Clients are sometimes surprised when they see the medical provider who has a lien on their personal injury case try to also bill the client’s health insurance. Can a medical provider with a valid lien do this in Missouri? The answer is sometimes yes, and sometimes no, depending on whether the provider is “in network” with the client’s health insurance.
The Missouri medical provider lien statute can be found in RSMO 430.230. It was designed with the “dual purpose of ensuring that injured patients are promptly treated without consideration of their ability to pay and financially protecting health care providers to enable them to continue to provide care.” Kelly v. Marvin’s Midtown Chiropractic, LLC, 351 S.W.3d 833, 835 (Mo. App. W.D. 2011). Similar to contingency fee legal agreements, medical liens allow individuals access to professional services without having to pay any costs up front. The public policy behind such agreements is to “level the playing field” by making access to professional services not only for those that can afford it.
Some courts have read the lien statute as giving medical providers an unqualified right to place a lien on patient debts caused by third parties. However, even if this right considered unqualified , as with any other statutory right or other legal right, it may be modified or waived by a contract. Coffer vs. Wasson-Hunt, 281 S.W.3d 308, 312 (Mo. Banc 2009). If a contract exists that limits a medical provider’s right to treat on a lien, the medical provider may not put a lien on the personal injury claim.
The key to determining if a contract exists that so limits a medical provider’s right is if they have agreed to be “in network” or “out of network” with the client’s health insurance. If the client’s health insurance company is “in network” with the medical provider, then the medical provider is contractually obligated to accept the negotiated rate from health insurance and cannot assert a lien on the client’s personal injury case for the full balance of the bill. See Morgan v. Saint Luke’s Hosp. of Kansas City, 403 S.W.3d 115 (Mo. App. W.D. 2013).
If the client’s health insurance company is out of network with the medical provider, there is unlikely anything that would prevent the medical provider from asserting their lien. In this situation, the medical provider could theoretically assert a lien and submit the claim to the client’s health insurance.
The difficulty for the plaintiff’s lawyer and the client is that they are not party to the medical provider’s agreement with the health insurance plans. Such agreements are private contracts. A plaintiff’s lawyer and their client may only find out whether the medical provider is in or out of network after that provider attempts to bill the health insurance.
A scenario where the provider may be able to assert a lien on a medical bill that is “in network” is if the provider forgoes immediate collection of the bill that the patient owes not covered by insurance after the discount applied. This assumes that the medical provider has first billed the insurance company and obtained the discounted rate per the “in network” contractual agreement. Often there are amounts leftover that are the patient’s responsibility (i.e. co-pays and deductibles). The provider would likely be able to place a lien on these amounts provided that the lien is for the patient’s portion of the providers charge at the negotiated rate.