Hi, I'm Billy Gwaltney and this is the CYA podcast. This show is for the physician who understands the importance of protecting everything you've worked so hard to achieve. Each week I'll bring you tips and advice to help you cut through the clutter and misinformation and show you exactly what you need to preserve your income and way of life. If you're ready to achieve the peace of mind that only financial security can bring. Let's get started.
(00:28): Hi there. Welcome back. You're listening to the second part of last week's episode. Let's jump back in turnaround time. How quickly do you all typically pay once you get the expenses? So someone has an accident, gets the expenses, get some to you on a Monday. How long does it take to get paid? I can safely tell you that something we monitor all the time and with the way we have it.
(00:52): Now, if the way our forms design and what we ask you to submit, it is not uncommon. If we were to open the mail and get it in at eight o'clock and review that we will have the money deposited into your account. The next day, our turnaround time on that is usually less than three days. Wow. Quick turnaround. It is in the specific to the non-disabled injury benefit. I had a, a client, another client that filed it cardiologists, and he, he was, he had a bike accident and so he filed it. I got it in the forms. He liked T he texted me from the emergency room. That's how, like he knew he had this benefit and he knew he was going to need it. And I guess he wasn't injured enough to, to, to not be coherent. So he, he was able to, to make sure that he got his claim form in and he got it in.
(01:43): And then about three weeks later, he texts me and goes, Hey, I haven't gotten my money. And so I reached out to, to the folks at Ameritas, our team did, and I was, and I thought that was odd. And I was like, okay, three weeks sounds like a long time. I would have thought it would be in quicker. And I reached out and sure enough, it had actually been deposited in his account, like two days after he had filed. Right. He just, he just didn't see it. So you know, that, that might bring up another topic about financial planning or whatever, but, but that's irrespective, he, it was just really interesting where I said, Hey, they said that it deposits your account. And I gave him the date and he came back and goes, Oh my goodness, I'm so sorry. I see it. And, and it was just I was the reason I asked you that open-ended question was just to see, was that an exception that he got paid so quick? Or, or is it more the rule that you really do try to do that quicker than, than not? And it sounds like we do. And a lot of that, Billy is not only on the non disabling claims, but also on our disability. We do a lot of listening and we had heard a couple of years ago that our process, although at that time, our turnaround was probably 10 days, which quite honestly, 10 days, I didn't think was
(03:00): All that bad, but it's like what? We kept hearing that, you know, our own people are like, well, I think we can do this better. So we created a, an algorithm that comes in. We also said, well, what are the common things that's preventing us from making that payment upfront? And we just started wiggling away saying, well, if we were to ask for this or that at the initial claim form, then we wouldn't have to do any reaching out to get additional information. So a lot of it was listening to the needs of our clients, trying to make it better and then changing our form and our process. So to where I would say that probably a well over 80% of our claims are in and out in less than three days. Now, those, those that go beyond that are usually because we couldn't read or they forgot to attach a statement or a copy of the bill. Right. And so once we get those back in, they're paid, but the majority are in out three days, we're done. We have a lot of them seriously. They come in and they're out the next day. So
(04:05): Well that, that's good to know. And I'm sure reassuring for folks to hear going back to the general macro question and some feedback that you've already given, kind of knowing what, you know, I would consider you, I'm guessing most of the people listening to this would consider you an insurance company insider, you know, you're an executive at an insurance company would knowing what, you know, underneath the hood, behind the scenes, however you want to describe it. Would you buy an individual own occupation policy? In other words, would you be confident that it would perform if you were disabled or is it, is it not worth it? I mean, is it throwing money down a drain?
(04:46): I, it doesn't take me but five seconds to respond to that. Based on all that I've seen, I could not encourage people enough that if given the opportunity to buy an individual policy, absolutely buy it. I would add that I would, I would look at it even if I had a group policy again, for the reasons we mentioned, you know, in this day and age companies get bought out, they merge you change places you move. So although you may have a great what you consider a great coverage with group today, that's not a promise for tomorrow, right. Whereas if you bought your own op now, and I would encourage you also to buy it when you're young or the rates are, are good and you're healthy, healthy, then you've got that to take with you. So regardless of if your company gets bought out or you decide you want to move out on your own, or you want to partner with someone that coverage is yours, that's that protection that regardless of what happens that goes with you, and quite honestly, sometimes your occupation changes. You know, I've seen people who start out in career as this type of physician, and as the years go on things evolve and they get the different interests and suddenly what their occupation was when they bought it is a lot different than what they have now, when they potentially could go out on the claim and we don't insure you well at the time of claim, you were only a GP and now you've specialized in the pain management or whatever, right? What were you disabled right before the disability? So that definition can change as well. Is that what you're saying
(06:35): Goes with you? Absolutely. And the only other thing, Billy, I would say that just again, from the experience I've seen with people is I see young physicians who say, well, you know, I'm, I'm with this group and we've already got some really good coverage. And so I'll get a little with, you know, an individual just enough to kind of make up the difference, but I'm not going to go ahead and get all that I need. And then years later suddenly that group gets bought out or they decide we're not going to fund this anymore. You're on your own. So here they are now at age 55, and that's certainly still a young age, but at 55, your health is a lot different than you were when you were in your thirties. So yes, you may still say, well, I need to go out now and get, you know, 10 more thousand of coverage because I lost my group.
