Sign in to follow this  
WhoCares1000

Health Insurer sending checks to patients

Recommended Posts

13 hours ago, Harry Seaward said:

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. 

The attorney has never tried it because if there was no assignment he won't sue on a conversion theory. He would just sue on a breach of contract theory which he obviously still wins anyway. 

Remember there are two causes of action here. You can sue for the damages of breach of contract to pay for the services or conversion of an insurance check.

It makes a difference because a decent majority of the time the policy holder is not the same person as the patient. I.e., if the patient is a spouse or child of the policy holder. The patient is obviously liable for breach of contract for services rendered. But the attorney would not sue the policy holder unless the medical provider took back an assignment from the policy holder. Hard to get assignment from policy holder in emergency situation. 

As far as Georgia goes. I'm not sure they would be successful at prosecuting one of those cases. But it is Georgia so who knows. 

Share this post


Link to post
Share on other sites
1 hour ago, usctrojanalum said:

a decent majority of the time the policy holder is not the same person as the patient

Conversion doesn't require a contract. The patient, regardless of their relationship to the policy holder, knows they are not entitled to keep a $1.5 million (or even a $15) check. That knowledge constitutes conversion. The attorney's decision to pass on that cause of action doesn't negate its existence. 

Share this post


Link to post
Share on other sites

The only thing is that I think to prove criminal conversion would require the DA to show intent and most of the time, either that is not happening OR the person is smart enough not to say anything (and come to boards like these asking for advice to keep the funds).

However, I think civil conversion would be easy to prove. The defendant got the funds and did not forward them on. I think that is why Anthem BCBS is stonewalling out of network providers. They want to make it as hard as possible for them to collect in hopes that they will accept the lower in-network rates.

And of course most attorneys will go the breach of contract route. That is the easiest one to prove.

Share this post


Link to post
Share on other sites
6 hours ago, usctrojanalum said:

It makes a difference because a decent majority of the time the policy holder is not the same person as the patient. I.e., if the patient is a spouse or child of the policy holder. The patient is obviously liable for breach of contract for services rendered. But the attorney would not sue the policy holder unless the medical provider took back an assignment from the policy holder.

This may be due to NY state law and how policies are written there. Having lived in GA for 17 years I can attest that in GA policies are written that the insured is responsible for ALL expenses incurred under themselves as an individual and all dependents named in coverage on the policy.  This is probably why GA is also starting to pursue these cases as conversion.  

The bottom line is what you can expect is that in some cases BCBS will force providers to join the network.  For those that remain steadfast against doing so patients will be forced to pay for care up front to avoid the entire conversion and refusal to pay issue.  Ultimately care will get more expensive and harder to attain.

Share this post


Link to post
Share on other sites
On 3/3/2019 at 9:31 AM, Harry Seaward said:

Conversion doesn't require a contract. The patient, regardless of their relationship to the policy holder, knows they are not entitled to keep a $1.5 million (or even a $15) check. That knowledge constitutes conversion. The attorney's decision to pass on that cause of action doesn't negate its existence. 

Yes, but you're making an assumption that the patient is personally keeping the money as opposed to the policyholder.

There have also been extremely unfortunate situations where an adult child > 21 years of age but still on a parent's insurance went to a medical provider who was out of network. Insurance money goes to the parent who is the policy holder and then the child patient gets sued who is basically stuck in the middle. I disagree with you guys, I really can't see how the hospital would have standing to go after the parent directly, without an assignment in the insurance proceeds signed by the parent. That's not conversion. The parent paid the premiums and is entitled to the benefit.

Another interesting wrinkle is when the patient or insured later files a Chapter 7.  Bankruptcy Attorney (different from the health provider attorney) has taken same path. Adversary proceeding seeking to have to the amount exempt from a discharge where there is an assignment to the proceeds, but if there is no assignment, then not fighting the discharge.

Share this post


Link to post
Share on other sites
14 minutes ago, usctrojanalum said:

Insurance money goes to the parent who is the policy holder and then the child patient gets sued who is basically stuck in the middle.

There can't be more than 2 or 3 examples of this happening. In any event, being a victim of a crime is an affirmative defense. No attorney with 2 brain cells to rub together is going to pursue a case like this as soon as they see the insurance company sent a check to the parents.

