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  1. #1
    Join Date
    Sep 2018

    Default Medical Billing for a Procedure I Thought Was Covered by Insurance

    My question involves collection proceedings in the State of: MI

    I had a minor outpatient procedure 3/2017 (I walked in and out in an hour, performed in the office setting). The physician was in-network and apparently used a mobile anesthesia group that was not in-network. I also had a secondary insurance, which apparently the anesthesia group does not participate in. I did speak with the doctor's office prior to the procedure asking what I would owe and was told it was all covered between the 2 insurances.

    I received a bill 8/2018 from the anesthesia group stating I owed them $908 for the services. I did talk to them and they had excuse after excuse for not sending me a bill prior and requested that I speak with the insurance company to ask that they consider them in-network. I explained to them that even I knew insurances after a year generally do not accept claims or allow appeals, but they insisted that they had several clients that have done this. I did get a letter on 9/17/18 that indeed, it is way too late. So now because of negligence on all parties, they have sent the bill to collections after 1 billing cycle!

    I have contacted the doctor's office twice with no return call and I plan on tomorrow going there to speak to them in person. I am willing to pay a portion but do not believe I should be responsible for anything higher than my deductible, which I think is more than fair ($250). Is this legal, what they are doing, by waiting to notify clients and they can no longer appeal to the insurance company?

    Thank you so much for listening to me...

  2. #2
    Join Date
    Sep 2005
    Behind a Desk

    Default Re: Medical Billing for a Procedure I Thought Was Covered by Insurance

    When you want to know what your insurance covers, you have to ask your insurance company. Medical offices are not able to authorize insurance coverage, they are not able to access the full terms of your policy, and they are not able to identify or fix any errors by your insurance company that may make it appear that you are covered for something when in fact you are not. Here, it appears that you had in-network coverage, which the doctor's office was able to confirm, but then you received the service from an out-of-network provider.

    I understand the frustration of dealing with this type of nonsense, but unless and until we get serious reform of the health insurance industry we will continue to see this type of issue.

    You can try to get your insurance company to cover more of the bill; you can try to settle the claim with the medical practice that sent you the bill; you can try to convince the first doctor to try to do something to "make things right" given that they apparently suggested to you that all of the care you were to receive would be covered as in-network.... but in terms of payment, what matters is that you have a contract with the provider to pay any amount of their charge that is not covered by insurance.

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