(07:23): And you may find that, wow, you can get it, but you're going to have an exclusions put on it because some preexisting conditions you're going to say, well, wait a minute, my rate that I was paying, this is three times more than that. Well, because you're now double the age you were. So, and I'm not a salesperson, I'm a claims guy. I just see this happening when people get, and they're like, gosh, you know, your coverage that you gave me for the only 5,000 is really helping me because I don't have this go to coverage with my group or with other things. So even though you have coverage with individual and group, we absolutely view our definitions differently. And it's not uncommon where we may be paying the claim. And you're still arguing with your group carrier, whether you're going to get paid or not. Right.
(08:14): Good point. Good point. Good point. Well, another point. So I've got an extra question for you here. You mentioned about exclusions. Can you explain kinda, you know, to the, to the level of detail you're comfortable you know, giving a general explanation for how you handle claims, if someone has a spine exclusion on their, on their policy, your lower spine or, or, or whatever the exclusion is, how does that factor in, in terms of, at time of claim? And again, is there any kind of benefit of the doubt where, where you that you're not just looking to lean on that exclusion as an out clause.
(08:53): So to speak a great question, we get asked that a lot, I will preface this by saying somewhat of a disclaimer. I do know that the way we handle our exclusions is not unnecessarily a blanket statement for the industry. And I'll explain that a little bit more detail when I'm done, but the way we view it and a back exclusion is probably the one I get asked, you know, for whatever reason, the underwriting, the underwriting, they put an exclusion on the lower back, and the fear is, well, wait a minute. You know what I don't, why do I have that exclusion? We go through, look, you're covered for everything else. What's the chances that one thing will happen, but, well, what if I get in a car wreck, you know, and it messes my backup, and you're just going to hang your hat on that and say, well, we can't pay.
(09:45): Yeah. Cause your back, you know, is hurt and you have an exclusion. Here's where merit is has always looked at it. And this is where I say, I don't want you to say, well, Ameritas handles it way. This way. Doesn't everybody. The answer to that is no, either steam or not. Every insurance company handles it the same way. And it's a lot has to do with how it's written in their policy. So that would be my word of advice. But in Ameritas, what we talk about is we look at time of claim. We go back and say, well, why was the exclusion put on that on your policy? And what was it for? It was lower back. Well, did this current disability, was that prior condition? Did it contribute toward this disability or not now in the case of natto after that?
(10:42): You know, a lot of times it does not matter if you'd had a perfect back or one with some minor problems in the past. If you get T-boned, the chances that your back is going to be messed up is pretty great. So we would look at that and say your preexisting condition of your prior back problem that did not contribute toward this current disability. So we would honor the claim. We're not looking for a reason or a Lupo to not pay the claim. Now I'll give a couple more examples, because I think the more you here, the more you start getting the idea of what's covered, and what's not, you'll have someone who, again, we're going to stick with the lower back was excluded and they're up on a ladder because they're thinking they're going to help paint and they stumble and fall. And when they fall, they hit their upper part by their neck and they injure the upper part of their neck.
(11:35): But the immediate fear is, Oh, great. You're not going to pay this. It's my back. Well, again, we exploded your lower back this again, right? You use my deck. And my, my thought of my definition is preexisting contribute toward this disability, upper back, lower back, no problem at all to pay that claim. So I'm letting you know that the exclusions are there, they're there for a good reason. Do we ever utilize them? Absolutely. maybe now I should give an example of the time when it would be excluded. You have a lower back exclusion and years later, you end up having to have surgery on your lower back. And we look at it. We always tell you, go ahead and please submit the claim. Let us look at it. Just because you have the exclusion doesn't mean it's an automatic. So it's always a good thing to go ahead and submit the claim again.