Share this post


Link to post
Share on other sites

Yeah, that's just not true at all. The child is not a victim of a crime and still remains principally liable for the debt. I agree child may have third party claim against parent, but I don't think many children would go that route. 

Share this post


Link to post
Share on other sites

The parent is committing conversion for sure and probably fraud. Both criminal activities. The child is a direct victim of those crimes because they are now liable for the money the parent illegally kept for themselves.

Share this post


Link to post
Share on other sites

We will just have to agree to disagree. It's not conversion. But BlueCross agrees with me. We may get an answer if they win this lawsuit. 

Share this post


Link to post
Share on other sites
4 hours ago, usctrojanalum said:

We will just have to agree to disagree. It's not conversion.

Ok, we'll agree to disagree. But it is conversion. 

Share this post


Link to post
Share on other sites

It's not. Conversion is when you take someone else's property. The medical provider rights never vest in that money. It doesn't belong to the medical provider until it's paid to them or there is an assignment in the insurance proceeds. But I get it, third party beneficiary law is not easy to understand.

Share this post


Link to post
Share on other sites

I thought we were agreeing to disagree, but....

2 hours ago, usctrojanalum said:

It doesn't belong to the medical provider until it's paid to them

Regardless of if this is true or not, the money definitely doesn't belong to the patient or insured. Therefore it's someone else's (most likely the insurer) property, if not the medical provider. If the rightful owner declines to push the issue for whatever reason, that's their business, but it doesn't change the fact that someone took something that dosen't belong to them. 

This is obviously a case of the insurance company trying to put the screws to the medical providers. Here's how you know: if you flip it around to where a medical provider sends the insured a check intended to pay the insurer for an overpayment of services, we both know the insurer wouldn't "agree" with you if the insured argued the money belonged to them. 

Share this post


Link to post
Share on other sites
9 hours ago, usctrojanalum said:

But I get it, third party beneficiary law is not easy to understand.

And clearly you do not understand it.  The first thing to understand is how the claim process starts that generates the check to the patient.  When an insured has a procedure done (where/what facility does not matter) the provider generates a CPT code for all the procedure(s) done along with all the relevant CPT codes that indicate the diagnoses that justified the procedure.  I don't know of any provider that does not get the care pre-authorized when elective or does not get a financial agreement that spells out the patient is responsible for paying for all care regardless of what insurance does or does not cover.  Once the procedure is done the report, bill and all relevant codes the insurer needs to cover the care are sent to the proper department of the insurer NOT to the patient so that a claim is started and payment can be made.  The claim is then processed.  The insured's benefits are verified by the carrier and the amount they will cover is determined and ONE only ONE insurer [Anthem BC/BS] sends the check to the patient so that they may forward it to the provider.  An EOB [explanation of benefits] is sent sent to the patient detailing what was covered, what was not and why if applicable, and what portion the patient must pay out of their own pocket.  

9 hours ago, usctrojanalum said:

The medical provider rights never vest in that money. It doesn't belong to the medical provider until it's paid to them or there is an assignment in the insurance proceeds.

First and foremost the provider very much has a vested interest considering that EVERY patient and/or guardian signs a financial guarantee prior to any care being performed except in life threatening emergencies.  That guarantee specifically states they will pay the provider any insurance proceeds they may receive on behalf of the provider. Most patients simply scribble their signature and never bother to read it.   How exactly do you think the providers get the insurance information to start with in order to create the claim that causes that large check to be sent to the patient in the first place?   The patient willingly provides it and gets the care without having to pay up front on their guarantee they will pay the provider when the insurer pays them.  

Do explain how a patient could reasonably expect to see a provider, authorize care and treatment, agree to pay for that care, provide their insurance information so that they do not have to pay the entire amount up front, and then receive a check intended to cover that care and keep it for their own use NEVER paying the provider?  Keeping money that the insurance company sends to the patient that they KNOW is intended to cover the care they receive is conversion.  PERIOD.

