7 secrets of health insurers

3. Health insurers typically pay a 10% to 20% commission to agents.

If you buy an individual policy from an agent, he or she generally makes that commission on your initial purchase and every year you renew.

4. You can take your health insurance gripe to an external review panel.

All grievances about your health insurance -- such as coverage denials or other claims problems -- start with a formal complaint directly to your insurer. But if you don't receive satisfaction from your insurer's own complaint-resolution process, you can make your case to an external review panel.

Only six states -- Idaho, Mississippi, Nebraska, North Dakota, South Dakota and Wyoming -- lack laws mandating external grievance panels, according to the Kaiser Family Foundation. Even in states without a law, though, health insurers have a grievance process.

HealthClaimsAppeals.org can guide you through the process of resolving an insurance dispute.

5. Your insurer may provide financial incentives to doctors who give you "best practices" treatment.

Health insurers are increasingly looking for ways to ensure patients receive the most effective care possible, which ultimately reduces health care costs and reduces patients' chances of developing chronic conditions.

Your doctor may have a "pay for performance" agreement with your health insurer, in which he or she gets higher reimbursement rates when prescribing treatments that line up with best-practices guidelines.

6. You might not be able to sue your health insurer.

Only 17 states have laws mandating that you can sue your health insurer in civil court in order to hold it accountable for treatment decisions, according to the Kaiser Family Foundation.

Those states are Arizona, California, Georgia, Illinois, Maine, Minnesota, Missouri, New Hampshire, New Jersey, North Carolina, Oklahoma, Oregon, South Dakota, Tennessee, Texas, Washington and West Virginia.

7. Your health insurer may be entitled to take your auto insurance settlement after an accident.

It's legal in most cases for a health insurer to place a lien on any third-party settlement money you get from an auto insurer after an accident if your health insurer has paid for your treatment from an accident. This practice, known as subrogation, simply means "substituting one for another."

Health insurers are allowed to recoup the cost of your medical care from the settlement you receive from the person who injured you. For example, if your auto accident medical expenses total $5,000 and you win a $10,000 settlement, your health insurer can take half -- but only if its "rights of recovery" are spelled out in your plan agreement or summary of benefits.

Published Aug. 28, 2008

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