The insurer ignores doctors and sends massive checks to patients, resulting in a lawsuit of a million dollars


These charges are part of a successful lawsuit in federal court that accuses Anthem and its Blue Cross entities of paying patients directly to pressure health care providers to that they join their network and accept lower payments.

The insurance giant is accused of paying more than $ 1.3 million in patient payments – money, court claims, which are due to institutions that deal with drug addicts and health problems mental.

Sovereign Health's lawsuit highlights part of the ongoing war between insurance companies and providers over payment and billing issues, placing the patient at the heart of the conflict by sending payments directly to patients after their search for off-network care. Patients are expected to send money to providers. Many times, they do it. other times, they do not do it.

Critics say it's a tactic of revenge against doctors, hospitals, treatment centers and other medical providers who do not accept the demands of insurance companies to be "networked" by making them lose money. The insurance sector challenges such a characterization.

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Arthur Caplan, director of medical ethics at New York University's faculty of medicine, called lunatic money-mongers "insane" patients.

"My general moral reaction is this: do you care about me?" "It's almost like winning the lottery, it seems to me, so I'm not surprised that there is abuse – and I'm enormously surprised that anyone who thinks it's an approach feasible.

"It's only in our jumble of bureaucratic, market-driven and bureaucratic bureaucracy," Caplan added, "could we think of this type of solution?"

Lisa Kantor, one of the leading attorneys representing five Sovereign Health entities and seven treatment centers at the heart of the federal file, said she was very concerned about this issue, especially since Sovereign treated such a vulnerable population.

"One of the things we need to worry about is that this money is put in the hands of someone who has an addiction problem," said Kantor.

Instead of paying the treatment fee, Anthem sent checks directly to patients, some of whom were still in rehab. It's a strategy that puts suppliers in the delicate and delicate position of trying to raise money – in some cases, very large sums – from the same people they were trying to help, Kantor said.

"They were trying to improve," she said, "and Anthem gave them every chance of not doing it."

When a patient sees a provider outside the network, she explained, patients sign an "assignment of benefits" contract that tells their benefit plan or administrator to pay the provider for services rendered to the patient.

However, some insurance plans have "anti-assignment" clauses that allow payment to patients, not claimants.

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Anthem, the parent company of Blue Cross's health care plans, declined to comment on this article, citing the ongoing litigation.

Anthem does not dispute that checks are made to patients for various care outside the network. But the insurance giant argued that the treatment centers did not have the legal capacity to litigate in federal court under the Employee Retirement Income Security Act, known as ERISA, because patients "do not assign any of their rights to ERISA to the provider".

"For this reason alone," said Anthem in the documents, "every claim alleged by plaintiffs fails in law and should be dismissed with prejudice."

ERISA is the federal law that sets minimum standards for the most voluntarily established pension and health plans, covering approximately 141 million workers and beneficiaries.
Anthem also testified before the courts that previous decisions had determined that the "anti-assignment" provisions were lawful and that the insurer was not doing anything wrong: "Indeed, the courts of many other countries have ruled that anti-assignment clauses contained in the ERISA schemes were valid and enforceable. "

Patient: A family member received $ 240,000 from the anthem

Health care providers, health professionals and lawyers familiar with this practice of insurance have told CNN that patients who receive money from insurers can not usually be held criminally liable they never give the money back to their supplier. But patients can be held financially responsible.

Although many patients send money to providers, others might realize that they are on a fortunate adventure, pocketing money, dodging and dodging every time. a doctor or medical office makes contact with them.

Many are simply confused as to why they are receiving money.

Candyce Ayn, a Georgia resident who recently underwent surgery with an off-grid doctor, said she had received more than $ 3,500 from Anthem, but explained that the amount had been reduced from more than 240 $ 000 sent to a family member by Anthem. surgery a few years ago.

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"The big check was surprising," she wrote in an email. "It was more than what we had paid for our house!"

