When you go to a MedExpress and give them your insurance card, you also have a co-pay, right?
So you pay your $10 or $25 co-pay for the visit with your credit or debit card.
What you probably don't know is that you are also signing a pre-authorization agreement that allows them to bill the full cost of the visit from that card if the insurance company turns down the claim.
Without any further notice to you ...
Now we aren't talking after the insurance company turns down the claim and you appeal it and then they turn it down again.
No, as soon as MedExpress receives the first turn-down they charge your card.
If you want the money back, then you have to collect it from the insurance company yourself.
This is particularly convenient when the largest insurer in the State of Delaware, Highmark, is a part owner of MedExpress.
Here's why this is such a great little money-maker for Highmark-MedExpress:
Highmark has an official policy of rejecting all claims automatically that lack the slightest piece of information or have the most insignificant error:
[Highmark] Blue Shield no longer attempts to correct or retrieve the missing information in the situations listed in the charts on Pages 3-5. Instead, these situations will result in a rejected claim. You will need to resubmit the claim with corrected data.Ostensibly this is telling the provider (the clinic) that you have to get it right or you will have to re-submit.
But when the provider is MedExpress (partly owned by Highmark) the process works a bit differently.
If the claims that MedExpress submits are rejected, and then MedExpress collects the full balance from you, MedExpress has been paid in full and Highmark is now off the hook for the cost of the claim unless you file and win an appeal. Industry sources tell me that fewer than 30% of of rejected claims are ever appealed; and only about 30% of the appeals win.
Moreover, by the time you have received the Explanation of Benefits form rejecting your claim (which you need to appeal), MedExpress will likely already have billed your card, as the timelines on electronic claim submission are so fast:
Remember, electronic claims process within seven to 14 days, while paper claims may take 21 to 27 days to process.Think I'm kidding? My daughter ended up in a situation where we had to visit MedExpress in mid-May. The Explanation of Benefits form arrived two days after MedExpress attempted to charge the entire cost of the visit to our card.*
In other words, we would have had no grace period to appeal without paying the full cost to MedExpress.
I know that some labs are moving toward this system, but the incestuous nature of the Highmark-MedExpress relationship should point out the obvious: there is now no reason for MedExpress billing departments to worry about getting your claims right the first time (they'll still get the money) or even to re-submit corrected claims (they've already got the money) or even to support your appeal (you are appealing to the company that owns them).
And, oh, by the way, if you have doubted my earlier posts suggesting that Highmark is pursuing a monopoly on Delaware health care, take note: thanks to concessions like those that Senator Patti Blevins and Insurance Commissioner Karin Weldin Stewart rammed through when Highmark came to Delaware back in 2011, Highmark now has a 73% market share of health insurance in western Pennsylvania.
Single-[non]payer health insurance is on its way to Delaware right now; the irony is that the entity controlling it will be Highmark.
Prediction: if nothing changes, Highmark will move to drive either Bayhealth or Christiana Care out of business within 2-3 years.
*Ironically, by accident, I discovered one way around the MedExpress/Highmark billing shuffle. Right after you visit MedExpress, call up your bank and report your card lost. That will either cost you $5 or two days inconvenience, or both, but MedExpress won't be able to run the bill against your card and will have to either bill you in the traditional manner or get the claim straight. Yes, it has come to things like that.