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Reimbursement: From Private & Public Payors
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Assignment of Benefits

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Document: 7500
Chapter: Reimbursement: From Private & Public Payors
Pages:
9

  • Insurance/Reimbursement
  • Legal Issues
    Payor Issues
  • Legal Issues
    Payor Issues
    Reimbursement

The following is an introduction to the document. To download the full text of the document, please log in.

An “assignment of benefits” enables a physician who has provided services to an insured or managed care patient but has no contractual agreement with the payor to legally obligate the payor to pay the physician directly. An assignment is a legal transfer to the physician of any rights and benefits (as specified in the assignment agreement) the patient has under his or her contract with an insurer, health maintenance organization (HMO), or preferred provider organization (PPO). In such cases, the physician becomes the holder of the patients’ rights and benefits and may assert such rights and benefits against the patients’ plan or insurer, HMO, or PPO. Without an assignment of benefits agreement, the patient is required to pay the physician and then seek reimbursement from the payor. However, inmany cases, patients prefer that the physician secure payment from the payor, making the patient’s involvement in payment unnecessary. Physicians sometimes prefer this approach as well, as it eliminates the potential that the patient will fail to forward the insurance company’s check to the physician. Generally speaking, in order for the physician to receive payment from a payor with which the physician does not contract, an assignment of benefits form is needed. With such a form, the patient transfers his or her contractual right to receive payment from a payor to the physician. Indeed, one court has ruled that an unpaid provider of health care services could maintain an unfair competition law (UCL) lawsuit against the health plan that did not timely recognize and pay an assigned claim pursuant to Business & Professions Code §17200 as the provider alleged an “obligation to pay based on the assignment of the [p]atient’s rights…”. See Coast Plaza Doctors Hospital v. UHP Healthcare (2002) 105 Cal.App.4th 693, 704.

Keywords:

  • CMA On-Call
  • Health Plans
  • Managed Care
  • Payment
  • Reimbursement

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