Checks always arrive for her recent surgery, she said; Adding to the confusion, the checks were made to her spouse, the main policy holder. She also said that Anthem had not explained or explained why the money had been sent.

"The checks arrived for partial amounts, some for amounts different from those expected and I received more checks than expected," she said.

She paid her providers, she said, and she thinks most patients are probably like her. "Maybe a small percentage thinks" Vegas, I'm coming! "But I think it's mostly a confusion on the part of the patient and not at all a malfeasance." Especially since there are a lot of controls in play and they've never been had the experience of going out of the network before. "

She is grateful to have insurance, but "placing the checks on behalf of the patient provides an opportunity for things to go wrong."

Insurance companies also prevent doctors, hospitals and other providers from knowing whether a check has been issued to a patient, refusing to disclose information, according to those familiar with the practice of insurance. A letter from Blue Cross, shared with CNN, told a provider that the insurer did not have "the power to disclose financial information" and that "we can only ask him to contact his patient".

Sometimes it forces health professionals to sue patients.

"I can categorically assert that a health care provider never wants to be able to sue any of his patients for money that should have been paid by the company's." Patient Assurance, "said David King, a Nashville lawyer who regularly represents suppliers in litigation with insurance companies." This practice of the insurance company unnecessarily involves its own member in the insurance company. conflict – and forces the provider to sue the patient for his money. "

Cathryn Donaldson, a spokeswoman for the insurance advocacy group, American Health Insurance Plans, defended the practice of sending checks to patients, saying that it is because 39; insurance have "no contractual relationship with the hospital, doctor or health care provider". She also challenged the term "pay patients", saying "pay back" is more appropriate.

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"In the case of off-grid care, I want to clarify that the term" revenge tactics "is inaccurate and does not reflect how health insurance providers handle the external costs of the network," said Mr. Donaldson.

She added that insurance companies are protecting patients because doctors, hospitals and off-line specialists "charge rates of their choice", resulting in millions of patients receiving unexpected "unexpected medical bills" who can often blow up the bank. "

Caplan, NYU, found the idea of ​​sending money to patients was ridiculous. "Are you going to give those sums of money that many people never see in a year and tell them that their job is to transfer them to the off-grid service provider?" he said. "You can not be serious."

In a country where the vast majority of people live by paychecks, Caplan said, such policies would put almost everyone in a moral and ethical stalemate because "it is subject to almost irresistible temptations."

"I guess the temptation is to take money and run," Caplan said. "I can certainly understand the temptation to not play ball … I just think it's a ridiculous burden to impose on the individual."

Barbara L. McAneny, president of the American Medical Association, criticized what she called "intimidation tactics" aimed at forcing doctors to "register in the network" – tactics that she believes have become more widespread as insurance companies grow and power.

"Doctors want to be able to negotiate equitably with major health insurers without fearing the twisted tactics that thwart patients," McAneny said in a written statement to CNN.

She said many health insurers ignore "benefit transfer" agreements between patients and doctors, deciding to send payments directly to patients.

"The reality is that insurers are refusing to recognize these agreements to create a commercial advantage over physicians who are not part of the insurer's network," said McAneny.

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Kantor said, "How can you run a business and stay there if you can not get paid?"

Kantor represents Sovereign Health, which shut down last year due to financial problems and a federal investigation, and after being accused of fraud by another insurance company – allegations that have been challenged by the Society.

The case against Anthem and its Blue Cross entities has been linked to litigation for years. Kantor recently joined the case on behalf of provider Sovereign Health, streamlined it and began focusing on payments that, she said, were paid directly to patients.

She filed a petition in late January targeting $ 1.3 million, which she said was going to patients from 2012 to 2015. She said they are waiting for a hearing on the amended complaint.

In one case, a woman from Washington State received nearly $ 375,000, Kantor said, and the treatment facility tried for more than a year to recover the $ 500,000. patient's money. She added that one Blue Cross entity sent more than 50 checks to this woman between August 2014 and May 2015 after she sought treatment for five months in 2014.

