Doctors and health care service providers have yet another reason to be concerned. As if plaintiff’s negligence lawyers, medical malpractice lawsuits and Medicare/Medicaid audits and lawsuits do not pose enough threats to one’s practice and personal assets, now medical insurers are filing lawsuits on the basis that waiving or not collecting copayments from patients constitutes fraud.
For example, Horizon Blue Cross Blue Shield of New Jersey recently sent a letter to non-participating physicians (see below), which condemns practitioners “routinely waiving applicable patient liability amounts (i.e., deductible, copayment and coinsurance amounts, and the difference between the submitted charges and our plan payment).” Horizon Blue Cross Blue Shield further states that it has filed lawsuits, alleging that waiving such member liabilities is fraud. Further, “the Office of Inspector General has already identified the waiver of copayments and deductibles as a potential violation of the Medicare and Medicaid Anti-Kickback Law.”
Thus, in addition to routine and minor billing errors constituting “fraud”, now a medical service provider who neglects to collect a copayment of $20 can expect a State and Federal lawsuit.
Doctors have always been “deep pocket” targets. Now, doctors can expect additional threats to their business and personal assets.
Doctors are well advised to protect their business and personal assets from all external threats, whether from patients, patients’ lawyers, insurers or the government. For additional information on asset protection for doctors, please click here.
The text of the Horizon Blue Cross Blue Shield letter follows:
August 21, 2009
Dear Non-participating Physician:
I am about writing an important issue concerning Horizon Blue Cross Blue Shield of New Jersey and its effort to support affordable health care for the people of New Jersey.
We’ve become aware that certain non-participating providers are routinely waiving applicable patient liability amounts (i.e., deductible, copayment and coinsurance amounts, and the difference between the submitted charges and our plan payment) for eligible services rendered to our members.
This type of action is unacceptable to Horizon BCBSNJ. Member out-of-pocket expenses are an important element of our plan designs. They keep our members mindful of the true nature of health care costs and encourage them to use network providers, which helps us to keep premium costs down.
When non-participating providers waive applicable patient liability, it creates a superficial perception that our members – health care consumers – are saving money. The result is actually the opposite. Waiving of applicable patient liability serves to drive up health care expenses for all which contributes to rising health insurance premiums and in turn, to increased numbers of uninsured families and individuals on our communities.
Horizon BCBSNJ, in an effort to protect our members, had filed suit against various non-participating providers alleging that the routine waiving of applicable member liability is fraud. By waiving member deductibles, copayments and coinsurance amounts, non-participating providers are overstating and misrepresenting the actual charges for the services they provided. In the context of Medicare and Medicaid fee-for-service, the Office of Inspector General has already identified the waiver of copayments and deductibles as a potential violation of the Medicare and Medicaid Anti-Kickback Law.
We are proud of the products and services we provide to our members, including the various plans we offer that include out-of-network benefits. We recognize the importance of providing this choice to our members. But we also know that a member’s decision to use a non-participating provider should be made with the knowledge that he or she will, and should, incur a higher out-of-pocket expense.
Health care affordability and access to quality health care are among President Obama’s top priorities, which we wholeheartedly support. We believe we have an obligation to keep health care affordable for our members. Thank you for your attention to this important matter.