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Should I seek legal advice over medical billing issue

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joshanelson9

Junior Member
St Louis, Missouri

First off if I am in the wrong area I apologize but I really have no idea where this would fit.

My Father has an eye disorder and has been receiving treatments for the last 4 years. About every three months he has a checkup and depending on how it goes he may or may not receive treatment. Until now we have had no billing problems with this physician. Back in January my Father went for a checkup and had another treatment, but this time was a little different because his insurance had changed from just a private plan he had through work to medicare and a private supplemental plan. His treatments before this point were covered through the private plan and an assistance program provided by the treatment's manufacturer. The assistance program provided us with a card to submit to the doctor's office. On the back of the card it states that if you are enrolled in Medicare you do not qualify for the assistance program. As my father checked in for his appointment in January he asked if this would be a problem. I was with him because we wanted to make sure that we had everything in order because of the changes in insurance. The reception desk told us they did not know, but they would get us an answer before my father received a treatment. As my Father was getting checked out he told the doctor of our concerns and he said they would let us know before he did a treatment. Shortly after being checked out, we were told that we would still be able to use the assistance program by a secretary at the office. We assumed that they had checked and made sure this was accurate and the Doctor proceeded to administer a treatment to my father. We finished up and left the office.

Now with the assistance program we usually get a bill for around 20 dollars which has always been paid. We received the bill for the January's visit about two months latter, it was the same as every other bill we had gotten over the years and my Father paid it. My Father then had another check up in April. We gave them all of our information again and proceeded to have a normal check up which was followed by another treatment. Once again we received a bill like we had always had about two months latter and it was paid. With out the assistance program the billing would be around 1000 dollars.

Yesterday we received a phone call from the doctors office that only said that we needed to discuss enrolling in another assistance program. We thought this was an odd call because no one had told us that the old program was a problem. So we returned the call. The person that handled these matters at the office was unfortunately not able to talk to us, but the person on the phone told us that they could tell us what was in their notes on the account. They then told us that my father was no longer eligible for assistance program that we had been using, but if we called back tomorrow that their were other programs we could apply for and should be able to take advantage of. They also informed us that we would be responsible for the treatment that had been received back in January. Unfortunately these treatments are not cheap and that was a huge shock to us. We were only doing these treatments because the assistance program made them accessible to my Father. If we would have known this back in January when we asked if this would be a problem, we would have discontinued the treatments until something was worked out. But we also figured that this couldn't be the whole story because the person that handled all of this stuff at the Doctor's Office was not there.

The next morning we called the Doctor's office again to discuss these matters. We reached the person that handled these issues and she told us that we needed to enroll in another program in order to cover the April treatment. We proceeded to give her the information that she needed to accomplish this. Afterwards she mentioned that we needed to do this quickly because these programs could only cover charges that were no more than 90 days old. This was rather odd because the last treatment was 120 days ago. My father asked her if she realized it had been quite a few days beyond 90 days. She didn't really respond. We then began to discuss their contention that we would have to cover the January treatment. We explained to her what happened and she said that shouldn't have happened. She said she could work with us on this and mentioned a payment plan. My Father did not know what to say, and told her exactly that. She then began to tell us more details of the bill and as the conversation went on it was both clear to her and us that if they would have told us back in January that we could have gotten this worked out with another assistance program. She also told us what the costs of the 2 treatments were. The totals were not the same despite the visits being identical and every bill from them in the past being consistent from the last. My father did not yell at her or get angry. He was very polite and directly told them that he felt that these charges were their office's fault and not his. She did not dispute this but also did not offer us any sort of resolution. Now it seems we are stuck with a bill that may not be ridiculously high but is a considerable amount to my Father. I can cover the bill so that it will not be a burden on my Father but I feel that we should contest it before paying. Should we see a lawyer, threaten legal action or do something else? I really don't know and any advice would be greatly appreciated.


Thank You for your Responses
 


LdiJ

Senior Member
St Louis, Missouri

First off if I am in the wrong area I apologize but I really have no idea where this would fit.

