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The new trick from Highmark and MedExpress ...

I can't yet verify that MedExpress is the only urgent care clinic in Delaware with this neat new practice, but I'm pretty sure that the partly owned functional subsidiary of Highmark introduced it.

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.


Nancy Willing said…

I had family reunion - people in from UK, TX, VA, NY etc. - all week so didn't get a chance to email KWS. This post will give it all the more urgency.
What a scam.
tom said…
Here are a few other options for dealing with disreputable merchants who employ this sort of dishonest billing practices:

1. Always pay them with cash. You will still technically be "liable" for any additional fees they feel like billing to you, but they can't just take more money out of your pocket. all they can do is mail you a bill. and you deal with that by writing your insurance info on it and sending it back. They will probably report you as a suspected terrorist, but if you're reading this blog, you don't need to worry--you're already on all of the terrorist watch lists ;-)

2. use a prepaid "credit" card: this is like a gift card, but refillable. they often have fees, but if you shop around or wait for promotions to buy them it is not difficult to find free ones, so you may as well get one for any vendor you don't quite trust with a real credit card. load the card with the exact amount you are willing to pay, and just like cash, that is all they can collect from you. they can always decline the card, but a quick call to Visa (or whoever) usually rectifies that, especially if there are other customers in the waiting area to hear you say "I have Visa on the phone and they say they will authorize a charge of $25, so stop trying to overbill me and it will go through..."
delacrat said…
"Single-[non]payer health insurance is on its way to Delaware right now; the irony is that the entity controlling it will be Highmark."

How would Highmark be controlling single-payer ?

If Highmark becomes a monopoly then Highmark IS the single payer.
Unknown said…
I took my child to MedExpress for xrays. I remembered signing this form with a previous xray visit for a different child. It was only $60. So the amount was manageable. I thought this would be about the same price. I forgot to factor in the deductible that I hadn't met for this child. So the bill was $230. My MedExpress 'card on file agreement' says they will not auto-bill for anything over $150. I also noticed there was a statement saying that I could cancel this agreement at anytime. So I called and did so. They were set to bill me for the $150 in 2 days, but instead they will be mailing me an invoice for the whole amount. We also set up a payment plan. I think her name was Rae... she was very nice and helpful. (I was considering canceling my debit card, but I'm glad I made the phone call.)
Anonymous said…
I just visited a Med Express in the south hills of Pittsburgh, PA just to get a prescription. I knew I had a sinus infection and it had lasted more than 3 weeks so there was a good chance that it was bacterial. I asked what it would cost me now that I have a high deductible plan through Highmark, but they could not tell me since it goes through insurance. I spent three minutes with doctor. Blood pressure, temperature, a couple questions, a look up my nose and a prescription for Amoxicillin. That 5 minute visit with the doc cost me $207.50 after the insurance discount to tell me what I knew I needed before I walked in the door. I think it would have been cheaper to just call my PCP. It should not cost hundreds of dollars just to get a prescription. It also appears that Med Expresses 210 walk in the door fees is 68% higher than the national average. Nice! Thanks Med Express... I feel much better now.
Unknown said…
Informative article, thanks for sharing this great information. Claim Submission
manasimartin said…
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