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WhoCares1000

Health Insurer sending checks to patients

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@Clydesmom

We had this discussion a couple of months ago but I saw this article today and wanted to post it to show what is happening in this realm.

https://www.cnn.com/2019/03/01/health/anthem-insurance-payments-patients-eprise/index.html

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I have seen this a lot in New York, it is really predatory what the insurance companies are doing because of the ripple effect it has.

In reality what this leads to is the medical providers getting massive judgments against patients. The patients then have their credit ruined, wages garnished, banks accounts seized etc.  

 

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But on the other hand, I understand the position of BlueCross. A health insurance contract, like any other contract, is a contract between the insured and the insurance company. The insured pays the premiums. Medical providers are only incidental third party beneficiaries who rights do not vest in that contract. 

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1 hour ago, usctrojanalum said:

I have seen this a lot in New York, it is really predatory what the insurance companies are doing because of the ripple effect it has.

In reality what this leads to is the medical providers getting massive judgments against patients. The patients then have their credit ruined, wages garnished, banks accounts seized etc.  

 

If the patients used the money to pay the provider for the care they wouldn't have their credit trashed or judgments.  The problem starts when the check(s) roll in to the patient and they keep the money and don't pay the bill(s) for the care received.  

I know for my company we are required to get a specific consent form signed for Anthem BCBS patients that states if they do not forward the money to the company for our services within 30 days of receipt of the check(s) for services that we can and WILL sue to recover including all legal expenses and interest.  Fortunately we have had relatively few problem patients who think they hit the lottery and don't have to pay for the care they received.

What you are going to see is providers requiring payment up front for the care they render and telling patients they can wait for reimbursement from the insurance carrier.  How many people do you think can afford a five or six figure surgeon's bill to have their surgery up front while waiting 3-6 months for the insurer to reimburse them?

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1 hour ago, usctrojanalum said:

I have seen this a lot in New York, it is really predatory what the insurance companies are doing because of the ripple effect it has.

In reality what this leads to is the medical providers getting massive judgments against patients. The patients then have their credit ruined, wages garnished, banks accounts seized etc.  

How is it predatory? The patients seek out of network care they know isn't covered by their insurance, and then they keep money they know damn well doesn't belong to them. 

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28 minutes ago, Harry Seaward said:

How is it predatory? The patients seek out of network care they know isn't covered by their insurance, and then they keep money they know damn well doesn't belong to them. 

A patient almost never knows when their insurance goes out of network. That would be a highly sophisticated healthcare consumer who would know that. Plus, in emergency situations you seek care at the closest facility without thinking about whether the provider is in your network.

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37 minutes ago, Clydesmom said:

What you are going to see is providers requiring payment up front for the care they render and telling patients they can wait for reimbursement from the insurance carrier.  How many people do you think can afford a five or six figure surgeon's bill to have their surgery up front while waiting 3-6 months for the insurer to reimburse them?

This doesn't solve the problem of emergency care, which is usually where insurance reimbursement rates are highest. 

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1 hour ago, usctrojanalum said:

That would be a highly sophisticated healthcare consumer who would know that.

Looking the info up online is far from highly sophisticated. And even lower-tech but more accurate than that, every insurance ID card issued has a phone number on the back to verify benefits. I get that people don't bother to check into it, but they certainly have plenty of opportunity.

1 hour ago, usctrojanalum said:

Plus, in emergency situations you seek care at the closest facility without thinking about whether the provider is in your network.

Yes, this is very true. But not thinking about it doesn't change the fact, and more importantly, isn't an excuse for keeping $150,000 that doesn't belong to you. 

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1 hour ago, usctrojanalum said:

A patient almost never knows when their insurance goes out of network. That would be a highly sophisticated healthcare consumer who would know that.

NO!  You should always know where you local IN NETWORK facilities are for elective care situations. When a provider goes out of network notice is given to patients of that provider so that they can make arrangements for a new provider if they wish to stay in network.  The contracts are written for 1-3 years at a time so going "out of network" doesn't just up and happen one day with no notice.  

In fact some larger providers go to the lengths of advertising the contract is coming to an end and that the insurer is refusing to increase their reimbursement rates in the new contract.  All in an attempt to force higher contractual rates by scaring patients they will lose their providers.

1 hour ago, usctrojanalum said:

Plus, in emergency situations you seek care at the closest facility without thinking about whether the provider is in your network.

Which is why many states require an insurer to cover true emergency care as in network if the closest facility is not and the situation is critical.  Some insurers do this as a matter of course without a state mandate requiring it.

1 hour ago, usctrojanalum said:

This doesn't solve the problem of emergency care, which is usually where insurance reimbursement rates are highest. 

