+ Reply to Thread
Page 1 of 3 123 LastLast
Results 1 to 15 of 38
  1. #1
    badadjective is offline Junior Member
    Join Date
    Mar 2007
    Posts
    15

    Illegal Billing?

    What is the name of your state?
    New York State

    Dear Forum-Goers,

    I've recently run into a series of health problems, and have been seeing multiple doctors and getting tests performed at different laboratories. I am a recent college graduate, dirt poor, and therefore have taken advantage of the Family Health Plus program in New York State which provides me with an HMO medical insurance coverage through Medicaid and United Healthcare.
    After going to many doctors for the last 3 months (my insurance began January 1st of this year) I just received letters from United Healthcare denying coverage for almost all my doctor visits, procedures, and tests. The amount is in the thousands, many thousands. I do not have even $100 to pay.
    After doing some investigating by calling my insurance company, I was told that none of the doctors or labs I went to (besides my primary care) were participating members of my plan. After calling all of the doctors and labs, surprisingly they all told me "oops, I'm sorry sir. Looks like we don't take your insurance after all, we'll have to bill you!"
    Despite the fact that I ALWAYS have my primary care refer me to the doctor or lab and make sure they take my insurance, despite that I ALWAYS ask them to verify that they accept my insurance when I sign in as a new patient, and despite that I ALWAYS give them my insurance card and tell them not to take me as a patient of perform any procedures unless it is covered, I have been lied to by incompetent office staff and now am in thousands of dollars in debt.
    I spoke with the office staff and they admitted that they never verified me correctly, but that it's MY fault! Is this insane? Is this even legal? Can they bill me even though THEY made the mistake and lied to me?
    Your help is greatly appreciated and I look forward to your responses, thank you.
  2. #2
    cbg
    cbg is offline Senior Member
    Join Date
    Nov 2001
    Location
    Massachusetts
    Posts
    33,981
    "Yes, we take your insurance" does not translate into, "Yes, we are a participating provider on your insurance". It means that if your insurance company sends you a check, they'll cash it. What you need to ask is whether or not they are a participating provider. Who is in and out of network changes daily as doctors join and drop; as contracts are signed and expire. They did not necessarily lie to you; United Health Care has numerous types of plans and some doctors are covered on some and not others. It is by no means impossible that it was honest error. UHC has an excellent customer service department and a strong provider relations department (or they did when I worked for them ten years ago); either could confirm for you whether a doctor is or is not participating with a simple phone call.

    Unless it is specifically spelled out in your policy that the provider is responsible for determining what is and is not covered and treating you accordingly, it is YOUR responsibility, not theirs, to know what is and is not covered. The same goes for knowing who is and is not participating; it's your responsibility unless the policy specifically says otherwise.
  3. #3
    badadjective is offline Junior Member
    Join Date
    Mar 2007
    Posts
    15
    cbg,
    thank you for your response. I understand in legal matters that wording is important, and I should have been more clear from the beginning. I did in fact ask if they participate in my insurance, and always state that I do not want any service, procedure, or test that is not fully covered by my insurance. If I am told by office staff that that is the case, what am I supposed to do? United Healthcare unfortunately does not have good customer service anymore. I have opened appeals with them, requested they find doctors for me, and requested other services they are required by law to perform and I NEVER get a phone call back and they always refuse to let me speak with a supervisor when I ask. If I go to a doctor, how can I reasonably call my own insurance company every time the doctor makes a decision to perform a test or procedure if I can't get a response from my own insurance company and I get reassurances from office staff that everything is covered?

    I'm stuck between a rock and a hard place. I did everything in good faith and the way I thought I was supposed to, and now due to incompetent office staff I'm in debt in the thousands. I still don't understand how I can be held legally accountable for these fees. Am I really wrong?
  4. #4
    sealjoy is offline Junior Member
    Join Date
    Mar 2007
    Posts
    3
    Bad,

    I am no expert, but the one thing you can do before anything is done that could cost you, is get the office staff to put it in writing. so you have a legal leg to stand on if they do not participate.

