2425 E. THOMAS ROAD
PHOENIX, AZ. 85016
TEL: (602) 364-9221
DIRECT BACK LINE: (602) 364-9320
FAX: (623) 594-6385
PRACTICE LIMITED TO PERSONAL INJURY
IN NEW YORK:
171 LAKEVIEW AVENUE
WEST HARRISON, N.Y. 10604
What to do if you are in an accident:
Is Your Doctor Committing Consumer Fraud?
You've been injured in an accident and have begun treatment. You have a health plan (we'll talk in another installment about that particular rip-off). Naturally, you want to use your plan to the full extent possible (you're certainly paying enough in premiums). So the wise choice is to choose an in-network provider,right? Wellll, maybe. Here is the inside “scoop” of that system: these days, most any provider who wants a successful practice has to be in-network for the major health plans. In so doing, the doctor gets a nice, strong, steady flow of patients, i.e., income. However, there is a “downside”: every in-network provider must agree to accept what the plan pays them for their services, a discounted rate called a “capitated” rate. So, doctor gets steady flow of patients BUT doctor does not get paid full billed rate.
In addition, just about every in-network agreement specifies that the doctor, once paid by the plan, may NOT attempt to pursue the plan member (you) to recover the difference between the capitated amount and the full billed amount, a practice called “balance billing” Verboten under most plans.
Here is how some unscrupulous doctors avoid that restriction and what you need to be aware of to protect yourself: you give the office your health plan information. THEY DON'T BILL THE PLAN. Instead, they record a medical lien and put your attorney on notice of the lien. Ethical rules require the attorney to pay off any outstanding liens from your portion of the settlement or judgment. So your care ends up being paid not by your health plan, which the doctor never billed, but by YOU, AND at the full billed rate, not a capitated rate.
How to protect yourself from this blatant commission of consumer fraud? First, secure the doctor office's promise that they will bill your health plan. Second, DO NOT take them at their word. Check your EOB'S (explanation of benefits) and MAKE SURE THE OFFICE ACTUALLY KEPT THEIR WORD AND BILLED YOUR HEALTH PLAN. If they did not, insist that they do and if they resist, find another doctor who will and file a complaint with whatever agency of state government regulates that kind of doctor. Do NOT allow yourself to be victimized by this scam, which is widespread.
NEXT INSTALLMENT: The rip-off known as “self-funded” health plans
As promised, the “self-funded” health plan rip-off.
In our first installment, we talked about what to do if you're in an accident not your fault. Our next installment discussed the widespread consumer-fraud conduct of many doctors who are in-network but don't want to be paid at the discounted (“capitated”) in-network rate....and so never bill your health plan but stick YOU with the bill via a health care provider lien. Naturally, you pay the full billed amount, not any discounted rate.
The next rip-off? So-called “self-funded” health plans. In the old days, if you worked for a company and were provided with health care coverage, it was in the form of a health insurance policy. That's important because in Arizona it is absolute black-letter law that if your health insurance plan pays for any treatment of any kind, under no circumstances may the plan demand you reimburse them for any amounts the plan paid (so-called “subrogation”).
“But of course”, you say. “That's as it should be. After all, why am I paying premiums if I would have to pay the plan back?” Just so—until passage of the Employee Retirement Income Security Act of 1974—ERISA for short. The law was passed to protect worker retirement funds from being raided by the company. But this is Washington DC we're talking about, folks, so in the middle of the ERISA law is a series of statutes that allow companies, instead of purchasing actual health insurance to cover their employees, may instead opt to set up what is called a “self-funded” health PLAN. These plans are NOT health insurance. They are a kind of glorified savings account into which is deposited your premium payments and the company's contribution and out of which are paid bills for health care of employees. What's the diff? Because these plans are NOT insurance, they are not bound by any anti-subrogation law. So, you're in an accident. Your plan pays for your care? You recover money from the at-fault party? Here comes a letter from your health plan demanding you pay-them-back for any amounts they paid for your care. “Why”, you ask? Because they can. It's perfectly legal. “Then why am I paying exorbitant premiums if I have to pay the plan back?” you ask. Great question. Self-funded plans are mostly garbage, enormous deductibles, co-insurance and co-pays, with ridiculous premiums to begin with. And now you have to reimburse them, too? Sorry, but yes. What to do? In fact, there is only one thing you can do to protect yourself and that's what we are going to talk about in our next installment. It's called “med pay” and I am going to strongly advise each and every one of you to add it to your auto policy immediately.
By the way, virtually every health plan for any sizable company these days, AND if you work for the State of Arizona, are self-funded.
NEXT: FINALLY SOME GOOD NEWS!
First three installments: 1. what to do if you're in an accident. 2. How not to be scammed by your treating doctor who wants to be in-network (lots of patients=lots of $$$) but does NOT want to be paid at the in-network discounted price. 3. The rip-off, completely legal, known as self-funded health plans.
This installment: Finally, some good news. The one and ONLY way to protect yourself from what we've previously discussed: GET “MED-PAY” on your auto policy! “Huh?”, you say. “What's med pay?” Well, if you don't know, there's a good reason for that and we'll talk about that in a sec. But in the meantime, let me repeat myself: Call your agent NOW and tell him or her you want $5,000 in med pay coverage added to your auto insurance (this is for Az. peeps).
What is med pay? It is a no-fault medical coverage (meaning it pays medical bills if you're injured in a wreck, no matter who was at-fault), at 100% of the billed amount, no deductibles, no “co-insurance”, no “co-pays”. If you are injured in an accident and receive care, it PAYS, up to the limit. It is NOT entitled to demand reimbursement, as is a self-funded plan because it is health insurance, not self-funded. AND in Az, it is perfectly legal for your health care provider to bill both your health plan AND the med pay, so that you can use the med pay to buy down those ridiculous deductibles and/or co-insurance and/or co-pays. The cost for this wonderful coverage? Likely between $70 and $90 PER YEAR. That is not a typo. We're talking less than ten bucks a month.
So maybe you're asking “How come my agent never told me about this?” Politics. Every insurance agent is “graded” at the end of each year, and their grade is based upon on how many claims their customers filed against the company in the past year. Too many claims, and it's “Bye-bye. Go sell insurance for someone else.” Med pay generates a lot of claim activity, for obvious reasons, so agents figure, well, we just won't mention that coverage. I've been in practice 30 years, approximately 1,500 clients. In that time, the number of clients who have told me their agent informed them about med pay is.....two. Two in 30 years. So don't wait for your agent to do the right thing. Call him and her and tell them “I want $5,000 in med pay added to my policy NOW!”