(12:28): We're going to be asking your doctor did this preexisting condition that it contribute toward this present disability. So they may look at it and say, Oh yeah, this is the problem. They had 12 years ago, which is why you probably excluded it. It's gotten worse. And yes, it did contribute. Then that is going to be a denial. We've had others where they say, no, no, no, I know it's in the lower back. But you know, before it was because of this condition, although it's developed and it is still in the lower back, this is an entirely different condition and it has nothing to do with this preexisting, then we're going to pay it. So, Okay. So it could be, he could still be a lower back issue that still results in a claim,
(13:13): Even if that is technically excluded. That is absolutely correct. And I would end by saying that I, the reason I'm saying I'm only advising, this is the way Ameritas does it is because I am aware that in the industry, other companies, because of their wording, that they look at it and say, no, if you have any injuries and any injury to your lower back, it's excluded and distort. And it's not that they're trying to do it differently. That's just the way their policy is written. So I would my words of advice is if you have an exclusion, make sure you understand what is and is not going to be covered.
(13:52): And the time to understand that is that the time you're purchasing, not at the time of claim. I mean, because if, if that, if that company is going to exclude everything related to the lower back, that would be in their contract, that it would be worded as so. Right? Absolutely. If you're asking about an exclusion before you purchase the policy and you get ahold of someone at the company and they explained, well, this is how we would handle it. Your next question should be, can you put that in writing? Because if that's their practice, they should have no problem putting that in writing. If you call us and ask us at Ameritas, how do we handle it? Not only what we explain it, hopefully to the way I just did, we'll send you a brochure that explains the exact same thing, and the reason we're not afraid to put it in writing and explain it is because this is how we administer the claims,
(14:44): The question, and then I'll let you go when it comes to the specialties, like, and I'm thinking at one time, and I'm going to put you on the a little bit, cause you probably don't remember doing this. But a number of years ago, I had a, an electrophysiologist who wanted to confirm who was asking me and said, Hey, if I'm disabled from electrophysiology, he's buying a true own occupation, specialty policy with Ameritas. So he's an emeritus policy holder. If I can't do electrophysiology, can I still do general cardiology? And that would be a total claim. And at that particular point, we were able to confirm that that yes, that could be if unable, due to an illness or injury to perform the material duties of electrophysiology, then that would be a total disability claim. And then he could work as a general cardiologist, perhaps at the same employer and make that new income and collect his full benefit as well.
(15:40): Is that, and you put that in writing again, I don't know if you remember that, but that was a handful of years ago. That strikes me as something different in my experience that Ameritas is willing to do that. The other top companies are not willing to do where they just kind of say, well, you'll need to refer to our contract kind of approach number one. Is that correct? If you can't do correct? Yes, that is correct. Okay. And two, is that something that your company, apparently you just answered it, you're comfortable saying that upfront, not just saying, fill out the claims and we'll let you know at that point.
(16:14): Absolutely. And I think Billy that you really hit upon a key there. What are unwilling to, to tell you and say to you over the phone before you buy the policy, I certainly should be willing to say to you after you bought the policy. And the reason that that it's so simple is because I know it's going to sound trite, but when you're always just following the same philosophy and you know that this is how you do it, you're not afraid to put it in writing. So whether you buy the policy while I'm still here or five years from now, this is the way the Ameritas has always interpreted it. Okay. People will say, well, what if I don't have that letter? You know, you're going to treat it different. No, it all goes back to this. If you'll allow me to dive in just a little bit deeper at time of claim, that conversation that I talked about when we're talking with the physician and he, or she is telling us what they do, they know better than any of us, what their normal duties are.
(17:13): So they get a chance to explain, you know, well, I I've really majored my specialty in doing this, this and this. And we say, okay, great. Well now what we're going to do is we're going to get ahold of, you know, probably your office manager. And we're going to ask for the last year CPT codes, because what that's going to do is reinforce exactly what you just told us. And they're like, Oh, okay. Yeah, that makes sense. That's what I, that's how I build people. The insurance, that's going to tell you what I do. So when we get that back in, we'll do an analysis and we'll go, yep. That pretty well aligns up. You know, even though they are this type of doctor, which means they could do 20 different things, they have really specialized and they only do these three things and that's where they have specialized their service.
(18:02): And so if we look and say, okay, well now is this disability preventing you from doing the performing those materials, substantial duties? If the answer is, yes, they can't do that. Then they're disabled. Now, if they say, okay, but I was trained, I could have done those other 17 things, but I just never did. And we go, but my partner and partners have said, you know, if I could come back, I could go ahead and do some of these other things. And I probably wouldn't earn as much money, but what, what would happen to me if we did that now in that case, we would say, well, you never did those before. So in actuality, this is a new occupation for you. And that's how we would view it. I want to go ahead. If I'm not confusing folks too much, and I'll keep it with that.
(18:57): There were 20 things you could do. And in my first example, you only did those three. Now you cannot do those three. And you choose to do five of these remaining 17 that you never did before. Then that's a total disability. You get to keep all of your income from this new occupation. That's how we would view it, a new occupation. And we would still continue to pay you total disability. Right? The second example, if I don't lose you, it's, it's subtle, but it's a huge difference. Had always out of these 20 things you had always done about 10 of them, but your disability is now preventing you from doing three of the 10 that you used to do. And your partner said, well, if you come back, you can do those other seven and three more. So we'll get you back to 10. So you're doing some of the duties you used to do, but not all of them.