My Father has an eye disorder and has been receiving treatments for the last 4 years. About every three months he has a checkup and depending on how it goes he may or may not receive treatment. Until now we have had no billing problems with this physician. Back in January my Father went for a checkup and had another treatment, but this time was a little different because his insurance had changed from just a private plan he had through work to medicare and a private supplemental plan. His treatments before this point were covered through the private plan and an assistance program provided by the treatment's manufacturer. The assistance program provided us with a card to submit to the doctor's office. On the back of the card it states that if you are enrolled in Medicare you do not qualify for the assistance program. As my father checked in for his appointment in January he asked if this would be a problem. I was with him because we wanted to make sure that we had everything in order because of the changes in insurance. The reception desk told us they did not know, but they would get us an answer before my father received a treatment. As my Father was getting checked out he told the doctor of our concerns and he said they would let us know before he did a treatment. Shortly after being checked out, we were told that we would still be able to use the assistance program by a secretary at the office. We assumed that they had checked and made sure this was accurate and the Doctor proceeded to administer a treatment to my father. We finished up and left the office.

Now with the assistance program we usually get a bill for around 20 dollars which has always been paid. We received the bill for the January's visit about two months latter, it was the same as every other bill we had gotten over the years and my Father paid it. My Father then had another check up in April. We gave them all of our information again and proceeded to have a normal check up which was followed by another treatment. Once again we received a bill like we had always had about two months latter and it was paid. With out the assistance program the billing would be around 1000 dollars.

Yesterday we received a phone call from the doctors office that only said that we needed to discuss enrolling in another assistance program. We thought this was an odd call because no one had told us that the old program was a problem. So we returned the call. The person that handled these matters at the office was unfortunately not able to talk to us, but the person on the phone told us that they could tell us what was in their notes on the account. They then told us that my father was no longer eligible for assistance program that we had been using, but if we called back tomorrow that their were other programs we could apply for and should be able to take advantage of. They also informed us that we would be responsible for the treatment that had been received back in January. Unfortunately these treatments are not cheap and that was a huge shock to us. We were only doing these treatments because the assistance program made them accessible to my Father. If we would have known this back in January when we asked if this would be a problem, we would have discontinued the treatments until something was worked out. But we also figured that this couldn't be the whole story because the person that handled all of this stuff at the Doctor's Office was not there.

The next morning we called the Doctor's office again to discuss these matters. We reached the person that handled these issues and she told us that we needed to enroll in another program in order to cover the April treatment. We proceeded to give her the information that she needed to accomplish this. Afterwards she mentioned that we needed to do this quickly because these programs could only cover charges that were no more than 90 days old. This was rather odd because the last treatment was 120 days ago. My father asked her if she realized it had been quite a few days beyond 90 days. She didn't really respond. We then began to discuss their contention that we would have to cover the January treatment. We explained to her what happened and she said that shouldn't have happened. She said she could work with us on this and mentioned a payment plan. My Father did not know what to say, and told her exactly that. She then began to tell us more details of the bill and as the conversation went on it was both clear to her and us that if they would have told us back in January that we could have gotten this worked out with another assistance program. She also told us what the costs of the 2 treatments were. The totals were not the same despite the visits being identical and every bill from them in the past being consistent from the last. My father did not yell at her or get angry. He was very polite and directly told them that he felt that these charges were their office's fault and not his. She did not dispute this but also did not offer us any sort of resolution. Now it seems we are stuck with a bill that may not be ridiculously high but is a considerable amount to my Father. I can cover the bill so that it will not be a burden on my Father but I feel that we should contest it before paying. Should we see a lawyer, threaten legal action or do something else? I really don't know and any advice would be greatly appreciated.


