How to handle contract dispute btwn insurance and provider

[stacey]

What is the name of your state? CA

8 months ago I was taken to the emergency room of my local hospital (I had passed out from dehydration due to mononucleosis). The hospital was an in-network facility. The insurance company took care of paying the hospital bills at the contracted amounts.

There was a separate bill from the emergency room doctor. Because that bill was processed first, I had to the bill because I hadn't met my deductible yet (then the hospital bill was processed, which put me way above the deductible). I paid the amount the insurance company said to pay.

I continued to receive bills from the doctor's medical group for a larger amount. When I called my insurance company, they said that they have a contract with the provider, and therefore the provider is not allowed to charge more than the contracted amount. I called the provider, who said that they had no contract with the insurance company. Apparently the emergency room doctors have no contracts with insurance companies and are considered separate from the hospital (this is what the doctor's billing person said anyway). However, she refused to contact my insurance company to resolve the matter.

I called insurance again, and they sent the claim to be re-processed. It never was, or if it was, it was exactly the same. They also said there was definitely a contract. But they sent in an inquiry internally regarding the contractor. I contacted the provider's billing person and left a voicemail that this inquiry was sent, that I had paid the contracted amount, and to let me know if there was any problem. I never heard back, but I got another bill from them for a second emergency room visit (the mono really attacked my system badly) that didn't show any prior balance. I assumed the matter was taken care of.

Now it has gone to a collections agency. My insurance company has sent in a dispute to their processing center, but I have not yet heard back.

I know that legally I am responsible for my medical bills. The issue is that, if there is a contract, nothing more should be paid to the provider, and if there is no contract, the insurance company should pay the difference because I am over my deductible. In either case, I owe nothing. But I am still responsible. What should I do?

If I pay the collections agency, and it turns out there is no contract, then I can ask my insurance for reimbursement. But if I pay and it turns out there was a contract, who (if anyone) gives me the money back? I doubt the provider would hand it over. Would my insurance be responsible for getting it to me? If I took someone to small claims court to get it back, would it be the provider or insurance? And if there is never a resolution on whether there is a contract or not, what can I do, legally to get a resolution, when the dispute is really between the provider and the insurance company, not me??

Thank you! (also, if you reply, can you tell me whether or not you are an attorney in these matters?) Thank you!

Stacey

[averad]

[url]http://www.insurance.ca.gov/[/url]

Who is your Insurance carrier in California?

[stacey]

My insurance is United Healthcare (Definity Group).

[averad]

Is the ER doctor listed in the provider directory here?

[url]http://www.uhc.com/find_physician[/url]

or here

[url]https://www.geoaccess.com/uhc/po/Default.asp[/url]

[stacey]

Yes, the doctor is listed. What should my next step be?

Does this listing serve as legal proof? Should I print it and send by registered mail to collections agency?

Thank you.

[averad]

Talk with a supervisor and request the claim be paid in full until the provider relations can be corrected. Give all the details and if that returns nothing contact your Insurance commissioner’s office.