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  1. #1
    Join Date
    Oct 2011
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    3

    Default Being Billed Full Amount for Untimely Insurance Claim

    My question involves collection proceedings in the State of: NY

    In September of last year I visited a doctor's office. I assumed they billed my insurance and was awaiting a bill for whatever amount remained. I received one 6 months later for the full price of the visit, without insurance deductions or anything mentioning insurance on the invoice. I sent it back to them with my insurance information. I received two more bills for the same amount and no mention of insurance, so I called the doctor's office. They said they would file a claim but said that if the insurance rejected it because it was not submitted in a timely manner, then I would be responsible for the full amount. They told me that they didn't receive insurance information from me, but I know that I had my insurance with me when I went there. I have received a few more bills with no insurance information on them, so I contacted my insurance company. They say that the claim was submitted in April of this year (after the 90 day "timely" deadline, and around the time that I sent in my insurance info in the mail) and so they sent something to the doctor's office asking for proof of timely submission. Are they responsible for filing a timely claim? Will I end up being responsible for the full amount? Do they have legitimate cause to send this to a collections agency?

    Thanks

  2. #2
    Join Date
    Jan 2006
    Posts
    38,867

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    depending on whether you have a PPO type insurance or not will make a difference. If a PPO and this doctor is a preferred provider, the contract between the insurance company and the provider would rule. If you are sure they had your insurance information, most PPO insurances would simply tell the provider they are out of luck and are not allowed to seek payment from the patient.

    If this was not a PPO, you were liable for the bill regardless whether the insurance company was billed or not. You didn't pay it when you were made aware of the bill so yes, turning it over to a collection agency is a legitimate action.

  3. #3
    Join Date
    Jun 2006
    Location
    Massachusetts
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    24,521

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    Not just PPO's; any kind of managed care should be looked at.

    But it's not the plan design that rules; it's whether or not the specific policy makes the doctor responsible for submitting claims. IF it does, then it's likely the doctor is out of luck (assuming that they definitely had your insurance information). IF it does not (and I am using emphasis deliberately) then you are going to have to pay the bill.

    I assumed they billed my insurance and was awaiting a bill for whatever amount remained.

    Regardless of plan design, always a bad idea. EVEN IF the doctor is responsible for submitting the claim, if you do not receive a bill or an explanation of benefits within a reasonable time after the visit, ASK. If the hold up is due to missing information that you can supply and you do not take any action, that can turn the tables and make you responsible after all.

  4. #4
    Join Date
    Oct 2011
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    3

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    Thanks for the information, guys.

    cbg, I have another question: Assuming the policy says the doctor is responsible for submitting claims, would I need to provide proof that they had my insurance information? I am sure they did, but I can't think of any way I would be able to prove it.

  5. #5
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    That's really going to be up to your insurance carrier. Once you read the policy and determine whether or not submitting claims is the doctor's responsibility (and for the moment assuming that it is) you'll want to call your insurance carrier and speak to a department that will be called Provider Relations or something on that order. They will be able to tell you what kind of proof they require, if any, and they will be the ones to talk to the doctor for you.

    In fact, if you don't have a copy of the policy, it might be faster just to call them and ask what kind of responsibility for submissions the doctor has. You are entitled by law to a copy of the SPD (assuming that this is an employer sponsored plan) but it can take time to get one, and a phone call to the carrier might settle the matter faster.

  6. #6
    Join Date
    Jan 2006
    Posts
    38,867

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    Quote Quoting paste
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    Thanks for the information, guys.

    cbg, I have another question: Assuming the policy says the doctor is responsible for submitting claims, would I need to provide proof that they had my insurance information? I am sure they did, but I can't think of any way I would be able to prove it.
    was this the first time you had ever visited that doctor? If not and you have proof they billed your insurance previously, they are going to have a hard time explaining how they lost your information.

  7. #7
    Join Date
    Oct 2011
    Posts
    3

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    Yes, this was the first time.

  8. #8
    Join Date
    Mar 2008
    Posts
    1,995

    Default Re: Being Billed Full Amount for Untimely Insurance Claim

    You might want to take a look at this link, and you might want to order their "letter of appeal".

    http://www.healthsymphony.com/bluenote2.htm

    I'm in NY, and I had some familiarity with this issue, not with untimely filing, but with a provider placing me for collections. In NY, the process is governed by both NYS insurance laws, and Health Department laws. Under my plan, an HMO plan where service was provided "in network", it was illegal for the provider to place the claim for collections.

    I also had some familiarity with claims filing on the doctors side. My brother in law had a solo medical practice at one point in San Francisco, hired a billing clerk just to handle filing insurance claims and verify patients insurance. Apparently, the clerk was inexperienced and incompetant, or both, many claims were coded wrong, not filed, not filed on time, and when he tried saying "if the insurance doesn't pay, you'll have to pay" approach, many patients theatened to sue. At the time, people I spoke to said it's something like a lawyer failing to file paperwork on time, his client is damaged, and you can sue under his "E&O" (errors and ommissions) insurance.

    He wound up eating many of the claims, he fired the clerk, and his wife took over the administrative duties for two years. Finally he got into a group with several doctors, later on, was affiliated with a hospital where they handled the insurance and the claims. Seeing what happened to him, I can't see how he can go after patients if his own office screwed up.

    I can tell you in the last several years, I was under various medical plans, seen various doctors, and they all have a questionaire for new patients to fill out. And before I'm able to sit down with the doctor, they get a photocopy of my insurance card, and call the "800 number" on it to confirm I have coverage. One doctor couldn't take me for the first visit on a Saturday, because apparently they couldn't confirm if I have coverage on Saturdays. I can't possibly see how a doctor can tell you they don't have any idea about your medical insurance, if procedures are followed.

    And if this case ever goes the "legal route", you can ascertain what the procedures are for "new patients".

    BTW, in the billing dispute I had with a hospital bill where I was placed for collections, they also told me that I signed an agreement which says that "if the insurance didn't pay, I have to pay". But I pointed out to them that state law outlawed it, so if there was an agreement signed, if it violated state law, it's null and void anyway. So they shut up about what I signed.

    Just to mention that in the above case, I filed a complaint with the NY State insurance department who followed up the insurance company. Though it's not an untimely filing issue as what happened to you, I also learned in the above case that if a provider filed everything correctly, and not received payment the correct procedure is to file a complaint with the state, the provider is entiltled to collect from an insurance pool that the state had insurance companies to contribute into, and governed under the state's "prompt pay law" for health insurers. The wrong way is to hassle the patient with "if the insurance company doesn't pay, the patient has to pay".

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