Thank You for your Responses
The last time that I had a problem of this nature with a doctor's office, I wrote a letter directly to the doctor outlining the problem. I put "personal and confidential" on the outside of the envelope. Once I got past the office staff and got to the doctor directly on the issue, the bill was cancelled. I do not know if that will work for your father, but it could be worth a try.
 

ajkroy

Member
The problem with that, LdiJ, is that you are asking the doctor to give away services for free. Some doctors may be inclined to do that, others may not...but it isn't in the normal scope of how to handle such a situation, in my opinion.

It appears that the patient is unable to take care of his own affairs, and therefore has his son/daughter helping him. Unfortunately, the OP did not help the patient very much this time. As we always advise here at FA, the onus is on the patient to know their insurance benefits prior to any visits or treatments.

This is not the fault of the office, though you may get some traction by contacting the supplemental program and getting specifics of exactly what it covers. You should also research other plans to find out which cover this treatment, how much of the treatment is covered (100%, 80%, 50%, etc.), and how often. Then sit down with your dad and decide if those parameters are amenable to you.

As for the current bill, you can ask for them to wipe it out entirely -- but I think you'd be more likely to be successful with asking for a reduction of the bill and a payment plan.

Good luck.
 
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LdiJ

Senior Member
The problem with that, LdiJ, is that you are asking the doctor to give away services for free. Some doctors may be inclined to do that, others may not...but it isn't in the normal scope of how to handle such a situation, in my opinion.

It appears that the patient is unable to take care of his own affairs, and therefore has his son/daughter helping him. Unfortunately, the OP did not help the patient very much this time. As we always advise here at FA, the onus is on the patient to know their insurance benefits prior to any visits or treatments.

This is not the fault of the office, though you may get some traction by contacting the supplemental program and getting specifics of exactly what it covers. You should also research other plans to find out which cover this treatment, how much of the treatment is covered (100%, 80%, 50%, etc.), and how often. Then sit down with your dad and decide if those parameters are amenable to you.

As for the current bill, you can ask for them to wipe it out entirely -- but I think you'd be more likely to be successful with asking for a reduction of the bill and a payment plan.

Good luck.
I would be more likely to be inclined to agree with you if we were just talking about the January treatment, however, by April the doctor's office certainly should have known that there was a problem with the supplemental program.

I am a professional as well and I do not like to give away my services for free either. However there are times when its simply in the best interest of your practice to at least reduce the fees if there has been a mess up.
 

ajkroy

Member
January to April is not that long. Depending on how on-the-ball the office was with billing, they would have the initial determination by Medicare within the first few weeks, yes. But the timing for getting the secondary insurance processed can take much longer, and it isn't out of the realm of possibility that the office was not aware by April that the secondary wasn't covering it. It is less likely if this is a regular procedure they perform and this is an insurance they deal with regularly, but I am not getting that impression from the details from the OP.

I do agree that it would be good business practice to offer a reduction, and that is why I suggested to the OP that that might be the best place to start for negotiation. The main point I wanted to get across is that, from a negotiation standpoint, the OP and the OP's father are the ones who made the error by not knowing their own benefits. The office doesn't have to give them anything.
 

Zigner

Senior Member, Non-Attorney
On the back of the card it states that if you are enrolled in Medicare you do not qualify for the assistance program.
Frankly, that was enough warning. The OP was aware that his father no longer qualified for the assistance program.
 

Zigner

Senior Member, Non-Attorney
The last time that I had a problem of this nature with a doctor's office, I wrote a letter directly to the doctor outlining the problem. I put "personal and confidential" on the outside of the envelope. Once I got past the office staff and got to the doctor directly on the issue, the bill was cancelled. I do not know if that will work for your father, but it could be worth a try.
I don't disagree that it's worth a try. Even if he got a $20 reduction, it's worth it.
 

Proserpina

Senior Member
Frankly, that was enough warning. The OP was aware that his father no longer qualified for the assistance program.
That's why I'm questioning the whole issue - it was clear (and it always is clear with manufacturer discount plans) that there was an automatic disqualification. If anything, the Medicare/Medicaid disqualification is more or less guaranteed to be present.

Colour me confused.

(Though I agree there's nothing to lose by speaking directly to the physician/provider)
 

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