I am not sure what is more disturbing that a member of the bar actually believes this is okay or worse supports patients stiffing providers out of thousands of dollars after receiving care.  Hopefully one day you are lying on a gurney with a provider refusing you care until you cough up a credit card or cash first so that you learn why what Anthem is doing is SO wrong.

8 hours ago, Harry Seaward said:

This is obviously a case of the insurance company trying to put the screws to the medical providers.

That is EXACTLY what this is.  Proof of this is that only ONE carrier of all the major insurers (even the smaller ones) does this. ONE. 

Share this post


Link to post
Share on other sites

I have really no other response but to say that you're wrong. You are both not applying the elements of conversion correctly. You are also not understanding what it means to have "vested" rights to property.image.gif.61f6be6d67d878fd04aafefdbfc5dd19.gif

Just because someone signs some "financial guarantee" or whatever does not mean that person executed an assignment.

Share this post


Link to post
Share on other sites
13 minutes ago, usctrojanalum said:

I have really no other response but to say that you're wrong. You are both not applying the elements of conversion correctly. You are also not understanding what it means to have "vested" rights to property.image.gif.61f6be6d67d878fd04aafefdbfc5dd19.gif

Just because someone signs some "financial guarantee" or whatever does not mean that person executed an assignment.

Let's assume you are right @usctrojanalum and the courts rule that indeed, Anthem can simply send the check to the patient and it is not conversion if the patient keeps the funds.

If that is the case, we already know what will happen to elective care. The providers will either demand payment up front before the procedure OR they will simply refuse patients who are out of network. People will have to travel possibly 100s of miles to find an in-network provider willing to provide the service (which will probably overburden that provider).

The real issue will be emergency care. What this ruling allows is for patients to receive emergency care (which is required), have the checks sent to them (5, 6, or even 7 figure checks), keep the funds, and then when the provider comes for the funds, file for BK (granted I don't know how someone can spend 6 or 7 figure amounts and have nothing to show for it but it happens). I can see providers going to Congress real quick to get the rules changed to make a scenario as I described illegal if indeed you are right and it is not today because to most folks, this is unconscionable.

I think Anthem BCBS is trying to see what they can get away with here to force providers into their network but it might backfire on Anthem BCBS and their customers if they cannot get any care nearby their homes.

Share this post


Link to post
Share on other sites
1 hour ago, WhoCares1000 said:

If that is the case, we already know what will happen to elective care. The providers will either demand payment up front before the procedure OR they will simply refuse patients who are out of network. People will have to travel possibly 100s of miles to find an in-network provider willing to provide the service (which will probably overburden that provider).

Doesn't this already happen? Not so much the former, but definitely the latter.

Share this post


Link to post
Share on other sites
24 minutes ago, usctrojanalum said:

Doesn't this already happen?

Not with regularity though I can state in my area  providers are starting to tell Anthem out of network patients that they have to pay 100% up front for ALL care routine appointments not just testing, surgery or other procedures.  If the patient does not want to pay up front and wait for their money from Anthem then they are turned away and recommended to find someone in network.

1 hour ago, WhoCares1000 said:

People will have to travel possibly 100s of miles to find an in-network provider willing to provide the service (which will probably overburden that provider).

One of the factors influencing this is when the in network provider is one of questionable education, training, and skill.  We have a few here locally that patients have unanimously said they would not let them touch a house plant let alone a human.  Patients who cannot afford to travel to a skilled respected provider are forced to either go out of network or suffer with substandard care.

Share this post


Link to post
Share on other sites
1 hour ago, usctrojanalum said:

Just because someone signs some "financial guarantee" or whatever does not mean that person executed an assignment.

Well then you have not read one lately.  The one that all my patiens have to sign is a 2 part form.  The first is the consent to treatment and acknowledging they gave accurate and correct information in their medical history to me.  The second part is an assignment of benefits.  MOST providers use a financial guarantee form that is not only a promise to pay but says "we file insurance claims as a courtesy for you but regardless of whether we file or you the benefits are assigned to [provider llc] as payment for services rendered."  Well founded practices do not use a basic financial guarantee but a dual one like we do that is a guarantee AND an assignment of benefits.

If the patient has signed a document of that nature AND keeps the insurance money it is conversion.  PERIOD.

Share this post


Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

Sign in to follow this