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Avoid being scammed! “What You Should Know About Health Insurance Before Buying”

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For many of us, finding the right health insurance plan, can be a tedious task. When selecting a plan, you might need a psychic. COAST Surgery Center of Huntington Beach, CA explains why. We tend to pick a plan that fits our needs for today, but those needs change. So unless you have a psychic to tell you how your health, your family situation, or if your financial situation will be in the future, how will you really know what plan is best for you?

Most of us are clueless as to how insurance plans work and insurance companies don’t make it any easier to understand. There are tools to help us purchase a plan but it almost seems like we would need a PhD just to understand them. Once we have decided on an HMO or PPO, we may soon realize we have picked the wrong plan because many of us don’t really know what our policy covers until we need surgery and then we’re told it’s not covered or our co-insurance is super high. That’s when we realize our plan has too many restrictions and conditions.

“Wasn’t that the whole reason for purchasing the PPO plan and be able to see any physician we want?”

Those who work in medical billing have experienced how insurance companies use tactics that many of us don’t know about. We are deceived into buying a PPO plan without clearly understanding how they work. When we purchase a PPO plan, it’s mainly so we are able to see any doctor without having to be tied to a network or require a referral from a Primary Care Physician (PCP). After paying a higher premium for months or even years, something happens to you and you need a specialist. After carefully selecting the best specialist to treat you, the insurance calls to ask why you have selected that specialist. Here’s where the tactic begins. Although, they shouldn’t be contacting you, naturally, you respond that this doctor is experienced and has a good reputation. The insurance representative would then inform you that since you are using an out-of-network specialist, they will not cover the procedure as much as their in-network specialists and then hint that you should switch to their in-network specialist.

Most out-of-network doctors and facilities usually get paid Medicare rate, meaning very little. Therefore, patients may get hit with the responsibility of what the insurance doesn’t pay and they never tell us that. Insurance companies know our fear of having to pay more out of pocket if they don’t cover as much. So do we then switch to an in-network doctor or pay more out of pocket? We chose our physician for a good reason and we cannot risk our health to just any doctor. Wasn’t that the whole reason for purchasing the PPO plan and be able to see any physician we want?

Insurance companies should not use tactics to scare us when we are in a stressful situation. They are taking advantage of our vulnerability to coerce us into making an irrational decision. If we are out-of-network, they are not supposed to suggest that we go in-network when verifying coverage. Insurance companies will continue to make money, while patients, physicians, and facilities providers lose. Health plans are constantly changing and premiums are increasing each year, while coverage is getting reduced. So before you buy, make sure you get the right information for not only your needs today, but for when you do actually use the coverage.

If you feel that you have been scammed or mislead into purchasing a plan that isn’t right for you, you can file a complaint with the Department of Insurance at 800-927-4357 or with the Department of Managed Healthcare at 916-324-8176.

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FBI INVESTIGATORS ARE CREATING CRIMINALS

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Dr. Robert Joseph, a podiatrist in California, who was indicted by the United States District Court for the Central District of California for the illegal practice of colluding with pharmaceutical marketers for writing prescriptions of compounding drugs, is now working undercover for the FBI. In exchange for a lower sentence due to his indictment in 2018, Dr. Robert Joseph is now working undercover to deceive medical facilities and doctors by intentionally offering illegal deals.

This article is to help warn medical facilities and doctors of the devious practice that the FBI is taking to catch them in the act. It is one thing to investigate incidences due to patient complaints or whistleblowers but to intentionally embed a mole to create a problem when there is no problem, this is how the FBI works. If Adam is tempted by the apple because it was offered is that the same as if he had already bit the apple without the temptation created by Eve? In this case, the FBI is going fishing in hopes of finding something.

A medical facility in Huntington Beach, CA was a victim of Dr. Robert Joseph and the FBI. Dr. Joseph came into the facility wearing a concealed camera and had the intention of catching them by offering an illegal deal. Fortunately, this medical facility did not take the bait but wanted to share their experience with the public so that other medical offices and doctors will be aware of Dr. Robert Joseph.

As the public, we want doctors to care about us and to do what’s best for us and not be greedy. That is the oath they take when they become doctors. There are doctors who are tempted to sway but being tempted versus actually acting on greed is not the same. What the FBI is doing is turning the tempted into greedy criminals. 

Ref: https://www.justice.gov/file/1076086/download

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$150 CÓ ĐÁNG VỚI RỦI RO LÀM HẠI GƯƠNG MẶT CỦA BẠN KHÔNG?

