Insurance Fraud?

[k_young221]

I live in New Jersey. My dad has an insurance policy under which I was a dependent until last year. While I was covered under his policy, I had to go to an emergency room. The hospital was out of network, so the hospital sent my dad a bill for their services. My dad filed a claim with the insurance company, who sent him the money to pay the bill. Instead of paying the bill, however, he kept the money and sat on the bill until it was referred to a collections agency. When the agency contacted him, he gave them my address and told them I should pay the bill. My dad also called the insurance company (I was no longer a dependent at this time) and told them not to give me any information about anything, so I wouldn't be able to figure out what had happened. (I was able to piece all of this together after about half a dozen phone calls.) It sounds illegal for him to keep the money the insurance company sent to reimburse him for a bill he never paid. Is it illegal? And do I have a right to insurance coverage information that pertains to my own health care, even though my dad is the subscriber of the policy and doesn't want me to have any information? And how do I get the collections agency off my back? Any help will be greatly appreciated!!

 

[I AM ALWAYS LIABLE]

My response:

First, what your Dad did was not illegal. It was HIS policy, he was paying the premiums, and a valid claim was paid. What he did with the money was HIS business. His name was on the insurance check - - not the hospital's, and not yours.

Since you're an adult (and I presume you were 18 years old or older at the time services were rendered), he has no obligation to pay your bills - - despite that fact that you were covered under HIS policy. All because your name was on the policy as a covered dependent doesn't mean that he's obligated to give you the money for which HE was paying premiums.

You're the one "on the hook" for your own medical expenses.

IAAL

 

[lkc15507]

k young:

I want to add a couple of things. I agree with IAAL that you are ultimately responsible for the payment of your health care claims to the provider. However, I want to add a couple of things. You asked about being able to obtain information from the insurer regarding the payment of your claims even though you are a dependent on the plan. IF you are 18 or older, you are entitled to the information--your claims payment information and your personal health information (PHI) that the insurer has, regardless of whether or not you are the primary policy holder. You will have to be able to supply a "reasonable" amount of personal identification before the insurer should release this info to you--regardless of your father's request. In fact, IF you are over 18, your father is entitled to claims payment info only but NOT your personal health information regarding your claims (unless you give signed consent for him to have that info).

Second, I find it very odd that an insurer would pay the policy holder for services rendered without accompanying proof that the policy holder had already paid the claim to the provider--whether or not it was "in network". (From your post, your father's plan has "out of network" benefits or they would not have paid your father.)

Talk to the insurer again, do not let up. You are entitled to claims payment info & PHI even though you are a plan dependent (if you are over 18.)

Try to enlist the help of the provider by having them resubmit the claim to the insurer. If your father was paid in error, the insurer can request a refund from him. Insurers pay providers (rather than the insured) for legitimate health care claims as a norm--for the very reason you are describing--someone "profiting" from collecting insurance on an unpaid bill. Best to you lkc15507

 

[k_young221]

Okay, I called the insurance company a few more times, but they're not buying it. They said I don't have a right to the information, and they won't speak to me unless my dad gives them permission. What law says that I'm entitled to my own health information? Maybe if I say, "Look at Law XYZ, paragraph 2..." they'll get it.

On the up side, I did convince them to send the claim to their investigations department to find out whether my dad cashed the check.

Thanks for the help!

 

[lkc15507]

k young:

OH BOY! Asking for that specific 'law' is a tall order. The regulations are contained in HIPAA (Health Insurance Portability and Accountability Act) which is an amendment of ERISA (Employee Retirement Income Security Act of 1974). We are not talking about a simple "law" stating "you have to give her the information". These laws are huge and require much interpretation. I suspect that the reason you are having trouble is that new privacy regulations under HIPAA went into effect on April 14, 2003. Many insurors and providers are really "freaked out" by those regs and are being over diligent in the protection of that information--to the point of protecting it from those who own it (ie you, in your case). In fact, the new regs provide for not much new in the way of protection of PHI (personal health information). Most reputable business entities covered in the new regs were already observing these same guidelines.

