# criminal charges on pay to patient non payment. Is it possible?



## Cavalier40 (May 26, 2016)

I work in a substance abuse rehab. We have clients who can stay in treatment as long as 6 months depending on some issues. Since we are out of network with out local blue, FEPs will always pay to the patient (among other policies under ERISA who do not have to follow the state assignment law) Our main concern is FEPs who actually pay to the policy holder. If they take the money (which can be in the tens of thousands of dollars) and run, are they committing a crime? Are we able to approach a District Attorney? Or is the only thing we can do is bill the treatment and report to a credit agency? I can see not making a big deal when dropping a balance to patient responsibility because of insurance non payment, however in this case the insurance did pay, they just did not pay the provider. 

This effects some of our patients because if their parent is the policy holder, the check is cut to them. They can spend all of the money while their child is in treatment which actually puts the financial responsibility on the patient since they are the ones receiving the services. The policy holder is also not the one signing the legal documentation that the patient signs while in treatment such as the financial responsibility agreement. 

In our past we have had people buy cars, new teeth and worst of all take the money to buy drugs and relapse. While a federal assignment law is a pipe dream, there has to be a way to protect providers from those who steal this money other than not admitting them into our center. 

Any insight on this would help.


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## JAMETH345 (May 28, 2016)

I spend the majority of my time working Anthem accounts like these, because we're out of network.   We do pain management, out patient, and the best we can do is note the account, "Anthem has sent the patient $x,xxx.xx, if he/she doesn't bring the payments, no service".  I maintain a large spreadsheet, trying to keep track of this. Cumulatively, over many patients, and several years, the amount outstanding is very significant.   If all of those patients brought all of that money tomorrow, it would probably cover our payroll (doctors, nurses, PAs, billers, etc.) for several months.  So I understand the frustration.  If you have any tactics/tricks for getting payments, please share.



John Methgen, BS, CPC-A, CPB


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## suki_26 (Jun 2, 2016)

This is a big problem all around. It would be sooo nice if the Insurance companies would just send us the checks directly but I understand they want us to join their network. GHI is finally realizing that it is taking up their time to answerer our calls and then reissue checks etc. and they are finally sending the checks directly to us.

I don't have a magic tip but this is what we do...........

For patients we see in the hospital who may not be our regular patients (We are Internists and PCPs) , at the time of billing we send out a letter directly to the patient letting them know we have billed their insurance, we are out of network, and if there is a payment it will be coming directly to them. We state it is their responsibility to remit the check to us in a timely manner.

Once time has gone by we do the usual... send statements with a note on the bottom saying a payment for $xx.xxx was sent directly to you by your insurance company, please remit.

After still more time we then call the Ins comp to see if the check was even cashed.... BCBS will tell you everything you need to know.... United Healthcare tells you nothing, (they should just say on their recording "if you are an out of network provider please hang up now because we don't offer customer service for you")

If the check hasn't been cashed, we call the patient explain the situation and advise them to call the ins comp and get it reissued.  

If the check HAS been cashed we call ...explain as politely as possible that they should have received a check, please look and send to us.
...if they get nasty and say they never received the check we are mistaken, then we politely let them know the check # amount and importantly the Date THEY cashed the check. explaining the ins comp has records of this and that is where the information came from.

If after all of this and still nothing...... they go to collections.

There is no easy way with these and unfortunately we have some patients that purposely make appointments around the holidays and use these checks as their own personal loans. 

We have found the letters sent at the time of billing has really helped a lot!!


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## nidhim (Jun 22, 2016)

Which state are you in since there are handful of states where Blue Cross cannot send the money to the patient if the patient has signed assignment of benefits. I believe currently the states that have to honor AB is AL, NJ, TX, NV, IL, TN, WY, CO,GA,CT (NY too but not 100% sure).

Hope this helps.

Thanks
Nidhi


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## CodingKing (Jun 22, 2016)

I am not a lawyer but I know you cannot arrest someone for failure to pay a debt. Its a civil matter not a criminal one.\

You should look into charging patients up front or a sizable deposit.