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 Các phương pháp điều trị da bất hợp pháp đang được cung cấp trong các nơi chăm sóc da mặt và tiệm cắt tóc như được phát hiện bởi các cuộc điều tra bí mật gần đây về các nơi chăm sóc da mặt và tiệm cắt tóc ở Nam California. Đàn ông và phụ nữ đang trả 150 đô la cho mỗi lần khám cho các phương pháp điều trị bằng tế bào gốc, vi kim và collagen của các chuyên gia thẩm mỹ không được cấp phép hành nghề y tế. Tất cả những nơi chăm sóc da mặt và tiệm cắt tóc nói rằng họ có y tá và bác sĩ trong đội ngũ nhân viên nhưng các quy trình thực sự được thực hiện bởi các chuyên gia thẩm mỹ không có bằng hành nghề y này. Họ quảng cáo cung cấp tế bào gốc, collagen, vi kim để tiêm Vitamin C, PRP (Platelet-Rich Plasma) injections và phương pháp điều trị bằng laser IPL cũng như các quy trình làm đầy, botox, dùng kim để nặn mụn và mài da siêu nhỏ. Tất cả các quy trình này đều đi dưới bề mặt da và xâm lấn, vì vậy chúng cần có giấy phép hành nghề y tế và phải được y tá hoặc bác sĩ thực hiện. Hội đồng Nghề Làm tóc & Thẩm mỹ Tiểu bang không cho phép các chuyên viên thẩm mỹ và chuyên gia thẩm mỹ tham gia vào bất kỳ thủ thuật xâm lấn nào. Chúng chỉ được phép hoạt động trên bề mặt da. 

Khách hàng thường nhầm lẫn các dịch vụ thẩm mỹ xâm lấn này với các dịch vụ hoặc sản phẩm chăm sóc da mặt và biểu bì. Ví dụ, một loại kem dưỡng da có thể quảng cáo rằng nó làm mịn và đẹp da của bạn (dùng trong mỹ phẩm), tuy nhiên, nếu nó quảng cáo rằng nó sẽ chữa khỏi hoặc điều trị mụn trứng cá, thì đó có thể được coi là hành nghề y. Một chiếc máy có thể quảng cáo rằng nó hỗ trợ thẩm thấu các chất dưỡng ẩm, dưỡng ẩm để làm đẹp làn da của bạn (dùng trong mỹ phẩm), tuy nhiên, nếu nó tuyên bố sẽ giảm cellulite hoặc kiểm soát cơn đau, thì đây được coi là một phương pháp hành nghề y. Một chất lột da có thể quảng cáo rằng việc sử dụng nó sẽ loại bỏ các tế bào da chết không mong muốn và thúc đẩy làn da sáng, đầy sức sống (dùng trong mỹ phẩm), tuy nhiên, nếu chất lột da tuyên bố loại bỏ các đốm nâu hoặc sẹo, thì đó có thể được coi là hành nghề y học. Người tiêu dùng cũng nên biết ai đang thực hiện các thủ tục này. Ngay cả khi họ có treo giấy phép của y tá hoặc bác sĩ tại doanh nghiệp, hãy yêu cầu cá nhân thực hiện dịch vụ trình ra giấy phép hành nghề y của họ và đảm bảo rằng đó là giấy phép được cấp bởi Bộ y tế chứ không chỉ là Giấy phép của Hội đồng Nghề làm tóc & Thẩm mỹ của Tiểu bang. 

Với $150, khách hàng đang tự đặt mình vào rủi ro và các quy trình hoặc sản phẩm này sẽ gây ra tổn thương vĩnh viễn nếu không được thực hiện bởi những người hành nghề y được cấp phép bởi Bộ y tế. Nếu người tiêu dùng phát hiện ra rằng một hành vi bất hợp pháp đang diễn ra, hãy báo cáo các hoạt động này cho Hội đồng Nghề Làm tóc & Thẩm mỹ Tiểu bang tại www.breeze.ca.gov


IS $150 WORTH THE RISK OF DAMAGING YOUR FACE?

 Illegal skin treatments are being offered in beauty salons as discovered by recent undercover investigations of salons in Southern California. Men and women are paying $150 per visit for stem cells,  micro-needling, and collagen treatments by estheticians and cosmetologists that are not medically licensed. These salons say they have nurses and physicians on staff but the procedures are actually done by estheticians and cosmetologists. They advertise offering stem cells, collagen,  micro-needling to inject Vitamin C, PRP (Platelet-Rich Plasma) injections, and IPL laser treatments as well as fillers, botox,  extractions, and microdermabrasion procedures. All of these procedures go below the surface of the skin and are invasive, so they require a medical license and must be administered by a nurse or physician.  The State Board of Barbering & Cosmetology does not allow cosmetologists and estheticians to engage in any invasive procedures. They are only allowed to work on the surface of the skin. 

