Certain health plans that were in effect prior to March 23, 2010 may be "grandfathered health plans" under the Patient Protection and Affordable Care Act. If your plan is grandfathered, then your plan will include some consumer protections from the Affordable Care Act, but may not include other protections that apply to non-grandfathered health plans. If your plan is a grandfathered health plan, notice indicating that fact will be contained in your Certificate Booklet or your group's summary plan description.
The FBI recommends consumers protect themselves from health care fraud by:
- Safeguarding insurance cards and benefit information. Make sure there is a legitimate reason to provide your insurance card or insurance information to others to protect yourself from identity theft. Be especially vigilant if your information is requested when services are offered free, or any offers are made during telemarketing calls.
- When receiving medical supplies, confirm what was sent was actually what you ordered — for example, instead of a power wheelchair, you receive a much cheaper scooter.
- Be aware of your surroundings in medical facilities. For example, when completing a physician visit, be wary of a medical office that lacks normal medical equipment, or if personnel fail to conduct common patient health checks, like taking your temperature and blood pressure.
When it comes to health scams, be your own health care advocate. If it sounds too good to be true it probably is. For example, the FDA (Food & Drug Administration) warns consumers to be leery of a one-drug-that-does-it-all for serious diseases such as Alzheimer’s, arthritis, cancer, diabetes and heart disease.
Part of being your own health care advocate involves reviewing your itemized benefit statement often referred to as Explanation of Benefits (EOB). You may receive this information in the postal mail or email depending on the preferences you’ve set on your account.
Reviewing your EOB can help you watch out for some of the Association of Certified Fraud Examiners common health care fraud schemes:
- Billing for services not rendered.
- Confirm your recent doctor’s visit to make sure you received all the services listed.
- Incorrect reporting of diagnoses or procedures (includes unbundling).
- Unlike billing for services not rendered, you, as a patient did get service, but the diagnoses and/or procedure aren’t represented correctly on your bill. For example, delivery fees are typically included in equipment cost, therefore, if you have a separate delivery charge you should check with your insurance carrier about the charge.
- Billing for a non-covered service as a covered service.
- Most insurance plans don’t pay for elective services, for example cosmetic surgery or injections to remove wrinkles. Coding a surgery or injection that is elective to get the insurance company to pay for it may be considered fraudulent behavior in a court of law.
- Misrepresenting dates of service or the location.
- A doctor might receive more money if they separate services you receive and show they occurred on different days and/or in a different location, for example a surgical center versus their office.
- Misrepresenting provider of service.
- A doctor, nurse, physician’s assistant—these are all types of health care providers. Your EOB should indicate who you saw when you visited the doctor’s office.
- Waiving of deductibles and/or co-payments.
- Most health plans, including Medicare and Medicaid, do not allow doctors and hospitals to waive a co-pay or deductibles.
- Overutilization of services.
- Having more tests or exams than needed; again, being your own health care advocate is important so if you don’t understand why your doctor is ordering a test or exam, ask.
As a member, you have rights and responsibilities when receiving health care. As your health care partner, we want to make sure your rights are respected while providing your health benefits. That means giving you access to our network of health care providers and the information you need to make the best decisions for your health. As a member, you should also take an active role in your care.
You have the right to:
- Speak freely and privately with your health care providers about all health care options and treatment needed for your condition, no matter what the cost or whether it is covered under your plan.
- Work with your doctors to make choices about your health care.
- Be treated with respect and dignity.
- Expect us to keep your personal health information private by following our privacy policies, and state and Federal laws.
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Get the information you need to help make sure you get the most from your health plan, and share your feedback. This includes information on:
- our company and services.
- our network of health care providers.
- your rights and responsibilities.
- the rules of your health plan.
- the way your health plan works.
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Make a complaint or file an appeal about:
- your health plan and any care you receive.
- any covered service or benefit decision that your health plan makes.
- Say no to care, for any condition, sickness or disease, without it having an effect on any care you may get in the future. This includes asking your doctor to tell you how that may affect your health now and in the future.
- Get the most up-to-date information from a health care provider about the cause of your illness, your treatment and what may result from it. You can ask for help if you do not understand this information.
You have the responsibility to:
- Read all information about your health benefits and ask for help if you have questions.
- Follow all health plan rules and policies.
- Choose an In-network primary care physician, also called a PCP, if your health plan requires it.
- Treat all doctors, health care providers and staff with respect.
- Keep all scheduled appointments. Call your health care provider’s office if you may be late or need to cancel.
- Understand your health problems as well as you can and work with your health care providers to make a treatment plan that you all agree on.
- Inform your health care providers if you don’t understand any type of care you’re getting or what they want you to do as part of your care plan.
- Follow the health care plan that you have agreed on with your health care providers.
- Give us, your doctors and other health care providers the information needed to help you get the best possible care and all the benefits you are eligible for under your health plan. This may include information about other health insurance benefits you have along with your coverage with us.
- Inform Member Services if you have any changes to your name, address or family members covered under your plan.
If you would like more information, have comments, log in to contact us or call the Member Services number on your ID card.
We want to provide high quality benefits and customer service to our members. Benefits and coverage for services given under the plan are overseen by your Certificate of Coverage, Member Handbook or Schedule of Benefits and not by this Member Rights and Responsibilities statement.
Reviewed 2/2018