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## karlene.dittrich (Jun 23, 2016)

Check your state for theft of services laws which as a provider of services you can utilize.  For small balances you can utilize small court (check your state for amount limits), and for Theft of Services over $500 it is a felony.   Another great option to consider is to learn and optimize on federal laws and provider rights that protect you and your entitled revenue.  As an appeal specialist with over 30 years experience in healthcare management and insurance reimbursement, I have a vast amount of knowledge of payer compliance requirements and use it to hold payers accountable.  Using that knowledge, I have as both an employee and consultant for healthcare recovered thousands of dollars, others felt were uncollectible.  Healthcare providers should understand that payers continuously disregard their specific compliance requirements (denial specific state and federal laws) building their empire, at the expense of providers acting and providing medical and surgical services in good faith.  They use unsupported intimidation as a weapon.  In order to remain viable, it is imperative that healthcare providers  learn and utilize claim related federal laws and rights that hold BS and other payers accountable for such inappropriate acts.  It might surprise healthcare providers in all areas to know that most denials and all commercial and managed medicare recoupments made by payers are contrary to applicable rights and laws that protect providers. 

As it pertains to this matter, if you have a valid assignment of benefits you have the right and ability to appeal and file suit against the payer.  As a claims recovery, ERISA appeal specialist and consultant for healthcare providers nationwide, I cannot stress enough the importance and need for healthcare providers to learn and understand laws applicable to payer compliance and claims handling.  Utilize your provider rights to get the revenue you are entitled to and prevent the detrimental impact payers continue to non-compliantly rely on to retain what belongs to you.  If you would like to know more about provider rights, outsouce options or would like special training in this important area give me a call (770) 378-7178.  You can also check out medrevenuesolutions.com for more information regarding provider rights.  If providers don't start fighting for their rights and entitled revenue they will slowly lose both.   Karlene Dittrich, CBCS, CPC, CPMA


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## JAMETH345 (Jun 23, 2016)

When I contact BCBS about payments made to patients, they almost never tell us if the checks are cashed, who cashed them, what dates they were cashed, or the check numbers. usually they only tell us how much was paid, and the process date. and sometimes they won't even tell us the amount of the payments.  And they usually won't send us or fax us EOBs either.  sometimes availity will have the check number, but it's not typical.  Also, I'm in Nevada, and roughly 2/3 to 3/4 of the time they're sending the payments to the patients, not to us. 

Are there any free online sources for information about Theft of Services, because I think we should be going after these people.

Thank you.


John Methgen, BS, CPC-A, CPB


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## ljones88 (Jun 23, 2016)

As a provider of services, shouldn't the group have a say in who they see if they are non-par with that insurance company? Or at least have a system in place to collect from the patient before services are rendered?

I'm not sure how it works with Rehabs but as ENTs if we are non-par the patient has to pay before services are rendered. We advise that we will submit the claim on their behalf, but if the claim is denied or processed out of network, we are not legally obligated to accept the adjustment. For example, we are non par with Aetna Medicare lines of business, but we will see the patient as long as they sign a financial responsibility form and payment is received up front. 99.999999% of those claims are processed out of network and applied to the patient's OON deductible. The claims usually indicate a "contractual" adjustment (although we are not under contract with that LOB) and to bill the patient for a lesser amount than what our charge amount is. Since we are non-par and the patient has signed the financial responsibility form, we don't take the adjustment. 

For patients with insurance plans that pay the patient directly if we are non-par (in our case it's only been GHI) we usually have those as a secondary payer. In those cases, we gather as much info as we can that states that the payment was issued to the patient, note the account, and bill the patient. If no payment is received, they go to collections. If they come to the office for follow up its up to the physician if they will render services to the patient without payment for old balances. Most of our physicians will refuse service but there are those few cases where patients truly need workup by our specialist (cochlear mappings, head and neck cancers, craniofacial surgeries, etc) and the physician isn't going to put money before care.


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