance companies. A general contractor who submits an estimate in an unacceptable form to the insurance company or adjuster just annoys them, and slows down your claim.
Another reason to find restoration contractor is that they are usually full service contractors. They will be able to do temporary or emergency cleanup and board up. They will own the equipment for drying and water damage remediation. They are familiar with the kinds of damage that fires, wind and water do to commercial building. Finally, they are experts at writing accurate estimates for these specific kinds of damages.
General contractors who do not make their living in insurance restoration do not have this kind of equipment and experience. Period.
Do a search online for restoration contractors in your area. You can also look in your local Yellow Pages under “Disaster Restoration,” or “Fire Restoration,” or “Water Damage Restoration.” Look for logos in the ads that say “DKI,” or “RIA” These are professional organizations for restoration contractors. You can also go to the following websites to identify restoration contractors in your area.
DKI - Disaster Kleen-up International. Headquartered in Chicago, IL, is a network of the leading independent property damage restoration contractors across North America. You can ask for a referral at 888-735-0800, and also find them at: www.disasterkleenup.com
RIA - The Restoration Industry Association is the leading trade association for cleaning and restoration professionals worldwide, and the foremost authority, trainer and educator in the industry. You can ask for a referral in your area at 800-272-7012, or the website: www.restorationindustry.org
Call at least two restoration contractors, if possible. Ask them to meet you at your business location to inspect the damage within 24 hours of the loss.
Remember this important point…there is NOTHING in your policy that requires you to get two or three estimates. Meeting two contractors is just a smart way to find one that you like best and want to work with. Interview them about their experience and expertise. Check out their references, and ask them for a list of satisfied customer that you can call by phone. Get a copy of their insurance certificate to be sure they have liability and Workers Compensation coverage. Call the insurance companies to confirm coverage. ONLY AFTER THE CONTRACTOR CHECKS OUT should you hire him.
You might see many restoration contractors drop by after a loss to see if they can help you with temporary repairs, like tarps on roofs, board-up, and contents removal. Don’t be annoyed...they are trying to get some new business. Appreciate their effort for what it is. Get written estimates from them BEFORE you sign ANYTHING. They will sometimes tell you that they were sent by the insurance company (maybe true, maybe not), and that it is your responsibility to protect your property from further damage (which is true). They may tell you that they will “direct bill” the insurance company (which they may do).
WARNING!!
Be very careful on contents removal, sometimes known as “pack out.” The more contents they clean, the more money they make. The cost to clean something is usually a fraction of the cost to replace it. However, I have seen restoration contractors charge more to clean an item than it costs to replace it. So, when the restoration contractors are involved, the claim value may be reduced, which benefits the insurance company. That is why many adjusters will bring a restoration contractor with them to the loss location. Remember that many policies pay REPLACEMENT COST, and following major fires, large windstorm and water losses, your damaged possessions could be replaced instead of being cleaned. Every penny that goes for cleaning your contents comes from the contents limit of liability shown on your policy declarations page. So, theoretically, a substantial amount of your insurance money to replace your items could go to the restoration company to only clean the items!! If the restoration contractor cleans a bunch of your property, and you reject it as unusable, there will be less money for replacement of your property.
So, if the adjuster and restoration contractor are all gung-ho to pack-out your property, that’s probably a good idea. Getting your property off the loss site will at least prevent it from further damage. But you should be the person that controls which contractor packs out your property. You should also bet the person that controls what gets cleaned and what gets thrown away. This may take you a significant amount of time to sort through, but that time investment will mean a much larger settlement amount.
Under no circumstances allow the adjuster or restoration contractor to make the determination about what business personal property is repairable or replaceable. The adjuster will typically want to clean items and give them back to you. You own the property...it’s your call. Fight hard about this issue!
ANOTHER WARNING!!
Sometimes, adjusters and insurance companies will tell you that you must use their “approved contractor.” Unless you can find that requirement written into the terms and conditions of your insurance policy, don’t believe it. It’s your property. YOU be the person that makes the decision on which contractor or other vendor to use.
The contract for cleaning and restoration of your property will be between you and the contractor...not the contractor and the insurance company. MAKE SURE YOU ARE IN CONTROL!!
Workers Compensation Insurance: Is The System Stacked Against Workers?
Perhaps someday I will write an entire book just about Workers Compensation (WC) Insurance. Many experts before me have already done so, and I’m reluctant to plow that ground again. But I do have some comments about WC that you should know.
Workers Compensation Insurance is a very flawed system in every state of the United States. It began with the lofty intentions of politicians in each state who enacted laws to protect injured workers and get them medical benefits and treatment for their injuries. But, like most laws enacted by politicians, there are unintended consequences. Further, business lobbies, insurance companies, trial lawyers and medical lobbyists contribute huge amounts of money to the politicians at both state and Federal levels. Injured workers are individuals for the most part, and don’t have lobbyists.
Would it be too difficult for you to guess which side gets the political favors in Workers Compensation legislation?
Here’s an example of a system stacked against the injured worker. In most states, injured workers are barred from filing lawsuits against employers for their injuries. The injured worker has only the Workers Compensation system in which to receive benefits.
There are two narrow exceptions where the Workers Compensation preemption might not apply, and an employer might be subject to lawsuit:
• The employer intentionally causes injury to an employee. This exception for intentional acts is very narrow. It is not ordinarily enough that an employer creates conditions where there is a very high probability that an employee will be injured. Customarily, the employer must have committed a specific negligent act intended to cause injury to the employee.
