Monday, October 12, 2009

If the Patient Has Insurance, Are You Guaranteed to Get Paid?

Allow me to explain the basic difference from the provider's perspective between an HMO. and traditional insurance. If the patient has an HMO, the agreement to pay the claim is between the provider and the insurance company. Under traditional insurance, the payment agreement is between the insurance company and the patient. Put simply, with traditional insurance, the patient is still responsible to pay the provider. If the insurance company does not pay for any reason, the provider can turn the insured over to collections, or even start a lawsuit. The provider has no cause of action against the insurance company. By contrast, in an HMO, if the HMO does not pay the provider, the provider cannot sue the patient (assuming the patient is insured and authorization was received) the provider sues the HMO. . It appears that none of a health reform proposals, working their way through Congress addresses this issue. Many providers have seen patients receive reimbursement checks from insurance companies, and yet, never paid for their birth. Likewise, insurance companies are known for denying claims for any reason, and quite often simply losing the claim or the supporting documentation. For health-care reform to work, major changes need to be made in the daily battle between insurance companies and providers. It's not enough that everyone has insurance, the abusive claims practices must stop! Likewise, the explanation of benefit process must be simplified so that the average American can understand EOBs without hiring a medical claims consultant. Alan

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