Medical Billing Problem

[djmom]

My question involves collection proceedings in the State of: NC

Hi-
I have some medical billing issues dating back to 2008. Payments were not being made by my insurance company because they said the doctors were "out of network" (they weren't).

Basically after many calls to the insurance company over a period of many months it was finally revealed that the physican practice had submitted the claims incorrectly.

So then I deal with the physician practice for months trying to get them to understand they made an error and to fix the problem. I thought this was resolved in May. ( I had been told before they had fixed it also).

Now I start getting bills again and come to find out the girl did not follow up and the error was not corrected. Now the insurance company says they have no contract with my husband's old employer and they will not discuss the account with me or the practice.

I tried to get the practice to write this off as it was their mistake (that could have been fixed if they dealt with it promptly.) They have refused and I guess I will go into collections.

I want to go to court. It is just wrong for me to fold and pay money I don't owe for a problem they could have fixed if they had just been competent.

Now here is the catch. My notes are not very good so I do not have the date of all of the calls. When I thought things were not a big problem early on, I didn't even take notes.

But I am sure the practice/billing office has records of my calls (it is a huge organization.)

I would like to take them to court, but can I subpeona for this information (of my calls and all "work" on my account?) Without that I have a record of only maybe 4 or 5 calls.

Do I possibly have a case and are there any magic words to get this written off? I started out very pleasant but in the last few calls I have started crying and was angry (I wasn't rude to the person who was talking with me)

Any help would be greatly appreciated.

[Mr. Knowitall]

Sometimes having a bill go into collections can result in the proper submission of the claim - collections agencies don't care if you pay them or an insurance company pays them, as long as they get their cut.

Have you tried dealing directly with your insurance company to find out if you can submit something to them, or if you can pay the bill and obtain reimbursement from them?

Watch the dates, as the insurance company may have a deadline (e.g., 1 year) for submitting claims.

[lealea1005]

Basically after many calls to the insurance company over a period of many months it was finally revealed that the physican practice had submitted the claims incorrectly.

This statement does not make sense to me. Why did it take "many months" for the insurance company to check whether the Physician was a contracted provider? It takes them 2 seconds to determine whether a Physician is in network. What kind of claim error are they claiming was made my the Physician?

[djmom]

I have no idea why it took so long. Part of it I think is because one company (NCAS) did the administration for the insurer (PHCS). The relationship is not clear to subscribers. So I kept calling NCAS and they would say they do not have the doctors listed as in network. And I would say, but you are on the website and the doctors say they are in network. So then I would call the practice (hospital group) and tell them that they are listed as out of network.

Then they 9the practice) would say that they would "research" it. "It will take several weeks until you hear back from us." Then they wouldn't call back. Then I would call back and they would say it is being researched.

This goes on forever. I am still calling NCAS. Finally one person from NCAS calls PHCS for me and says to me, they need a tax form from the doctor to get them in the system properly. So that is my "aha" moment, I call the rep and tell them what they need to do. They have no clue what I am talking about. Finally, one day I get transferred to someone who understands and submits that and the claim. This was in May. I don't hear anything and think it is fixed.

So then I get the bills now and call the lady and say I thought this was fixed. She says I sent it in but "I got pulled to another project and I haven't followed up." So then we both call NCAS and they say, "we no longer have a contract with your husbands ex-employer and it is too late to fix it." ( This whole thing has taken almost 2 years.).

So now my big problem is that my notes on all of this STINK. I am kicking myself and wondering can I go to court because the practice let this drag out forever until it is too late. And force the practice to turn over records of the many many calls I have made. I have notes, but sometimes I didn't write which company (insurance or the practice) I was talking to.

I know it is a big mess. I will never again conduct this sort of thing by phone. I will send certified letters.

So my basic question: can I get these phone call records subpoenad?

[lealea1005]

Actually, I do believe PHCS administers for NCAS, not the other way around. Unfortunately, it is all too common for insurance websites not to be up to date with their listings of network providers. There's constant flux in the system as the smaller insurers are absorbed into the larger "umbrella" of administrators. A Doc that may have been contracted with NCAS at one time, may not have signed a contract with PHCS and isn't aware tht PHCS now administer for NCAS (mostly because we are not notified of the change before it happens and only find out when a claim is submitted and we get the EOB). It's complicated and confusing.

In any event, they needed to submit a W9 with a tax ID # to PHCS, along with the initial claim. HOWEVER... If the Physician group was not contracted by PHCS (regardless of their contract status with NCAS), it would still be processed as out of network. You owe the amount.

Have you tried asking the Physician group whether they would be willing to accept the "in network" amount for payment?

Hope this info helps.

[djmom]

They were contracted 100 percent for sure. The W-9 was not sent in until the 11th hour, over a year later and literally 5 days before my husband's employer dropped NCAS. I didn't know they had dropped NCAS because my husband was fired.

So now they (NCAS) are telling me (and the provider) that my husband's old employer should pay, because NCAS says they are not the insurer, but that they just did the administration on behalf of my husband's company.

This is going to be really fun contacting my husband's employer as they have since fired him and their very small human resource/benefits department was completely incompetent, messed up things like withoholding from paychecks all the time and would not do their job even when he was an employee.

I really don't want to ask if they (the provider) will accept the discount amount because that is like admitting that is my responsibility which it isn't. We will ask if it comes down to us having to pay it so our credit isn't ruined.

Basically, the physician group screwed around too long and now in the end we will either go into collections and ruin our credit (to take a stand) or pay it and be out almost a thousand dollars for something that was not our respsonsiblity. Like most people, this will be a big hardship for us.

Of course, our next step is to go through the employer, but I am not optimistic. It goes without saying all correspondance in the future will be via certified mail, return receipt requested.

I appreciate everyone's responses. This whole thing is really stressful and making me physically ill.