From an opinion columnist in California comes news of lawsuits filed by two major Health Insurance Companies, Aetna and United Healthcare. The major Defendant appears to be Bay Area Surgical Management, which is owned by physicians. Aetna and UHC charge BASM with manipulating the payment schedule for Insureds who are treated by "out-of-network providers" which is a feature of most Health Insurance Coverages and Plans. Allegedly, even when doctors are "in network," the clinics they own and to which they refer Insureds-patients, are suddenly "out-of-network providers". Aetna and UHC further allege that the physican-owned-clinics like BASM greatly reduce the Insured-patient share of their bill, even as they pursue the Health Insurance Companies for the full amount of the "usual and customary" fee charged by out-of-network providers, rather than the agreed lower fee charged by in-network providers:
The idea [behind Health Insurance Plans] is to encourage patients to use network providers who accept negotiated fees, which saves everyone money. The Aetna and United lawsuits say the BASM clinics winked at the patient obligations by waiving the coinsurance charge and promising not to bill patients for any balance not covered by their insurers. They then allegedly filed sky-high claims with the insurers, hoping to be reimbursed for the whole sum.
The opinion columnist insightfully reports a glaringly obvious fact that emerges from Aetna's and UHC's allegations. It is otherwise perhaps hidden in plain view in their lawsuits . "The whole point of our private commercial health insurance system is that the industry supposedly has the expertise to identify and eliminate unnecessary healthcare and excessive billing." This rationale has been used to justify ever-increasing Premiums charged by Health Insurance Companies, and to justify the generous CEO compensation they pay. "Yet they say they got snookered .... The insurers don't have a good explanation" for failing to catch this alleged fraud and for why they paid "what they now say were manifestly inflated claims. There's no good explanation for dereliction on this scale." Id.
Dennis Wall is Co-Chair of the Health, Life and Disability Insurance Subcommittee of the American Bar Association's Insurance Coverage Litigation Committe. He will be a co-presenter of a webinar, "The U.S. Supreme Court Decision on Constitutionality of the Affordable Care Act," for West Legal Education Center. The webinar will be broadcast live beginning at Noon E.T. from the West Legal Ed Center web site on Friday, July 20, 2012, and will thereafter be available 24/7, registration for any of which is available through West Legal Ed Center for a charge.
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