When you go for medical treatment, the staff always asks for a copy of your health insurance information and then they bill your health insurance. If you are injured, the insurance process is very different. The medical facility not only wants to know who your health insurer is, they want to know about any other insurers: worker’s compensation, the insurer for the person who hit you, your automobile insurance. Why do the facilities ask for this information? The medical facility wants to figure out if any other types of insurance may be applicable. For example, worker’s compensation, automobile insurance (yours or the person who injured you). They want to know all possible insurers to see who will pay the most on their bill. If you have ever looked at your explanation of benefits from your health insurer after a visit with your doctor, you will see that what you were billed and what was paid by your health insurer are often two different amounts. Health insurers and medical providers have negotiated amounts that they will pay and accept for various treatments/procedures. When an insured is injured and other insurers are involved, medical providers use that as an opportunity to try to get out of the negotiated reimbursement rate they agreed upon with the health insurer. The medical provider will attempt to bill insurers with whom they may not have agreements. The lengths to which these medical providers go in order to extract the largest payment continues to expand. For example, our office had a recent case in which a senior citizen who was riding in a car that was struck by a drunk driver was hospitalized for several weeks. Her bill from Summa was over $100,000. The lady was on Medicare and had a supplemental insurance policy with Medical Mutual. All of the doctors and various outsider medical providers involved in her care billed Medicare and Medical Mutual and were paid.
Summa, however, elected not to bill Medicare and instead tracked down the responsible auto insurance company and sent their bill to an entity called American Medical Recovery and had them claim a lien on the proceeds from the insurance company of the person responsible for the collision. The responsible insurance company had a $100,000 policy limit. The responsible insurance company ultimately offered to settle their case for $100,000 (their policy limits). As there was no other insurance coverage available, the $100,000 limits were accepted. Then the responsible insurance company said, “Should we just send the check for $100,000 to American Medical Recovery since they claimed a lien in excess of $100,000?” Obviously, that would leave our client with nothing and would reward Summa for their creativity in refusing to accept the health insurance coverage that our client had at the time.
Let’s examine the legal issues here. Ohio has a statute that states healthcare providers must bill health insurers. You would think that statute would resolve the issue. By law Summa must bill the healthcare insurer, however, the Ohio Supreme Court in their own infinite wisdom has ruled otherwise. Thumbing their collective noses at the statute, the court recently held that a healthcare provider may bill whomever they like but can also collect from whomever they like. According to the Ohio Supreme Court, Summa’s action is perfectly legitimate. If our firm had adopted this position, our client would have received nothing. Summa would be paid $100,000, and our client the victim of a drunk driver who left her with some permanent injuries would get nothing. Well, that won’t happen on our watch. The thought of that prospect offends the common sense of justice. Decisions like this roll out of the Ohio Supreme Court on a regular basis and the average Ohio citizen has no idea of the implications of the rulings made by this court. Supreme Court decisions are set in the abstract and are frequently not easily grasped by voters.
Citizens receive a very rude awakening when they are confronted by an incident in which they find themselves injured and subsequently incur a large amount of medical bills. Ultimately, we must blame ourselves, the Ohio electorate for electing politicians and this includes most judges or justices. Many of these politicians gained their positions with the financial backing of big business, the insurance industry and/or a special interest group. We as the electorate choose our judicial candidates by listening to sound bites on television created as advertising campaigns that are bought and paid for by a who’s who in the insurance industry.
Citizens who don’t vote, have no right to complain. Citizens who do vote need to look carefully at those seeking election. Who is financing their campaign? What is the agenda of those financing the campaign? What is the agenda of the candidate? It is our obligation as voters to pay attention to who we elect and what they do.
As Justice Warriors for our clients we are always looking for laws (tools) to use in our quest to seek justice for our clients. Help us help you. Vote for those who truly care about people.