• The employer is required to carry Workers Compensation coverage but fails to do so.
In my opinion, the Workers Compensation laws that prohibit lawsuits against employers violates the 7th Amendment, which guarantees citizens a jury trial in civil cases.
The deck may be stacked against injured workers in another way, which is that the injured worker may only seek medical treatment from a list of doctors approved by the employer or his Workers Compensation carrier.
Most injured workers receive medical treatment for their injuries and recover quickly. But whether your injuries are minor or major, the process of filing for benefits and receiving benefits can be complicated and frustrating. Most employees have no real awareness about how the system works, and only become familiar with it once they are sucked into the system by an injury.
If you are an employee who has sustained an injury, you would be well served to consult with a personal injury attorney soon after the injury. Workers Compensation is usually simpler than regular litigation since it takes place in an administrative setting and may have relaxed evidentiary rules. Also, attorney fees are often limited by state statute.
Injured workers typically need to seek legal counsel when they are refused benefits, or are told that they can return to work before they are medically able to work, or are denied disability in spite of disabling injury.
If your employer sends you to a doctor that declares you fit to return to work, even if you do not believe that you are yet able to work again, I recommend consulting a WC attorney before returning to work.
One of the tactics used occasionally by employers is to bring the recovered worker back to a position specially created for that employee to accommodate their injury. Then two or three weeks later, the employer eliminates that position and lays off the employee, ending his eligibility for workers compensation. Presto...no WC claim.
Another tactic is to refer the injured worker to doctors who are more motivated by a long-term business relationship with the WC carrier than accurately diagnosing and treating employees. In that scenario, if the doctor declares too many injured workers to have continuing disability, the carrier will terminate the business relationship and send workers to another doctor who will play the game.
A personal injury attorney specializing in WC can help protect your rights. If you seek counsel from a WC specialist, he or she will typically know the local administrative judges or hearings officers who preside over WC hearings. He will likely also know the doctors and insurance defense attorneys who are trying to block or diminish your claim. An attorney who is plugged in to the WC system in your area is your best resource to help you collect the benefits that you are due.
Workers Compensation Insurance is a very flawed system in every state of the United States. It began with the lofty intentions of politicians in each state who enacted laws to protect injured workers and get them medical benefits and treatment for their injuries. But, like most laws enacted by politicians, there are unintended consequences. Further, business lobbies, insurance companies, trial lawyers and medical lobbyists contribute huge amounts of money to the politicians at both state and Federal levels. Injured workers are individuals for the most part, and don’t have lobbyists.
Would it be too difficult for you to guess which side gets the political favors in Workers Compensation legislation?
Here’s an example of a system stacked against the injured worker. In most states, injured workers are barred from filing lawsuits against employers for their injuries. The injured worker has only the Workers Compensation system in which to receive benefits.
There are two narrow exceptions where the Workers Compensation preemption might not apply, and an employer might be subject to lawsuit:
• The employer intentionally causes injury to an employee. This exception for intentional acts is very narrow. It is not ordinarily enough that an employer creates conditions where there is a very high probability that an employee will be injured. Customarily, the employer must have committed a specific negligent act intended to cause injury to the employee.
• The employer is required to carry Workers Compensation coverage but fails to do so.
In my opinion, the Workers Compensation laws that prohibit lawsuits against employers violates the 7th Amendment, which guarantees citizens a jury trial in civil cases.
The deck may be stacked against injured workers in another way, which is that the injured worker may only seek medical treatment from a list of doctors approved by the employer or his Workers Compensation carrier.
Most injured workers receive medical treatment for their injuries and recover quickly. But whether your injuries are minor or major, the process of filing for benefits and receiving benefits can be complicated and frustrating. Most employees have no real awareness about how the system works, and only become familiar with it once they are sucked into the system by an injury.
If you are an employee who has sustained an injury, you would be well served to consult with a personal injury attorney soon after the injury. Workers Compensation is usually simpler than regular litigation since it takes place in an administrative setting and may have relaxed evidentiary rules. Also, attorney fees are often limited by state statute.
Injured workers typically need to seek legal counsel when they are refused benefits, or are told that they can return to work before they are medically able to work, or are denied disability in spite of disabling injury.
If your employer sends you to a doctor that declares you fit to return to work, even if you do not believe that you are yet able to work again, I recommend consulting a WC attorney before returning to work.
One of the tactics used occasionally by employers is to bring the recovered worker back to a position specially created for that employee to accommodate their injury. Then two or three weeks later, the employer eliminates that position and lays off the employee, ending his eligibility for workers compensation. Presto...no WC claim.
Another tactic is to refer the injured worker to doctors who are more motivated by a long-term business relationship with the WC carrier than accurately diagnosing and treating employees. In that scenario, if the doctor declares too many injured workers to have continuing disability, the carrier will terminate the business relationship and send workers to another doctor who will play the game.
A personal injury attorney specializing in WC can help protect your rights. If you seek counsel from a WC specialist, he or she will typically know the local administrative judges or hearings officers who preside over WC hearings. He will likely also know the doctors and insurance defense attorneys who are trying to block or diminish your claim. An attorney who is plugged in to the WC system in your area is your best resource to help you collect the benefits that you are due.
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