I’m hoping you might shed some light on the recent practice of health services requiring full payment for a procedure and then the patient expected to be reimbursed by the insurer. Case in point: our son has a scheduled knee surgery and we’re having to pay the anaesthesiologist in full before the surgery is to proceed; we are then expected to seek reimbursement from our insurance provider. The argument is the health professional has previously had trouble with payment from insurance companies. Besides in principle being against the very essence with the purpose of having health insurance, is this even legal?
Auntie’s answer: Actually, it is not legal. Under the law it is the responsibility of the health practitioner or health care facility to submit claims to the insurance company for payment of a patient’s treatment, after any deductibles, coinsurance or other charges that exceed the standard fees allowed.
An official with the Health Insurance Commission explained that the Health Insurance Regulations (2017 Revision) 15(4) specifically say that when someone shows an insurance identification card to a provider and it is established that a contract of health insurance exists, “any claim under the contract in respect of the covered medical benefit shall be deemed to be assigned to the health care facility or the registered medical practitioner”.
In simpler terms, that means the provider must submit a claim to the insurance company for reimbursement and the patient should not be paying the full amount up front. But if an insured person provides a receipt or other evidence of payment of the benefit, then the insurance company needs to pay him or her whatever it is liable for under the contract.
In addition, Section 21 of the Health Insurance Law (2018 Revision), “Approved insurer shall pay benefit directly to health provider”, covers the same points.
But more importantly for you, the official added, “The commission would invite you to file a formal complaint with the department so that this matter can be investigated.”
The telephone number for the HIC is 946-2084 or you can email HIC@gov.ky. Please let me know if the HIC is able to help you.
The laws mentioned above can be found on the CNS Library
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