    I would also get them to put in writing that they did not properly validate you for your records that you could use in a lawsuit if able.

    Seal
  5. #5
    lealea1005 is offline Senior Member
    Join Date
    Jul 2006
    Location
    supratentorial region
    Posts
    2,603
    Quote Originally Posted by badadjective View Post
    cbg,
    thank you for your response. I understand in legal matters that wording is important, and I should have been more clear from the beginning. I did in fact ask if they participate in my insurance, and always state that I do not want any service, procedure, or test that is not fully covered by my insurance. If I am told by office staff that that is the case, what am I supposed to do? United Healthcare unfortunately does not have good customer service anymore. I have opened appeals with them, requested they find doctors for me, and requested other services they are required by law to perform and I NEVER get a phone call back and they always refuse to let me speak with a supervisor when I ask. If I go to a doctor, how can I reasonably call my own insurance company every time the doctor makes a decision to perform a test or procedure if I can't get a response from my own insurance company and I get reassurances from office staff that everything is covered?

    I'm stuck between a rock and a hard place. I did everything in good faith and the way I thought I was supposed to, and now due to incompetent office staff I'm in debt in the thousands. I still don't understand how I can be held legally accountable for these fees. Am I really wrong?


    Just a thought/question from a provider's point of view on the situation...did you specifically tell the office staff that you were covered under the Medical Assistance program that is part of United Healthcare? Is there any place on your insurance card that specifically states "Medical Assistance"? From what you're stating, staff members at several offices are "incompetent" and I find it hard to believe that it got by ALL of them. I can tell you, in my state, nowhere on a UHC member's card will it indicate that patient is part of the medical assistance program. We must specifically ask when we call for verfification. We don't always get the correct answer from their representative. (things apparently have changed, cbg )

    However, now that you have been provided services and are responsible for payment, perhaps you can call each office and explain the situation and ask whether they would consider reducing their payment to what United Healthcare would have paid. It's no guarantee, but it's worth a shot. Good luck!
    Last edited by lealea1005; 03-28-2007 at 09:24 AM. Reason: spelling error
  6. #6
    ecmst12 is offline Senior Member
    Join Date
    Feb 2006
    Location
    Philadelphia, PA
    Posts
    35,403
    Since this is a Medicaid plan, you could try contacting your local medicaid office and see if they will intervene on your behalf. Obviously being on Medicaid, you are not going to be able to afford to pay for these treatments so hopefully they will be able to work something out between UHC and the doctors for you.

    Sealjoy, no doctor's office is going to put anything in writing guaranteeing that your treatment will be covered. In fact they make you sign a paper saying that you will pay anything your insurance denies. THEY don't even know whether insurance will pay until they submit the bill, half the time. Ultimately it is the patient's responsibility to find out if a doctor is participating or not. The best way to do this is by calling customer service, looking in the provider directory, or most plans have web sites where you can look up doctors now. The doctor's office is NOT the best place to find out if they are in network; with the hundreds of plans out there even within the same insurance company, it's impossible for them to know every single one.
  7. #7
    lealea1005 is offline Senior Member
    Join Date
    Jul 2006
    Location
    supratentorial region
    Posts
    2,603
    Quote Originally Posted by ecmst12 View Post
    Since this is a Medicaid plan, you could try contacting your local medicaid office and see if they will intervene on your behalf. Obviously being on Medicaid, you are not going to be able to afford to pay for these treatments so hopefully they will be able to work something out between UHC and the doctors for you.

    Sealjoy, no doctor's office is going to put anything in writing guaranteeing that your treatment will be covered. In fact they make you sign a paper saying that you will pay anything your insurance denies. THEY don't even know whether insurance will pay until they submit the bill, half the time. Ultimately it is the patient's responsibility to find out if a doctor is participating or not. The best way to do this is by calling customer service, looking in the provider directory, or most plans have web sites where you can look up doctors now. The doctor's office is NOT the best place to find out if they are in network; with the hundreds of plans out there even within the same insurance company, it's impossible for them to know every single one.

