TUCSON, Ariz., Sept. 4, 2012 /PRNewswire-USNewswire/ -- Healthcare plans promise to provide all "necessary and appropriate" care to their subscribers. But the contracts they have with providers contain a clause that could prevent a person from obtaining care that could save her life.
Farmer and hardware store owner Frank Lobb spent 10 years in court trying to understand why four hospitals refused to provide treatment recommended by his wife's physician—even though he offered to pay for it. Denied treatment, Sandra Lobb died.
Alcohol rehabilitation was a "covered service" in the healthcare plan. However, a plan functionary determined that "given Sandy's age and her condition, the cost of the care being prescribed couldn't be justified."
The cost would have been $7,000. Mr. Lobb, though not a wealthy man, would have gladly paid it to save Sandy's life. But no one could accept his money.
Had the care been a luxury item, such as cosmetic surgery, or an experimental treatment, or some other noncovered service, there would have been no problem. But a clause that is in every provider contract in Pennsylvania (and probably every other state), by state law, forbids the provider to bill a subscriber anything beyond the copayment or deductible for a covered service—no matter what.
This is called the Enrollee Hold Harmless Clause. It is claimed to protect subscribers from balance billing. But its real purpose is to protect the plan from insolvency. The plan simply has no liability for anything, if it decides not to pay.
Insurance companies are only supposed to make decisions about payment. They can't practice medicine and make decisions about treatment. The Enrollee Hold Harmless Clause, however, gives the plan a tool to make sure that providers virtually always agree with its decisions on what is necessary and appropriate.
Lobb explains how this "Trojan Horse" works in the fall issue of the Journal of American Physicians and Surgeons. www.jpands.org/vol17no3/lobb.pdf His book, The Great Health Care Fraud, is reviewed in the same issue. www.jpands.org/vol17no3/bookreviews.pdf.
Insurers try hard to conceal this clause, as it is "the beating heart of the managed-care business model," Lobb writes. It enables the managed-care/ hospital cartel to maintain complete control over the huge stream of healthcare revenue. If a service is "covered," the plan can make sure that no subscriber is able to obtain it from a contracted provider, even if he is willing to pay, without the plan's permission.
Employers who provide health benefits, and physicians who sign contracts, have a fiduciary and ethical duty to divulge this clause and its implications, Lobb writes.
The Journal is an official publication of the Association of American Physicians and Surgeons (AAPS), a national organization representing physicians in all specialties, (www.aapsonline.org) which was founded in 1943 to defend the sanctity of the patient-physician relationship.
SOURCE Association of American Physicians and Surgeons (AAPS)