Insurance sends payment to the patient when lab is OON?!

[sabre5883]

Hi ya'll, I've been going cross-eyed researching this and continue to produce more questions than answers. I've called countless reps and always just end up getting nowhere.

Have you ever encountered a payer send the laboratory's payment to the patient? Specifically, I am encountering this with BCBS when the lab is out of network. What ramification does the patient face if they do not forward the payment along? How can the lab hold the patient accountable?

Many thanks!
Steph

 

[CBLENNIE]

This is a very common practice because there is no contract between the health plan and the provider, the plan then reverts to applying contract provisions between the plan and the member and most plans indicate the benefits belong to the policy holder and therefore they are issued the payment.

Some of this issue was resolved with the CAA of 2021 Section 102 "No Surprises Act" but the provisions are limited to emergency services or when a patient received care from an out-of-network provider at an in-network facility without informed consent or prior authorization (a physician's office doesn't count as a facility) then the benefits are to be processed at the in-network benefit level and payment is supposed to be issued to the provider. Rarely does this happen with an independent lab. However, if you are billing for a pathologist who provided emergency services or provided the services to the patient at an in-network facility the No Surprise Act.

The patient is not obligated to forward the check from the insurance company to an out-of-network provider, they should use the funds to pay their bill with the provider, but they are not legally required to. However, there is nothing that can be done to force the patient to pay their bill to the provider, just like you can't force anyone to pay many of their bills. You can try to collect from the patient and if they don't pay then if your state allows it, you can send the patient to a collections agency to attempt to collect on the bill.

I know this is frustrating for out-of-network providers who go unpaid because the patient does not pay their bill, but the patients are frustrated that their provider utilized and out-of-network provider for services without their knowledge and the patient was not offered the opportunity to choose an in-network provider. No one wins in this situation.

 

[sls314]

As for what ramifications the patient receives, it would likely be the same as any other unpaid bill. You would send them to collections. If is a persistent issue, you could consult with an attorney to see if there are any other options you could explore.

I am familiar with a situation from many years ago where a patient received a check for a surgery performed by a non-participating provider. They used the money to purchase a car. According to what was publicly reported at the time, the provider sued the patient for fraud, because there was an advance agreement to sign the insurance check over to the provider when it came. I do not recall if the provider won the fraud suit, only that it was filed. (I could probably try to dig up a news link, but it was long enough ago that the news archive might not be readily accessible online.)

Of course, even if legal action is available to you, you'd have to weigh the cost to pursue vs what you'd collect. Ex - you might not want to incur significant expense in legal fees and staff time to collect on a one-off $200 lab payment.

Good luck!