Who pays for care when errors are made?


Increasingly, health plans are beginning to follow Medicare's lead and refuse payment for at least some care related to medical errors. The most recent to take this step is WellPoint, the nation's largest health plan as calculated by number of beneficiaries. The Blues are well on their way to taking a similar position.

All of this raises questions that I don't think have sufficiently been addressed. Who will pay for the care delivered to address these errors? Before you suggest that it's obvious that providers will, let me propose a few alternative scenarios:

  • The insurer refuses to pay, but the hospital disputes that the error was its fault. They bill the patient.
  • The patient sues over the error, collects, and then finds that the insurance company collects whatever they'd spent on it (which can happen due to provisions in some health plan contracts).
  • The hospital stands behind the high-admitting doctor who made the mistake, and allows him to balance-bill the patient for additional care. If the doctor is an ED doctor, particularly, he may not be on the hospital's managed care contract, which may make the balance-billing arrangement perfectly kosher.

Sure, I know that many state hospital associations already have vowed not to bill for care related to never events, but the associations vary in what they're accepting financial responsibility for. Meanwhile, insurers are developing their own lists of unacceptable errors, which may not overlap in each case.

All I'm saying is, that I see the makings of a mess here, and one that isn't really being discussed enough. Folks, things could get pretty nasty fast once enough insurers get tough with non-payment policies. It wouldn't hurt to take a hard look today at how you'll handle disputes that fall between the cracks. - Anne

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