This scam consists of a medical provider accepting a patient under an insurance plan, and after the first few visits informing the patient that the provider has "quit" the insurance plan as a preferred provider.(This is more common with dentists and other professionals rather than physicians.)
The idea is that at least some patients will continue with the medical provider rather than find a new provider.
Usually this "change" is accompanied by a false protest that your insurer is unfair or "cheap" in their payment of fees. The patient is asked to make meaningless protests to the insurer or demand that their employer change plans on behalf of the medical professional.
The medical professional does in fact receive the same fees as called for by the insurer's fee schedule (except for HMOs). Since the patient has been told that the medical professional is no longer "in the plan", the patient pays the difference between the insurance payment and the stated fee. This has three effects:The change in "preferred provider" status usually occurs after the first visit or series of visits.
- The patient no longer gets the benefit of the rates listed in the insurance plan.
- Similarly, the patient no longer gets the benefit of the negotiated rate schedule established by the insurance company, so that the fees are far more arbitrary.
- Since the medical provider is in reality still in the insurance company's plan, the reimbursement of fees may be at a lower negotiated schedule, with the patient making up that difference as well.
The medical professions are indeed under pressure regarding costs and fees. Regardless, the medical professions have very well-funded and effective professional associations. If they believed that the "reasonable and customary" fees were in any way inaccurate or manipulated by insurance companies, the cognizant professional association would address the issue before the state regulatory agency, via private lawsuits funded by the association, and through very effective lobbying efforts.There is no way that an insurer will get away with cheating medical professionals. Life doesn't work that way.
Ironically, those most likely to be told the provider is "off the plan" are the patients who are most likely to timely pay their bills.
(Okay, I know this is obvious; however most people think the change in "preferred provider" status is coincidence and are inclined not to change their status as a patient.)Determine the specific recommended procedures. Request "pre-authorization" of procedures in order to obtain more details if necessary. If you schedule an appointment at all, make sure you cancel well before the appointment, and write down the time and who answered the call.
With the additional time, search out a suitable "in-plan" provider. If you're concerned about a repeat performance, express your concern that the provider not "go out of plan" after the first series of visits.
Meanwhile, examine the insurer's report of claim. (These mailings are often marked, "This is not a bill.") The report will usually include an indication of whether the claim is within the plan or with an out-of-plan provider.
Request pre-authorizations whenever it appears that any procedure may not be covered. You may still elect the procedure, but at least you'll get the opinion of your insurer on the matter.
Explain that you like the provider, but are only leaving because you were unable to change your plan. (If appropriate, explain that the insurer is still under the "false" belief that the professional is still in the plan, and therefore you will end up making up the difference between "reasonable and customary" rates and the plan's contract rates.)
There are a variety of tactics which blame the insurer. In general these can be identified by a request that the patient take up the problem with the insurer. As a practical matter, this is simply a way to convince the patient to accept the "switch".Occasionally the patient is informed that the information somehow "missed" being provided to the patient, because either the patient was new (letter to patients already went out earlier), or that the office didn't think being within an insurance plan was significant to the patient.
Some procedures are either not covered or a lesser procedure is covered. For these items, it helps to obtain pre-authorizations whenever possible. In many cases, you'll elect to have the procedure performed at your own expense, but at least then you'll know when the procedure isn't going to be covered going in. You may get better results if you appeal each denial of coverage.Such "out of plan" procedures are generally spelled out in the insurer's benefit booklet or policy. Insurers generally avoid "surprises" when it's much easier to spell out the limitations of the policy in advance.
The straightforward answer -- If you don't wish to use the policy's fee schedule, don't hold out as being a preferred provider. If you wish to use "first visit" discounts to build business, then offer "first visit" discounts.
This site first posted August 23, 2006; rev June 9, 2010 ~~ written in
WordPerfect 5.1 and works best with 