03/27/2019
Last week, we discussed what to do if you're in an accident and not at-fault. This week, how to avoid getting scammed by your treating doctor. Here we go: 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
