Late Medical Billing in New York

I received a medical bill now for $2800 after more than two years from the date of service (Sept 2007). I was never billed or asked to pay during this period until now. I was thinking everything was taken care of by the Insurance. Now after all this time I received a bill with a billed date of 2010 for services in 2007 for $2800. My insurance company will not cover because the claim was not submitted within 12 months from the date of service.
It would be of great help if anyone can tell where do I stand?

Have I to pay it ?, which I am not capable of.
or Should I pursue the insurance company because I had the coverage during that period of service?
or Should I tell the physician office, you billing me too late?

Please Please Help me!!!!

What was the source of the problem? If this was solely an error by the doctor's office, with your being insured for the procedure and their having correct information but failing to properly submit the claim, odds are the contract between the office and your insurer prohibits them from billing you for the portion that they were supposed to obtain from your insurer. I suggest talking to your insurance company about this.

This kind of thing is happening all to often now. I am personally dealing with some of these issues myself and am helping others who are fighting them also. The crux of the problem is that insurance companies have contracts with providers which the insured are not privy to. Providers have patients sign documents accepting responsibility for whatever insurance companies will not pay. They require insurance company pre-approval before they will perform any procedure. Then, low level clerks in the providers office make billing mistakes. The insurance companies reject the claims. A year or two later, the providers send bills to the patients for the first time. It is too late for the patients to submit the claims to the insurance company, because most require claims to be filed within 90 days.

Get out all documentation that you have to see what you legally agreed to. Demand that those sending you bills provide copies of whatever they have that proves you are responsible for the amount. Remember that an invoice is NOT proof of a debt. It is a demand for funds that are legally owed. A legally binding contract is a necessary criteria, if you demand it.

(I'll be emotional for a minute here). Fight it with vigor. A clerk's failure to properly file a claim with your insurance company two years ago, particularly after the provider required insurance company approval before conducting the procedure, does not make you liable for the bill. If they want to pursue it in small claims court, they need to prove that you owed the money. These things will all need to be dealt with if you properly raise them.

Good luck.

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Quoting lishaji

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I received a medical bill now for $2800 after more than two years from the date of service (Sept 2007). I was never billed or asked to pay during this period until now. I was thinking everything was taken care of by the Insurance. Now after all this time I received a bill with a billed date of 2010 for services in 2007 for $2800. My insurance company will not cover because the claim was not submitted within 12 months from the date of service.
It would be of great help if anyone can tell where do I stand?

Have I to pay it ?, which I am not capable of.
or Should I pursue the insurance company because I had the coverage during that period of service?
or Should I tell the physician office, you billing me too late?

Please Please Help me!!!!

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What were you told when you called that Physician's office about the problem?

If, as Scott mentions, the claim WAS submitted and rejected, there will be documentation of such via the electronic billing service's clearinghouse. If that is the case, the office needs to provide that information to the insurance company who must process the claim. You may not be able to get a copy of that rejection because there may be information for other patients who had claims submitted the same day.

Was the Physician a contracted provider on the date of service? If so, and they, indeed, did not file within their contracted timely filing period, there is an excellent chance that you are NOT responsible to pay the bill.

Regarding court....the only "proof" needed is that the services were provided in good faith and there is a signed agreement that you are responsible for any cost your insurance company deems "not a covered service" (which is different than the difference between the regular fee and the agreed contracted amount).

We had two insurances one PPO Family coverage and my wife had a HMO coverage from her part time job. On my wife's Doc Office visit ,the office confirmed the insurance was acceptable(didn't mention which one) and took the info of both the insurances, without any comments. Then, there was a follow up visit after a month, the issue of insurance never came up. Later after two years, we found out a claim was submitted by the doctors office to the HMO for the first time, obviously, because we received a the letter of rejection from the HMO for the first time. The claim was rejected because the HMO didn't cover the services rendered. Also we received the bill from the doctors office, for the first time, asking to pay. We asked the physician office why was the claim not submitted to the PPO. They responded they don't participate in the PPO plan and they are not responsible for submitting to the PPO plan claim. So we had to submit the claim to the PPO plan. The PPO plan would have covered if it wasn't submitted this late(2.5 years late).

Some body cite me 45CFR162.920-837 Claim submission. It is also specified in Medicaid manual that --Under HIPAA regulations, the acceptable reasons for a delay in claim submissions over 90 days will expand to eleven.

837 Electronic Claims over 90 days (but less than two years) from the date of service may be submitted if the delay is due to one (or more) of the following conditions:
Code Reason
1 Proof of eligibility unknown or unavailable - Eligibility status unknown on Date of Service.
2 Litigation - must be submitted within thirty days from the time submission came within the control of the Provider.
3 Authorized Delays - Delays previously approved.
4 Delay in Certifying Provider - Provider not certified by Medicaid within 90 days of Date of Service.
5 Delay in Supplying Billing Forms - Billing forms were not available within 90 days of Date of Service.
6 Delay in Supplying Custom-made Appliances ** NYS Medicaid does not accept this reason for delay and will deny a code value of “6”.
7 Third Party Processing Delay - must be submitted within thirty days from the time submission came within the control of the Provider.
8 Delay in Eligibility Determination - must be submitted within thirty days from the time of notification.
9 Original Claim Rejected or Denied – due to a reason unrelated to the billing limitations rule.
10 Administrative Delay in the Prior Approval Process- claims should be submitted within 90 days from the "Review Date" as noted on the prior approval form.
11 Other (IPRO Denial/Reversal or Interrupted Maternity Care) - Island Peer Review Organization previously denied claim but denial was reversed on appeal. Pre-natal care claims over 90 days because delivery performed by a different practitioner.

I DON'T KNOW WHAT THESE MEANS. BUT LOOKS PROMISING. I GOT A CALL FROM THE COLLECTION AGENCY YESTERDAY. LOOKING FOR HELP NOW.

why are you citing a law dealing with medicaid when you are asking about private insurers?

Have you verified with your PPO as to the doctor being "in network" or not for the time of the services? You need to do that to be sure.

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. Later after two years, we found out a claim was submitted by the doctors office to the HMO for the first time, obviously, because we received a the letter of rejection from the HMO for the first time.

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when was the claim submitted to any insurer originally? This sounds like they waited to bill even the HMO for two years but not real clear if that is the intent.

Thanks jk, I didn't have a clue whether it was medicaid. However I am surprised there is no law for private insurer. What is this HIPAA all about?

Yes, they waited two years to bill even the HMO, I don't know why. They say they have been going back and forth with the insurance company, but I never got any communication from the insurance company on that.

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=lishaji;425602] What is this HIPAA all about?

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HIPAA deals with confidentiality of medical records, who they can be disclosed to and under what circumstances.

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Yes, they waited two years to bill even the HMO, I don't know why. They say they have been going back and forth with the insurance company, but I never got any communication from the insurance company on that

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well, depending on the totality of the situation, you might have a legal defense to the debt but the only way to apply such a defense would be as a defense to being sued.

So, since it actually is your bill, the moral thing to do would be to pay it. Personally, I would suggest an attempt at negotiating the bill to a lesser amount due to their failure to bill anybody (which is the possible defense if your were sued) in an attempt to simply put this behind everybody.

If you want to argue the point and refuse to pay, that is up to you. Any possible defense is a gamble so you could ultimately lose and end up with a judgment on your credit record to boot.

Thank JK, for showing me where I stand. It is really helpful.
If there had been no screw up by the doctors office and had I received a bill in time, my PPO could have covered what HMO might have denied and the only cost to us is the little deductible for PPO-out of network participation. But now it looks, I have to bear the responsibility of somebody's mismanagement and pay much more.