I could explain further particulars such as the definition of PHI--quite lengthy itself and open to interpretation. Anything that can identify you as an individual and related to a health record is PHI--even down to the year of your birth in some cases. If over age 79, for example, the "pool" of indentifying informatioin is too small and therefore 'privileged'. Even your zip code could be considered identifying. I give these examples so that you may research on your own until I or someone else can quote the regs that pertain most to your situation. A visit to Dept. of Labor web site (www.dol.gov) is your best bet. To slightly narrow the search, ERISA is in Title 29 of the Code of Federal Regulations.

I will find the most relevant statutes / definitions and post back. But, beware, I visit the forum fairly infrequently. If you are in a hurry, search the Department of Labor, Medicare, your State Department of Insurance etc. for regs regarding HIPAA and ERISA. (Heck, a Google search of HIPAA will astound you.) Again, be warned, BIG topics and most are open to interpretation and then actionable only on a complaint by complaint basis. Nevertheless, you are the owner of your personal health information--most providers do / should know this. Keep looking in the meantime, and I will get back (with pages & pages!) of HIPAA regulations.

Also, in the meantime, you can't make them give you the info. But, be sure to acknowledge collectors in writing--make them validate their claim of debt. Then, keep after the insurer, only way is to familiarize yourself with HIPAA law. If you read much, you will soon be more educated than they. The internet has a huge wealth of info on HIPAA. I suggest a search of "HIPAA + privacy" and even that will be a huge return.

In a nutshell, I think your insurance provider is being over diligent. One thing I left out of the above is this: claims payment history IS NOT NECESSARILY personal health information (PHI). So, for the insurer to give you info re: who was paid what when, is not privileged information as it contains no PHI (diagnoses, symptoms, etc etc etc) Even if your father is the primary policy holder and you are a dependent!. Perhaps you could remind / inform them of this small fact.

Again, I will look for relevant statutes, but from an experience point of view, when I have an 18 year old dependent on a plan, I ask for authorization only from the 18 year old. The parents need a signature from the 18 year old dependent in order to have access to his / her PHI.

And, lastly, my own personal opinion....Daddy isn't going to be in a favorable light by any interested party...if / when he is found to be profiting from an insurance payment (DOL & DOI to name a couple).
best to you, lkc15507

 

[lkc15507]

k young:

Absent the pages and pages, I am going to recommend the following:

www.hhs.gov/ocr/hipaa/
http://cfr.law.cornell.edu/cfr

The first site contains all kinds of information regarding HIPAA and privacy. The second is a good site to read the federal codes. (There are others, but I find this site the easiest to use.)

45CFR160.103 , 45CFR160.202 , and 45CFR.203 provide definitions of PHI, covered entities etc. that must comply with the codes. The goal of these regs is to assure that PHI is not unduly disclosed to an entity not entitled to that information.

45CFR164.502 describes how that information can be used. Specifically, I think most pertinent to you would be 45CFR164.502 (a) (1) (i) & (ii). This outlines to whom a covered entity CAN give the information. Don't let them convince you that the "individual" referred to here means anyone but you. You own your PHI, not your father (read the definitions--PHI is what they are trying to protect). The claims payments result from your PHI, not merely your father's payment of a premium.

Although there may be internal policies that the insurer has that would prohib them providing claims payment history and PHI to anyone other than the policy holder, I would have to believe that their ultimate goal is compliance with these regs. Your task is to understand this info and convince them they can give you the information without being in violation of the regs. Once again, it is a matter of interpretation. Also, as you read all sections of those regs, (I didn't have time to pinpoint this) look for definitions of "personal representative", which is what your father would be under these regs--with your consent (again, if you are over 18). Claims payment history IS NOT PHI and therefore is not in need of protection (read those definitions).

Lastly, I should have mentioned this before, these regulations are federal guidelines. It would be helpful to know if your plan is an ERISA or non-ERISA plan. A non-ERISA plan could be governed by state laws rather than these federal ERISA laws. However, those state laws would have to provide equal or greater protection than the federal laws. The federal laws establish MINIMUM guidelines for the protection of privacy.

If you familiarize yourself with this information, try to convince a person with authority with the insurer that they will not be in violation of HIPAA by providing you with your own information. If that does not work, I would use the link from the first page of the first web-site I listed to submit a complaint.

Happy reading and hunting. As I said, these regs are open to interpretation and poor interpretation has led many covered entities to be over-diligent.

best wishes,
lkc15507