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CatchTheWind

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We have a situation in which the insurance paid the patient instead of us (even though we filed the claim as assigned), and the patient will not turn over the money.

My understanding had always been that if an insurance company pays an assigned claim to the patient, they have not met their obligation, and still have to cut another check to you and then deal with the patient themselves. However, this is a self-funded plan administered by an out-of-state BCBS plan (Horizon), and they insist that they do not, and will not, send a check directly to any out-of-state provider.

What are our options? Can we report the patient for insurance fraud to the attorney general of our state?... His state?... Report Horizon BCBS to the insurance commissioner of their state?
 
You can send patient to collections that's about it. Insurance companies pay the patient because they know they can get away with it. Usually there will be an anti assignment clause in the patients benefits contract.
 
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Insurance paid direct to patient

If carrier did pay correctly direct to the patient and you turn them over to Collection without success you can file a form with IRS and patient has to claim that $ as income and pay taxes on it. Follow your states collection laws..
 
Sad but true!

We used to have the same problem with BCBS. The self funded plans follow their own rules. Chances are you are not contracted with the plan (Horizon) even though you are contracted with BCBS.They do pay the patient and it is the patients responsibility to pay you.The patient owes the money no matter what they think. Are they thinking the insurance company is giving them a bonus for having their gallbladder out or whatever they had done? If they don't pay, you definitely can turn them over to collection and you should.Offer them a payment plan if you have to but they should pay. Hopefully they signed the authorization for the procedure which usually states they are responsible if their insurance doesn't pay.We had patients spend the insurance money and tell us they could't afford to pay us but we always offered payment plans to help them.

PS on this matter... you do not want to contract with the self funded plan unless they offer you the payments you want, they usually try to cheap out on payments.I would keep an eye out for patients with these types of plans and make arrangements ahead of time and tell them they may receive the payment from the insurance company but it is their responsibility to pay you.

Good Luck!
Davie
 
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