TUCSON, Ariz., March 12, 2013 (GLOBE NEWSWIRE) -- Enrollees in managed-care plans, which now dominate the health insurance marketplace, think that their plan will pay for any "covered service," and a denial is appealed as if it is a dispute over "coverage," writes Frank Lobb in the spring issue of the Journal of American Physicians and Surgeons.
In fact, he writes, such disputes should really between the provider and the plan over payment, not between the enrollee and the plan over the definition of "covered service."
The term "covered service" legally encompasses every service that the plan ever covers, if it is "necessary and appropriate," and generally excludes only things like cosmetic surgery or experimental treatment. The determination of "necessary and appropriate" is legally made by the patient's physician, not by the administrative officials of the plan.
If the patient's physician orders a service, Lobb explains, the plan's contracted providers are obligated to provide it. The catch is a secret provision in the provider contract, the Enrollee Hold Harmless Clause, by which the provider promises not to bill the patient. So, if the plan doesn't pay, the provider can't get paid. Hospitals are especially reluctant to provide uncompensated care and thus put heavy pressure on physicians they control to "agree" with the plan's determination of "necessary and appropriate."
This is one reason why managed-care plans try very hard to discourage patients from seeing "out of network" providers. Independent physicians enable patients to circumvent the ability to impose covert rationing through the benign-sounding Enrollee Hold Harmless Clause, which Lobb calls "the bedrock of the managed-care business model."
Lobb explains how managed care is not insurance. He compares it to an all-you-can-eat buffet, with the management in complete control over what is available. If enrollees understood that "a denial of 'coverage' is actually a refusal to pay for what has been promised, legally authorized, and pre-purchased," managed care would be headed for the dustbin of history, he states.
"The question of exactly what is and what is not a covered service under managed care is a deliberately false issue that the industry actively promotes," Lobb concludes. "This subterfuge, depending on a confusion of terms, protects the industry's bottom line while shielding it from the liability it will face when the scheme is exposed and managed-care companies are shown to be rationing agents rather than responsible fiduciaries."
The Journal is an official publication of the Association of American Physicians and Surgeons (AAPS), a national organization representing physicians in all specialties, which was founded in 1943.
CONTACT: Frank Lobb (267) 446-3826 Jane M. Orient, M.D. (520) 323-3110 firstname.lastname@example.orgSource:Association of American Physicians & Surgeons