Sharing experiences with Spot injury insurance
For those that don't know Spot is an insurance product (like Aflac) that you can submit injury-related out of pocket expenses to after your insurance is billed. It seems to be increasingly popular/advertised in the industry and is bundled with lots of different outdoors/sports memberships.
On paper, it made sense for me to buy Spot to complement a HDHP because Spot coverage is cheap compared to more expensive health plans that have better out of pocket maximums and deductibles. With Spot you get $25k of coverage with no deductible for basically any sports injury. I’m guessing that in most cases $25k>OOPM for even the most minimal HDHP, so Spot seems like a cheap way to deal with the high-risk-but-healthy profile that is probably common here.
I got to test this theory last year when I tore my ACL and MCL in March. I hit my OOPM pretty quickly and started submitting claims to Spot. Maybe this is common knowledge for those who work in insurance or the health field, but this has been a massively tedious learning experience for me and I’m curious if others have been able to more effectively navigate the system. Here’s what I have learned:
Spot basically white-labels a Mutual of Omaha insurance product. You work initially with Spot to file the first injury claim but they’re just a middle man. Once you submit a claim, all communication comes through Mutual of Omaha.
For each claim, Mutual of Omaha requires a provider bill, EOB from your insurance, proof of payment, and finally a form called a HCFA-1500. Depending on the provider, it can be easy or hard to get HCFA forms. My provider typically has to print these off and scan them to send them to me, so I don’t think they are commonly transferred between people. Most issues seemed to pop up from MoO not properly reviewing the HCFA form for a claim and protesting that items I had claimed weren’t in the HCFA forms. They were, but the forms are tricky and take more time to understand.
For nearly every single line item in every single claim I submitted, I received a letter saying that I am missing a document from the above list. I have dozens of letters. Some sent >3x for a single item of a claim. I had to buy an accordion folder to keep track of them. One rep from MoO told me that they were auto-generated and mailed, another said that the claim is reviewed before they’re sent. I have no clue. They drown you in mail for some claims, but not all of them and it makes it very hard to keep track of what is being disputed, what has been paid, and where each claim is in the process.
I pre-paid for most of my pre-op, op, and post-op because I get a 10% discount for doing so. This means that I don’t have a specific receipt for any procedure, and even if I did, it wouldn’t match the bill or the EOB. As I understand, this means that MoO has to pay the provider. This is fine, but it means that I now have to fight with my provider to get them to reimburse me for the total amount I was billed, not the amount I paid. The only way around this would be for me to forfeit the 10% discount and really stay on top of paying for each component of the procedure separately so they line up with the EOBs. The weird bit is that occasionally MoO will cut me a check (instead of the hospital), even though they haven’t received proof of payment. As with the letters, it isn’t clear to me why this happens.
The Spot plans are adjudicated(?) by the MoO Special Risk Services department. They have a phone line that is generally busy, but will eventually pick up. I have a lot of empathy for CSRs and try not to be rude on the phone, but several of the CSRs (there are only a few, and trust me, I feel like I know them all) are incredibly combative on the phone. Do not expect a MoO rep to explain something to you, or help you solve a problem. You are on the phone to convince them that you have dotted your i's and crossed your t's and that you aren’t going to back down.
Eventually I settled on a strategy where I’d mark each EOB, HCFA, and Bill with MoO claim numbers. I’d call weekly during downtime at work and go through each claim and ask for a status on it. Some CSRs would pick up on what I was trying to do and list off the status of each of my claims, but others would make me explain where each claim appeared on the EOB/Bills/HCFA only to send it off again for “re-analysis”.
I fully recognize that this is probably part of the game – that they intentionally make it challenging and convoluted in the hopes that you will cut your losses and simply give up. Especially given the fact that the insurance coverage is genuinely pretty cheap. But I never expected this amount of fight and red tape for something that is very cut and dry in my mind – my insurance has already paid, I’ve already been billed and paid the bill, so why am I spending hours on the phone trying to convince a MoO representative that the $418 line item on EOB page 4 is found on page 6 of the HCFA from 4/2/2024, which I was billed for on 5/1/2024… blah blah blah? I had my ACL replaced, did months of PT, and returned to sport before some of the first few claims I submitted were paid.
I suppose I’m mostly just venting here, but I am genuinely curious if others have had a similar experience and have figured out a better way to handle Spot/MoO?