NOTHING about emergency care allows the patient to keep the money from the insurer when it is sent to them.  If Betty goes to the ER with chest pains and is diagnosed with a heart attack then discharged 5 days later she cannot keep the out of network check for $175,000 for the cardiologist who put the stent because she didn't know he was out of network when the ambulance took her to the closest cardiac facility.  Regardless of whether the care is in network or out, emergency or elective the patient is required contractually to PAY THE BILL.

 

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For the record:  Anthem BCBS is the ONLY insurer that does this with payments.  We don't have this issue with any other major carrier.

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@Clydesmom I figured that was the case when I read the article. I know you were trying to keep it a secret but the cat is out of the bag now.

@usctrojanalum Since you are in or went to law school, I am sure you understand what conversion is. That is what is happening here. These are not simply cases of people not able to afford the co-pays and deductibles (which is an issue in and of itself). There are people who receive money from the insurance company that was intended to pay the provider and instead, converted the funds to their own use. Most of the time, all that happens is that they get a judgement against them for the amount they received from the insurance company. However, as the article states, some places are now looking at charges of felony conversion by fraud. Granted, the criminal cases are harder to prove because they have to show intent by the defendant whereas civil conversion is easier to prove because all that has to be shown is that the defendant received the funds and did not sent them, whether the defendant had intent or not. That is the biggest issue for emergency care because they cannot simply say that the patients insurance is not in their network, therefore we refuse to treat the patient. That is against the law.

I am glad to know it is Anthem BCBS that does that because that is who I am insured by. If I ever run into this situation, I will look at the EOBs to understand who gets what check and then cash and remit those funds to the provider ASAP.



 

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2 hours ago, WhoCares1000 said:

I am glad to know it is Anthem BCBS that does that because that is who I am insured by. If I ever run into this situation, I will look at the EOBs to understand who gets what check and then cash and remit those funds to the provider ASAP.

I wonder what would happen if you just refused the check and sent it back to them.

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2 hours ago, WhoCares1000 said:

I know you were trying to keep it a secret but the cat is out of the bag now.

I did not use their name in the thread you referred to where it reared its head on the forums but since the article was clear who was involved then it really has become publicly accessible information and renders being discreet moot.  

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10 minutes ago, texasrocker said:

I wonder what would happen if you just refused the check and sent it back to them.

Why would someone do that?   If the consumer uses the money to pay the provider, he has a record of the payment.

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8 hours ago, usctrojanalum said:

A patient almost never knows when their insurance goes out of network.

I wanted to add one more thought on this.  For emergency care it is VERY possible that the patient could end up at an out of network facility or at the least the physicians are not in network even if the hospital is.   However, when it comes to outpatient office visits and subsequent care such as tests or surgery the patients are told by the office staff if their facility is in or out of network.  While there may be some smaller offices that are still operating like it is 30 years ago the majority of providers now ask what your insurance is when scheduling the first office visit.  If not in the patient's network some will just tell the patient and get payment up front others will go with a policy of we don't see out of network patients and an in network provider needs to be contacted.  Ultimately the decision on where to get care is on the patient/insured NOT the provider.

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8 hours ago, texasrocker said:

I wonder what would happen if you just refused the check and sent it back to them.

I would have no clue because Anthem BCBS is the only major insurer to do this. All the others send the checks to the provider. Sending the checks back and telling them to pay the provider could create even more headaches than simply either signing over the checks to the provider OR depositing the checks and immediately sending the payment from your account to the provider. It will eventually be up to the courts to decide if what Anthem BCBS is doing is legal or not.

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7 hours ago, BV80 said:

Why would someone do that?   If the consumer uses the money to pay the provider, he has a record of the payment.

Just a perspective that no one else brought up.  I'm not saying one should do that but some people could have the attitude that it is not their responsibility to do the insurance provider's work.

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46 minutes ago, texasrocker said:

Just a perspective that no one else brought up.  I'm not saying one should do that but some people could have the attitude that it is not their responsibility to do the insurance provider's work.

Actually, that is the question for the courts to decide. "In the case of out of network medical care, should the insurance provider, who has no contract with the medical provider, be required to deal with the medical provider and leave the patient out of those discussion?" That is the crux of these cases in the articles. That is especially true in the cases of ER or mental health where the courts or the law require treatment regardless of ability to pay. In elective procedures, the provider has the choice of either demanding payment up front OR refusing care.

What is happening is that for In-Network providers, there are 3 contracts in play. There is the contract between you and the medical provider which states that you are responsible for the bill (unless a state or court order kicks in, say in Minnesota) regardless of you insurance provider, there is the contract between you and your insurance provider which states that they will pay for medical care under your contract, and there is the contract between the medical provider and the insurance provider which states how they will interact with each other. I know this because I have been in a few arguments between Anthem BCBS and a major medical provider here in Minnesota because I am being caught in a argument with the insurance/medical contract to which I am not a direct party of.