"We do not know what happened to the money in this case," said Kantor. "We just know that Sovereign, our client, did not receive it."

We do not know what happened to the woman, she said.

In another case, a New York man sent his fiancée's daughter to an off-grid center in San Diego in late 2014 for treatment, Kantor said. The man was reported to have received more than $ 130,000, including a check for $ 79,700.

"I do not know about you, but seeing a $ 80,000 check would make me think of an alarm," said Kantor Lawyer Tim Rozelle.

Lawyer: Do employees consider money as a "bonus"?

Anthem lost an "anti-summons" case in federal court last year. A Los Angeles area hospital sued the insurance company, accusing it of being "an act of retribution" for failing to accept the "unreasonably low contractual rates" of the company. # 39; insurer.

The Martin Luther King Jr. community hospital has accused the insurance giant of engaging in this practice, knowing that, in many cases, patients will not pass checks to their health care providers or will not use these funds to pay for their health care services. "

The hospital has listed three patients from the same workplace who have sought emergency care, complaining of chest pain and other ailments dozens of times. The insurance company paid these three people a total of about $ 250,000, the prosecution said.

During a deposition, Eric Chan, the hospital's lawyer, insisted to the director of human resources, who had helped administer the three workers' health plan on the plan's intent.

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"The intent of the plan is not to enrich employees, give them bonuses, in addition to receiving medical care, is not it?" Asked Chan.

"No, it's not," said the director of human resources.

But she acknowledged that she did not know that Anthem had sent money directly to the employees until the trial went off.

The Director of Group Contracts and Compliance at Anthem said under oath that the patients were "paid directly" by Anthem when they came out of the network "because the profit is theirs". On the other hand, the suppliers of the network are directly reimbursed, said the representative of Anthem in her statement.

In a ruling against Anthem, US District Judge Otis Wright described the delicate situation in which the hospital had been placed: "The plaintiff realized that these people had no intention of pay their hospital bills and took advantage of Anthem's practice of sending checks directly to patients.

"However, the plaintiff could not refuse these patients because, under federal and state law, the plaintiff was obliged to treat anyone who presented themselves in good faith in the emergency room."

The judge issued a final judgment in December, condemning Anthem and the other defendants to pay more than $ 400,000 to the hospital. Anthem appealed the decision.

Last year, the hospital agreed to network with Anthem – a sign, according to critics, that the global strategy of the insurance giant was working.

Threatened with arrest, the patient sends money to the provider

Sam Fenderson, assistant surgeon in the Atlanta area, said Anthem's tactics had very real consequences for providers like him.

He said that about $ 147,000 owed for his services over the past three years have been sent to patients, and that it is trying hard to recover the funds. "It was really frustrating because the payment was there," he said. "It was just a question from the patient who was sending me the payment."

He said that he had to take an extraordinary step by suing 17 patients to try to get the money. He said that four people declared bankruptcy, which means that he could not attempt to recover this money. Some of the other cases are still in small claims court.

Although most counties view the issue as a civil matter, Fenderson said, he discovered a county in Georgia that considers it a crime when patients keep the money. Newton County regards this crime as "flight-to-conversion" for amounts in excess of $ 1,000; prosecutors said they accused two people in the county.

Fenderson said that his patient had been threatened with arrest and that the money had been delivered fairly quickly.

Prosecuting a patient for money, he said, is a last resort and "not the way we want to operate". The tactic even creates tension among the surgical staff: some surgeons get angry if you chase patients, said Fenderson, as they still need to see patients for follow-up.

But if you do not act, he says, you work basically for free.

He said the problem seemed to be more common now than a few years ago. "It's not something that just happens to me," he said. "Hundreds of people I work with live the same thing."

Kantor said she hoped her case would upset the system.

"We will have to change what Anthem does," she said.

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