Customers often mistake these invasive cosmetic services for facials and epidermal services or products. For example, a skin cream can advertise that it smooths and beautifies your skin (cosmetic use), however, if it advertises that it will cure or treat acne, it could be considered the practice of medicine. A machine could advertise that it assists in the penetration of hydrating moisturizers for the beautification of your skin (cosmetic use), however, if it claims to reduce cellulite or manage pain, this is considered a practice of medicine. A skin peeling agent could advertise that its use will remove unwanted dead skin cells and promote vibrant, glowing skin (cosmetic use), however, if the skin peeling agent claims to remove brown spots or scarring, it could be considered the practice of medicine. Consumers should be aware of who is performing these procedures as well. Even if they have a nurse or doctor’s license posted at the business, ask the individual performing the service for their license and make sure that it is a medical license and not just a State Board of Barbering & Cosmetology License. 

For $150, customers are putting themselves at risk and these procedures or products cause permanent damage if not done correctly by some with a medical license. If a consumer discovers that an illegal practice is taking place, report these activities to the State Board of Barbering & Cosmetology at  www.breeze.ca.gov 

Ref: https://www.barbercosmo.ca.gov/forms_pubs/publications/skin_device.pdf

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Health Insurance Use Wordplay to Deceive Providers and Patients

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Huntington Beach, Calif., February 26, 2023 – Insurance verification is a critical step in the healthcare industry that ensures healthcare providers receive payment for services rendered to patients. The process involves verifying a patient’s insurance coverage and benefits with their insurance provider.

The initial step is to confirm that the patient’s insurance information is correct. Once the insurance information is confirmed, the healthcare provider checks the patient’s eligibility for the services they are seeking. This includes checking the patient’s policy coverage, deductible, co-pay, and co-insurance. If the healthcare provider is out-of-network, the provider and facility obtain authorization from the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) or RC (Reasonable and Customary) rate. Based on the UCR or RC rate provided by the insurance, the out-of-network provider, facility and patient understand how much the insurance company will reimburse if they are to proceed.

This is when insurance companies use wordplay to deceive out-of-network providers and patients. They develop terminology to define what their reimbursement rate will be by replacing standard terms like UCR and RC with “MNRP (Maximum Non-Network Reimbursement Plan)” and “California Fee Schedule Rates” or “Official Medical Fee Schedule (OMFS)” to confuse patients and providers. Most patients, let alone medical providers, will not understand what this means unless they read the fine print. This information is also not shared when providers obtain authorization over the phone from insurance companies. Their reasoning is, “don’t ask, don’t tell.”

So to be clear about what the reimbursement of an out-of-network procedure will be, out-of-network providers must ask the following questions:

1)     Will you pay according to the UCR / RC rate?

2)     What percentage will the Provider get paid?

3)     Will the plan pay according to benefits to the out-of-network provider?

4)     What is the patient’s copay and deductible?

5)     Will you be paying based on the Medicare rate?

6)     What is your reimbursement rate based on; UCR, RC, Medicare, MNRP, California Fee Schedule, or OMFS rate?

7)     What is the percentage of the “UCR, RC, Medicare, MNRP, California Fee Schedule, or OMFS” rate you are paying?

Most providers ask questions 1-4 but if providers do not ask the follow-up questions 5-7, they will realize that they were deceived. 

So what does MNRP, California Fee Schedule Rate, or OMFS mean? It means that if the provider is out-of-network, the insurance company is reimbursing them based on a percentage of Medicare rate and not the UCR or RC. 

How will that affect the patient? If a patient purchases a PPO plan so that they can go to any nationwide provider or specialist and goes to an out-of-network provider, the insurance company will only pay MNRP (Maximum Non-Network Reimbursement Plan), California Fee Schedule Rates, or Official Medical Fee Schedule (OMFS), basically Medicare Rate. Insurance companies do not disclose this to patients and don’t want to disclose it to out-of-network providers, fearing the provider will decline the service. If this is the case, the out-of-network provider will not want to perform the procedure.

On the other hand, if the out-of-network provider proceeds with the procedure based on good faith and only receives reimbursement comparable to Medicare rate, the patient has to absorb the remaining balance. Either way, the patient is screwed and was cheated by the insurance company. The patient was deceived by the insurance company when they purchased the PPO plan believing that they will be covered when they see a specialist for their treatment, but in the end, they are left with more out-of-pocket costs than they had expected.

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