Medical providers withholding claims until settlement

[Guest cc1898]

I'm wondering if anyone has encountered similar situations with medical providers.

A plan participant was injured by a third party over a year ago. Most of the medical providers submitted claims on behalf of the participant. The plan has a provision which states that it has a subrogation interest in any payments it makes for injuries from the above third party accident.

The participant's personal injury attorney has settled with the third party and is in the process of settling the subrogation claim and the medical liens. The settlement (the full amount of the third party's insurance) is rather small compared to the claims.

Here's the kicker- one of the medical providers has never submitted its bill to the plan. It has a policy of waiting until the personal injury attorney files a motion/petition to adjudicate the medical liens. Rumor has it that the medical providers do this in an effort to obtain the full amount of their claims and not the discounted ppo amount. If the settlement does not provide for the full payment, THEN they will submit their bill to the plan. Unfortunately, under the terms of the plan, this bill will be late and the plan will deny the claims pursuant to the terms of the plan.

The attorney has filed a motion to adjudicate this provider's bill for well above the settled amount and the plan's subrogation interest. It seems unfair and unethical that the participant and the plan should have to incur additional legal fees, etc. because the provider has a policy of waiting to submit bills.

[Ron Snyder]

You say

Unfortunately, under the terms of the plan, this bill will be late and the plan will deny the claims pursuant to the terms of the plan.

The "unfortunate" part of this is not that the provider decided to shoot craps with his claim rather than be treated like other providers. He is gambling that the plan and participant would pay his higher charges (plus a reasonable attorney's fee) rather than incur legal fees. The appropriate way to deal with this behavior is by winning in court. The court will not be impressed by this provider's use of the legal system to jack up his collections. But to have rights, those rights have to be defended. Short of a full blown legal battle, the Plan's alternatives may include use of an interpleader statute, arbitration or negotiate a settlement.