Providers Placed In Precarious Position

Providers Placed In Precarious Position

CA State officials allege in court papers that Dr. Martello aggressively collected or attempted to collect more from patients than insurance companies paid, a practice known as balance billing.  According to the article, the underlying issue is familiar: many physicians don’t believe they are getting paid enough for their services.  Doctors bill insurance firms and frequently get a fraction of their full fees.

Martello’s attorney, Andrew Selesnick, acknowledged his client was “very persistent” about collecting bills but said she was lawfully pursuing her rights to recoup fees for her services.,0,6165119,full.story

At the same time, AETNA has filed multiple lawsuits against various providers for allegedly NOT collecting patient’s out of pocket costs.  “Feb. 3 (Bloomberg) — Aetna Inc. is suing seven California surgery centers for a billing system that it claims “recklessly subverts” health care delivery.

“The lawsuit seeks to stop the centers from waiving the co-insurance payments people are supposed to be charged when they use doctors or facilities that don’t have contracts with their insurers according to the suit.”

The court case info: Aetna Life Insurance Co. v. Bay Area Surgical Management LLC, File 02/02/2012, Case #: 112CV217943, The Superior Court of California, County of Santa Clara.

It seems providers have been put in a very precarious position.   Selesnick argued that the state’s case against his client underscores a larger problem: no one wants to pay for medical services. “Dr. Martello is definitely passionate about being a physician,” he said. “She is equally as passionate about getting paid for the work that she did.”

In Aetna’s complaint, they allege that the providers participated in a “scheme” to “induce (Aetna’s) members to use a defendant facility’s out-of-network services, the defendant waives the patient member’s coinsurance and otherwise relieves the members from obligation to pay their charges. “

Aetna’s complaint further alleges that “By illegally striking at the very financial core of (Aetna’s) managed care network, their scheme also recklessly subverts and imperils (Aetna’s)  well-structured and successfully functioning managed care network made up of subscribers, medical care providers and medical facilities, which has heretofore served as a proven process for delivering excellent, affordable healthcare to citizens of California.”

On one hand you have carriers demanding providers collect all patient out-of-pocket costs or risk getting sued.  On the other hand when providers attempt to collect patient’s out-of-pocket costs that are legally owed to them, they are sued by the state.

Ultimately, patients and providers suffer by this process which undermines all Dr-Patient relationships.  Nancy Hauser, whose teenage daughter was treated by Dr. Martello, in CA, at Huntington Hospital in 2009 after falling at a friend’s house and cutting her head, said she was still dealing with the financial fallout of the physician’s billing practices.  “You go to a doctor with an understanding that the person has your interests at heart,” Hauser said.

It is essential for all providers to understand the rules and regulations that govern these issues.  Implementing compliant policies and procedures can go a long way in prevention.



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