In-Network Provider refuses to submit claim, self-pay, self-submit
Patient is in the state in KY, provider is in Kentucky Anthem BCBS KY (not Federal) insurance In network provider stated that that all Anthem BCBS KY members must self-pay due to the insurance not covering the procedure. Patient confirmed with insurance that it was covered, no prior authorization required and 20% copay. They relayed that to the in network provider who stated they still refuse to submit the claim. In network provider stated patient must pay in full, up front and out of pocket before they would provide the medically necessary procedure, however, that the patient will be able to self-submit. Denial Code: AKO "In network provider must submit the claim on the patients behalf. Patient can not submit claim due to the contractual agreement between the in network provider and Anthem. In-network provider misled insurance to believe patient waived the in-network providers right to submit the claim on patient's behalf. In -network provider is doing this to multiple patients and some of them are signing the form under the impression they can still self-submit since the form only states that they understand the doctor will not submit, mislead to believe they can self-submit after procedure.
I’m seeking information on the legitimacy of an in-network provider mandating a patient to pay in full, upfront, and out-of-pocket. The provider justified this by stating that the procedure wouldn’t be approved, hence they wouldn’t receive reimbursement from the insurance.
The provider informed the patient, who is insured, that they must self-pay and then self-submit if they wish to seek reimbursement. I’m interested in understanding if, according to the contractual agreement, which states “the in-network provider must submit all claims on behalf of their patient,” the provider would be breaching the contract by requiring the patient to self-pay and misleading them into believing they can self-submit. Consequently, the patient was unable to self-submit even when the insurance confirmed that the procedure was covered, no prior authorization was required, and a 20% copay was applicable.
In this scenario, the in-network provider charged the patient $5000, while the contracted rate was $3255.57. The patient should have had a copay of 20%, amounting to $651.11. As a result, the in-network provider profited over $2,000.00 by preventing the patient from using their insurance, leading to the patient being overcharged by $4,648.89.
Furthermore, after 90 days of the patient attempting to self-submit but being denied due to the contract stating only the in-network provider can submit on the patient’s behalf, the provider is claiming to the insurance that the patient signed a waiver, which they never did. This waiver would absolve the in-network provider from having to submit the claim, thereby not having to abide by the contract.
This waiver was never signed, and the person who informed the insurance of this on a three-way call with the patient, stated they have no access to these documents and therefore they have never seen it, yet misled the patient’s insurance to believe it existed. The in-network provider has yet to produce this form.
What should be the next course of action for a case like this? Is this a breach of contract? Can in-network providers select which claims they are going to submit on the patient's behalf?This is in Kentucky with Anthem BCBS (not Federal).
submitted by /u/ThanksInevitable9019
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