Claim Deadline has Passed

What is the name of your state?What is the name of your state? CA

Recently I was informed by my doctor (who I have needed to visit on a monthly basis for the last 4 years) that a severe billing error has kept him from issuing bills to me for the last 3 years. At home, I never discovered the error because, I'm currently still living with my parents and I simply assumed my parents were helping me to pay the bill. Meanwhile my parents conversely assumed I was paying these medical bills.

The sum of charges is over $18,000 for my doctor's services during that time period. He is an out-of-network provider, but he was highly recommended to me by an in-network provider when I was desperate for medical assistance.

When I first started seeing this doctor, my insurance was covering nearly 60% of the total charges, leaving me to pay the remaining amount, which was still a hefty sum, but doable. As soon as my doctor informed me of the billing error made by his secretary, I quickly attempted to claim benefits for these medical visits. I knew the deadline for filing a claim was 1 year, but I felt I had a legitimate right to request claims for this particular matter. If the bills from my doctor had come in a timely manner I would have easily been able to submit them to my health insurance for payment.

I spoke with a representative for my health insurance company who explained that the procedure to file for claims dating back further than 1 year required an appeal. Although the representative was very sympathetic, she said it was simply out of her hands and she encouraged me to appeal and wished me luck. Thus, I filed an appeal carefully detailing why nothing had been discovered about this error earlier and stating that I hoped the insurance company could help me. Sadly, today I received an explanation of benefits simply stating that they could not accept my reasons for appeal since my request for claims comes outside of the stated 1 year deadline. I realize this!!! This is why I appealed!!! Don't I have a legitimate case?

I recently read somewhere that a doctor is still within his/her legal rights to issue a bill dating up to 4 years back. Is this true? ... If so, I can't place any responsibility on the doctor for failing to send out bills which would have made it much easier to him! The insurance company doesn't accept my appeal. I'm deeply frustrated. The enormous bill now falls solely onto my lap. I can't afford to pay this huge lump of money. Can anyone guide me or help me resolve this?

Sincerely,
Pieter

[cbg]

You had the right to appeal. You appealed. Nowhere does the law state that you must WIN the appeal. The law does not state that if the claim is over the deadline through no fault of your own, the insurance company MUST violate their policy and pay the claim anyway. They have the right to adhere to their policy and decide that the claim is too far beyond the deadline for them to pick it up.

Your next step is to contact the insurance commission of your state. How long a physician may continue to bill, particularly under these conditions, is going to be fairly state specific. They will be able to tell you if, under your state's insurance law, the doctor can still hold you responsible for these bills.

If I may say so, it sounds as if you and your parents need to communicate better. For you to be assuming for three years that you never saw a bill because they were paying them all (and never once mentioning it to you) and conversely for them to assume that you were paying them all without any assistance, strikes me as indicating that none of you talk to each other enough.