For Out of Network care, the missing contract is between the medical provider and the insurance provider. The contract between you and the medical provider and between you and the insurance provider exists. Most other insurance carriers have said that even without a contract, we will send the checks directly to the medical provider. Anthem BCBS has taken the legal stance however where because no contract relationship exists between them and the medical provider, they will deal only with the insured. Again, whether their stance is legal or not is for a court to decide and I am sure the other insurance providers are watching this carefully to see whether they too can do this or not.

You still have a duty to pay the medical provider for your care, regardless of insurance. That is true even if the care was not authorized by you (such as an ER situation or a court ordered the care). If you get payment from the insurance company, you are required by law to remit those payments to the medical provider unless you already paid the medical provider prior to receiving the insurance checks.

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1 hour ago, WhoCares1000 said:

If you get payment from the insurance company, you are required by law to remit those payments to the medical provider unless you already paid the medical provider prior to receiving the insurance checks.

So then it may actually be illegal to send the check back to Anthem.

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12 hours ago, texasrocker said:

I wonder what would happen if you just refused the check and sent it back to them.

We did something similar. My wife went to ER and "service" was a joke. They didn't do anything until she finally left to seek help elsewhere. She told insurance not to pay, but they sent her a check, anyway. She just didn't cash it and insurance company finally just worked out something with "provider."

 

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3 hours ago, Goody_Ouchless said:

We did something similar. My wife went to ER and "service" was a joke. They didn't do anything until she finally left to seek help elsewhere. She told insurance not to pay, but they sent her a check, anyway. She just didn't cash it and insurance company finally just worked out something with "provider."

 

The problem is that the provider could have gone after your wife for that check. Apparently they realized that they had done something wrong and did not want that medical misadventure to be revealed in court where the records become public.

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5 hours ago, texasrocker said:

 

So then it may actually be illegal to send the check back to Anthem.

We don't know because situations like this have not been brought to the courts. Used to be, people could pay for health care and get reimbursed or would remit the checks because they were not for such huge sums. As healthcare costs have outpaced inflation as well as technology, we are getting into the realm where people are not acting in accordance to the rules as they used to.

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18 hours ago, WhoCares1000 said:

@Clydesmom

@usctrojanalum Since you are in or went to law school, I am sure you understand what conversion is. That is what is happening here. These are not simply cases of people not able to afford the co-pays and deductibles (which is an issue in and of itself). There are people who receive money from the insurance company that was intended to pay the provider and instead, converted the funds to their own use.



 

It's not conversion. The benefit belongs to the insured, it does not belong to the hospital. 

The medical provider is an incidental third party beneficiary.

The insured or the insureds employer pays the premium on the insurance contract, therefore the insured is entitled to the benefit of the contract if the medical provider is not participating.

I've litigated a lot of these cases in NY for sums that dwarf those listed in the CNN article. I've litigated 500k, 750k and 1.5 million dollar reimbursement checks sent to patients. 

Whether or not the provider can prevail on on a conversion cause of actions turns on whether the patient has assigned his or her rights to the insurance proceeds. Sometimes the medical provider gets an assignment, sometimes they don't. 

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But the insured is supposed to use those funds to pay the medical provider. The insured still is required to pay them regardless of any benefit from the insurance company. That said, it seems that at least one county in Georgia disagrees with you regarding criminal conversion because they are starting to press charges (and probably subpoenaing the insurance company and their records to find out if the insured has been paid). Again, whether they will be successful on the criminal part or not, I don't know. I do bet they are successful on the civil part. If it starts to lean on assignment then you can bet, at least in New York, the medical provider will demand that, in writing, for elected medical care and will fight for a change in law for required care (such as ER). Not all insured people are in a position to consent to medical care or can look up in vs out of network. Besides the ER, people can end up in the system through 72 hour mental health holds which most states allow the authorities to do and possible for months if the State decides to do a commitment. I have saw how all that works last year.

However you slice it, the insured are not supposed to keep those checks as if they won the lottery. Those funds are supposed to be remitted to the medical provider. We have had this discussion on a thread a couple of months ago where a medical provider refused to budge with a patient regarding collection until they provider got the payments the insurance company sent to the patient.

Now, I know what is going on with these boards when it comes to debt. I am not that naive. However, a credit card is something that you can live without so if the banks need to charge more to make up for those of us who fight them, so be it, I can decide not to use that product without too much hassle. However, one will need medical care at some point in their life and these people running away with 5, 6, even 7 figure checks will mean that the rest of us will pay that much more, either through higher care costs, higher deductibles and co pays, and/or higher insurance premiums. We cannot avoid that.

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4 hours ago, usctrojanalum said:

I've litigated a lot of these cases in NY for sums that dwarf those listed in the CNN article. I've litigated 500k, 750k and 1.5 million dollar reimbursement checks sent to patients. 

Are you telling us that courts have ruled that patients get to keep $1.5 million that an insurance company intended to be paid to a medical provider? If i have that correct, please post one of those rulings. 

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