Is there a private cause of action for violating Texas Insurance Code § 1271.155 and 28 Texas Administrative Code § 3.3725, both of which require payment of the “usual and customary rate” for emergency care provided by an out-of-network provider? If not, is there another vehicle to pursue the violation of those statutes? 2. Is there a claim directly under the patient’s ACA plan as the patient’s assignee? 3. Is a claim for quantum meruit viable where the provider alleges that the insurer failed to pay a usual and customary rate for the services provided? 4. What are the potential complication surrounding a claim under the prompt pay statutes? DISCUSSION 1. Is there a private cause of action for violating Texas Insurance Code § 1271.155 and 28 Texas Administrative Code § 3.3725? If not, is there another vehicle to pursue the violation of those statutes? Potentially yes. No court decision has ruled that there is not a private cause of action available for violation of Texas Insurance Code § 1271.155 and 28 Texas Administrative Code § 3.3725. …show more content…
See Emergency Health Centre at Willowbrook, LLC v. United Healthcare of Texas, Inc., 892 F. Supp. 2d 847, 849 (S.D. Tex. 2012) (alleging a violation of Section 1271.155 through various sections of Chapter 541 of the Texas Insurance Code); St. Michael’s Emergency Ctr. LLC v. Aetna Health Mgmt., LLC, No. H-08-2336, 2011 WL 12896736, at *2 (S.D. Tex. Aug. 22, 2011) (reciting that provider asserted claims for violations of the Insurance Code). Neither insurer in those two cases appears to have sought dismissal or summary judgment on the basis that Section 1271.155 does not confer a private cause of action. We have not found any case deciding whether Section 1271.155 (or any other section of Chapter 1271) creates a private cause of
Allstate insurance is the second largest property and casualty insurance company by premiums in the United States. Allstate insurance handles about 12% of the U.S home and auto insurance market. (Allstate, 2014). Many of Allstate’s customers fall under what one could refer to as a traditional selection of insurance for automobiles. Recently, Allstate has noticed a major shortcoming in lifestyle insurance, which includes coverage for motorcycles, boats, and other recreational vehicles, in comparison to its competitors. The motorcycle insurance sector is a 10.4 billion dollar industry and growing (PRWEB, 2012). The U.S. Department of Transportation website reports some astounding figures, including that 5,370,035 motorcycles were registered three years before the article, 7,138,476 motorcycles registered at the time of the article, and grew to 9,477,243 registered motorcycles at the end of 2012 (NHTSA, 2013). It is obvious as to why Allstate would identify motorcycle insurance as a worthy lifestyle product to devote marketing research dollars into in order to develop new strategies for cornering a share of the market.
Showalter, J. S. (2012). The Law of Healthcare Administration (6th ed.). Chicago, IL: Health Administration Press.
In the case of United States ex rel. Geraldine Petrowskivs. vs Epic System Corporation, Geraldine Petrowski worked as a the Supervisor of Physician’s Coding at WakeMed Health from 2008 until 2015. She was then trained to be a charge capture analyst for Epic’s billing charge capture system. After that she went on to work as a hospital liasion for the implemention of Epic at WakeMed Health. In 2015 Petrowski alleged that a glitch in Epic’s billing system had caused hundreds of millions of dollars in overbilling. Soon after, Petrowski filed a lawsuit with Florida’s U.S district. In the complaint Petrowski wrote “ Epic’s billing software defaults to charging for both the applicable base units for anesthesia provided on a procedure, as well as
Expanded and strengthened state private insurance companies are to be expected since more younger Texans enter the market thanks to the premium support. Texas can expect savings through more proper use of medical care, lower numbers in Medicaid, and savings from increased recipient cost sharing. Texas must refuse to comply with the new high-risk pools. There are many reasons Texas should not comply but the main reason is poor design. Currently, eighteen states have decided not to participate in these pools, Texas is undecided. Any person with a pre-existing medical disorder whom has been without insurance for six month will qualify. The law gave the Department of Health discretion in determining with conditions qualifies. Theoretically, the Department of Health could say the flu is a pre existing medical condition. If Texas does not refuse to comply with these pools it is only a matter of time before the demand will exceed the supply. A huge concern is when the funding is gone what do the state politicians do. I see two options. One, state officials will end the coverage all together and pull the plug. Two, continue to allow the program to run with the use of state tax dollars.
Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”
I have been a patient of the OBGYN side of Lone Star Circle of Care for years but just recently my primary care doctor stopped taking my insurance. So I made a new patient appointment with the Ben White location in Austin, Texas with Dr. Rivera for the 17th of February. I checked in on the 17th and sat down to wait. Thirty minutes went by and I asked the front desk if they knew how far behind Dr. Rivera was. The front desk did not seem interested in this question but did ask a person that came from the back how far behind Dr. Rivera would be. I didn’t get an answer but the front desk at that time did write in on the “Doctor running late” board that she was running thirty minutes behind. I sat down and waited, after another 12 minutes I asked for an
Rodwin, M. (1996). Consumer protection and managed care: issues, reform proposals, and trade-offs. Houston Law Review, 32(1319), 1319-1381
The private insurers are patients with other insurances. Under Medicare and Medicaid, services that are provided by the hospitals are paid by a prospective reimbursement. Prospective reimbursement is established before the services are provided. They have a defined dollar amount per day and per diagnosis. They also use a fee scheduled by CPT code or procedure code which is usually used for physicians. Since these types of insured patients only are billed a certain amount, most procedures are not fully reimbursed. Retrospective reimbursement is determined after the services have been delivered. This is one of the reasons organizations are struggling. Along with less reimbursement, the CPT codes or procedure codes have to be correct according to the procedure ordered. “If an organization wants to get paid, its better off taking the time to make sure all its codes are accurate, timely , and meet all payers’ requirements ”(Kapsambelis, 2004, p. 3).
Patients seek medical attention from the nursing homes. There nursing homes get a large amount of financial aid on behalf of the government. The financial assistance is given in order to ensure that all the necessary health care facilities are available at the nursing homes. There are few fraud cases that have seemed to occur in the nursing homes. One of the fraud cases that is becoming very common in nursing homes is that the patients are charged wrong amounts for the services that they acquire from the nursing home. The patient generally comes with some disease to seek medical attention. The nursing home raises fraud cases by advising unnecessary tests and procedures to be done on the patients. These tests or procedures may not be required for the patient. As the patient is limited in knowledge, the tests and procedures are done on the patient while charging the patient with a heavy amount of bill. (LLP, 2016) The nursing homes does not cater the specific problems that ha been raised by the patient rather they start to encounter on more details that are unnecessary and not even needed by the patient. The case is about a nursing home in Washington that charges heavy amounts to the patient for unnecessary treatments and procedures. (PEAR,
How did this happen? The doctor charged more than what the insurance company deemed usual, common, and reasonable for your area and you are responsible for the extra
The plaintiff’s attorney must show that there was a breach of duty causing a lack of medical care that another healthcare professional would have used.
In what is known as the largest malpractice case in Maryland is the case of Enso Martinez and Rebecca Fielding against John Hopkins Hospital. In this situation, Ms. Fielding was taken to the hospital for an emergency caesarean section. Grant...
Texas statutes created it a criminal offense to acquire or try associate abortion except once medically suggested for the aim of saving the lifetime of the mother. Appellant Jane Roe sought-after a declarative judgment that the statutes were unconstitutional on their face associated an injunction to forestall litigant city County public prosecutor from implementing the statutes. Appellant purported that she was single and pregnant, which she was unable to receive a legal abortion by a commissioned medico as a result of her life wasn't vulnerable by the continuation of her physiological condition which she was unable to afford to visit another jurisdiction to get a legal abortion. Appellant sued on behalf of herself and every one different girls equally settled, claiming that the statutes were unconstitutionally imprecise and cut her right of private privacy, protected by the primary, Fourth, Fifth, Ninth, and Fourteenth
...fe insurance, where the patient should decide how much of the money should be left for the beneficiaries. Since price variance is high fee for service would be the most ideal reimbursement model.
The Health and Human Services (HHS) settled a case with Blue Cross Blue Shield of Tennessee (BCBST) for $1.5 million for violating the Health Insurance Portability and Accountability Act (HIPAA) and security rules. There are security issues with BCBST in regard to confidentiality, integrity, availability, and privacy. There are also security requirement by HIPAA which could have prevent the security issue if it has been enforced. There are correction actions taken by BCBST which were efficient and some may have not been adequate. There are HIPAA security requirements and safeguards organization need to implement to mitigate the security risk in terms of administrative, technical, and physical safeguards.