(19:54): That's a case where then your partial disability, your residual benefit would kick in because yes, you are able to perform at least one or more of your duties. And you're now supplementing by doing others. That's where your residual benefit would come in. And obviously, you know, if you're doing different duties, your occupation, your pay is probably come down. Your residual benefit will help supplement that. So you're still collecting a benefit. So it's, it's a subtle difference, but it's one where I think it makes, makes a big difference on how we're going to pay the club.
(20:29): Right? So is back to your original example in the beginning, ophthalmology, if your ophthalmologist retina specialist is doing some clinic to drive the retina practice, is it would one of those three duties be doing clinic. And if they can go do clinic in a general ophthalmology setting, does that penalize them? Does that make sense?
(20:54): It does. And maybe I can best answer that by giving you an example of an ophthalmologist that we recently had on claim. And again, it was a learning process because we want to know what did they do at their practice? This ophthalmologist had truly limited their focus of doing cataract surgery. So even though over 50% of their time when we got the CPT codes was office visits, and yet only about 20, 30% was the actual surgery. He was unable to perform surgery. And so he was afraid that we were going to look at the claim because he, what he had done. Again, it goes back to what I said earlier. Our clientele are usually very ambitious. If they can work, they want to work. And he said, look, I can't do the cataract surgery anymore, but I'm, I'm kind of switching my practice to where I'm becoming what I am.
(21:54): these were his words, not mine. I'm becoming a glorified optometrist where I'm really just seeing people more, you know, for eye exams, routine, eye exams, and fitting them with, you know, contacts and glasses. Well, we looked at that and said, yeah, he's still an ophthalmologist, but people don't go to him anymore to see about cataract surgery. And this was again with us, really listening and learning what his practice was. He said, you know, yes, I had all these office visits, but they came to me because they wanted to know, do I need cataract surgery? They didn't come to me to get their eyes examined, to get a pair of glasses, because that really wasn't what I did. Right. People referred me were referred to me because they thought they might have a problem and might need cataract surgery. So he said, my practice now is I can't do cataract surgery. My patients no longer come to me for that. So I'm really just doing what would have in today's world would be clapped, classified as a common interest. So we viewed that as an entirely different occupation. So he was able to keep his total disability benefit from us and then collect what, whatever he was earning in his new occupation. So I think that kind of hits to what you were saying.
(23:14): It does. It does. That's really helpful. The same with like the electrophysiologist, the office visits are being driven by that specialty, in that particular area. And so in essence, they are starting over. Even if they're at that ophthalmologist, is, is building a new clientele or a new patient base based on something different than what they were specializing in.
(23:38): Yeah. And Billy, if you'll allow me, I think probably I'll do this quickly. Probably the best example that everyone probably hears the most, but it's probably used the most because it's probably the simplest to understand if you're a surgeon and that's what you do. You're a surgeon. Of course, when we look at your CPT codes, we're going to see that you have a lot of offices, you know, because you're seeing people both pre and post-surgery. And when you look at well, what amount of time are you actually performing surgery? It may only be 30% of the time, but if you become disabled something happens to your hands. You have a develop a tremor, so you can no longer hold a scalpel, et cetera. You're no longer able to do surgery. If you then say, well, I can't be a surgeon anymore, but a friend of mine has asked me to come in to practice with them, to basically be a GP.
(24:32): And obviously I have the skillset, you know, I can do that, although I never did it before. Is that going to be viewed as a residual claim because I'm still doing in office visits and all that. It's like, no, you are a surgeon. You are no longer able to perform surgery. You are taking on this new role of a GP. We viewed that as an entirely different occupation. So you would get the benefit of being able to keep all of that money while still collecting our total disability. Okay, great. Great. That's really helpful. This has been great, Dennis really want to thank you for your time and for your expertise and your openness in sharing, you know, your thoughts and your, you were expertise. So your feedback in this. And so hopefully our, the folks listening to this has gotten a lot of information from it.
(25:27): And if, depending on what they say, we may need to call you to have a, like a postscript or like a followup at some point down the line. I would welcome that if this prompts some other questions that people are really wanting to know, I'll do my best to answer them. I think that's great that we're all getting educated. Yeah, absolutely. Absolutely. Please feel free to text me anytime to arrange a conversation or with questions. My number is (704) 270-2376. Again, that's (704) 270-2376. I'd be glad to discuss your situation any time until next time. This is Billy Gwaltney. Thank you. As always for carving out a few minutes, take care.
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