Monday, January 21, 2013

HHS Codifies Insurance Fraud

I would love to see a list of which other industrialized nations with healthcare spending half ours has laws like this;

"If, for example, a patient received care for asthma and for diabetes from the same physicians and paid for the diabetes-related care out of pocket, the patient could keep the physicians from telling the health plan about the diabetes, officials say.

The health care provider or other covered entity could still contact the health plan if the patient did not really pay the full out-of-pocket costs for the care. If, for example, a patient's check bounced, a provider could contact the health plan for payment, officials say."

So hiding information from your healthplan who is being told to better manage health and cost is going to be law, sounds counter productive.

Plans have filing limits, if the doctor waits until the patient doesn't pay they might miss the time they have to file for reimbursement under the plan, or will plans now also be required to extend the time to file claims based on employees wanting to hide information form them. Not to mention the mess that makes of reinsurance contracts.

My advice to clients, this is reason 328 to go back to reimbursement plans. Dump the PPO and assignment of benefits and let members submit claims and be reimbursed at plan allowable. Solve not only this issue but excessive provider cost as well.

An after thought, employee suffers some condition related to smoking which they lie and tell their healthplan they do not do in order to get the lower premium. In order to continue paying the lower premium they hide any claims related to smoking. Until they get major claim at which time they let the plan pay. 
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