Should I Use My Health Insurance To Pay My Medical Bills when I was injured in an accident?

This is a great question and one where the answer can depend on various factors, some of which change frequently

First and foremost, most medical providers that treat patients injured in auto collisions (or other injury causing incidents caused by the negligence of another) are experienced in documenting their records with terminology that auto and homeowner insurance carriers look for, such as:

Diagnostic codes for the assessed injuries;
CPT Codes for the treatment modalities administered to the injured patient;
Mechanism of injury (how did the particular incident “cause” the resulting injuries);
Causation/allocation/apportionment (to what degrees are the “symptoms” caused by the subject incident, as opposed to the degree that pre-existing conditions have been “aggravated” by the particular incident, etc.;
Discussing recommended current and/or future restrictions because of the injuries;
Discussing if the patient will “more probably than not” require any additional care in the future.

Medical providers whose practices prioritize in treating “personal injury” cases, usually provide their treatment on a “lien” basis,” which means they do not collect any payment at the time of service but instead agree to wait until the patient’s “injury” claim settles. Your attorney likely works with several such providers and can usually offer quite a few to consider, based on location, schedule, etc. Many providers may also consider reducing the amount of their total bill (come settlement) dependent on the circumstances surrounding your case, including liability insurance limits of the at-fault party/parties, disputed liability, etc.

On the other hand, providers one might see through their health insurance usually require a co-pay payment at the time of service, plus the amount of the patient’s annual “deductible” under their health plan. While they might very well treat the symptoms complained of, they don’t necessarily document the mechanism of injuries, allocation/apportionment, or restrictions (etc.) because none of these factors necessarily impact the provider’s treatment of said symptoms.

If one treats through their health insurance, their primary care physician might need pre-authorization (approval) to be referred to another provider or specialty, such as diagnostic testing, physical therapy, orthopedic surgeon, pain management, etc. Also, some health plans limit the number of “sessions” you can have with a specific provider type within a calendar year (like the number of times you can see a chiropractor or physical therapist).

Some, but not all, injury providers may agree to bill your health plan and “lien” the portion of their bills that your health plan does not pay. Some health plans allow medical providers to “balance bill” against an injury claim settlement (not against you personally) the portion of their charges disallowed by the health plan.

Of course, your decision to treat through your health plan may also be dependent on the type of health plan you have:

1) Governmental Health Plans such as Medicare, Medicaid, and AHCCCS

These pay the provider a fraction of a provider’s billed charges. The provider must accept such payments in full and cannot balance bill an injury settlement. The injured patient owes nothing to the provider unless their particular plan allows for co-pays and deductibles. The health plan is entitled to reimbursement from any injury settlement, but the plan will often be reduced by your “cost of recovery” (your percentage of attorney fees). It can be hard to get treatment for accident injuries through such health plans, but if you can, the potential financial windfall to you can be huge since they pay a fraction of billed charges and will reduce, while the providers cannot balance bills.

2) Self-Funded ERISA Health Plans

These plans are offered through employers. Instead of buying health insurance with your premiums, they pool the premium monies collected and retain a third-party administrator to pay employees’ medical claims from that pool of money. These providers are also entitled to reimbursement and are often not obligated to reduce what they are owed (whether they must, or even may reduce, is dependent on the specific plan language). Since providers may also balance bills, it may be better to treat on a lien.

3) Private Health Plans

These plans may be offered through your employer, but individual health plans you may procure yourself are also private health plans. Such plans are NOT entitled to be reimbursed from any injury settlement, so treating through such a plan could increase your net in-pocket recovery upon settlement.

In reality, every case is fact-specific and different, so we encourage you to consult with an attorney to discuss your options and rights after any accidental injury.

Our Lebovitz Law Group attorneys have several years of experience in handling car crash cases and a long list of successful cases in their portfolios. With us, you don’t have to pay us unless we win the case. So, call us today for a FREE consultation.

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