    Exactly!!!
  8. #8
    badadjective is offline Junior Member
    Join Date
    Mar 2007
    Posts
    15
    Thank you all for your insight. I did think about getting them to sign something, but like you said they would probably not do that and it wouldn't help me at this point anyway because the charges are already there.
    Also, it does NOT say on my card that I am in a medical assistance program. It just says United Healthcare. But, when I call to find out if a doctor participates I always say that I have Family Health Plus through Medicaid and NOT United Healthcare. Regardless of whether United Healthcare tells them about my elegibility, isn't it the doctor's office responsibility to tell me if they participate? How can they accept my co-payment if they don't participate?
    And like I said, calling United Healthcare on my part is useless. I've tried countless times to get help from them and they literally don't EVER call back, and customer service tells me they can only forward the request to the proper department. It's a dead-end every time.
    I'm at my wits end with all of this. I don't have a single penny to pay them. I have excellent credit and don't want that to be destroyed for years because of dead end insurance and careless office staff.
    I have been instructed to contact the New York State Insurance Department by some. Should I open a case with them for each bill I receive from each doctor/lab?

    Again, thank you all in advance!
  9. #9
    moburkes is offline Senior Member
    Join Date
    Nov 2005
    Location
    South Cackalacky
    Posts
    15,365
    Quote Originally Posted by badadjective View Post
    Thank you all for your insight. I did think about getting them to sign something, but like you said they would probably not do that and it wouldn't help me at this point anyway because the charges are already there.
    Also, it does NOT say on my card that I am in a medical assistance program. It just says United Healthcare. But, when I call to find out if a doctor participates I always say that I have Family Health Plus through Medicaid and NOT United Healthcare. Regardless of whether United Healthcare tells them about my elegibility, isn't it the doctor's office responsibility to tell me if they participate? How can they accept my co-payment if they don't participate?
    And like I said, calling United Healthcare on my part is useless. I've tried countless times to get help from them and they literally don't EVER call back, and customer service tells me they can only forward the request to the proper department. It's a dead-end every time.
    I'm at my wits end with all of this. I don't have a single penny to pay them. I have excellent credit and don't want that to be destroyed for years because of dead end insurance and careless office staff.
    I have been instructed to contact the New York State Insurance Department by some. Should I open a case with them for each bill I receive from each doctor/lab?

    Again, thank you all in advance!
    Your doctor's office really doesn't know. What you don't understand, and I'm going to explain to you is this: United Health Care offers hundreds, if not thousands, of insurance plans. Literally. So, when you present a United Health Care ID card, your doctor, more likely than not, has received thousands of dollars from that insurance company for legitimate claims. The doctor has no idea (the billing department, really) that they don't participate in your plan. They only know that they participate in many UHC plans.

    Before you were treated, you were asked to sign a consent form. The consent form asked you for permission to share your private medical information with your insurance company, with collections companies (just the $ amounts), with labs, etc. It also stated that, while they will submit the claim to your insurance company, you are responsible for any $ that the insurance does not cover.

    You are responsible for verifying with customer service, at your insurance company, if a particular doctor is covered, which is why they ask for your member # before they will give an answer. They need to look up your particular plan first. Many insurance companies also offer websites that, once you enter your personal information, it will provide you with a list of covered doctors and facilities.

    Sorry that you had to learn this lesson the hard way.
  10. #10
    badadjective is offline Junior Member
    Join Date
    Mar 2007
    Posts
    15
    I understand that I am ultimately responsible if my insurance does not cover something because a procedure or test is not covered by my insurance, but how can I be responsible if they specifically tell me that they verified with my insurance and accepted my copay???
  11. #11
    ecmst12 is offline Senior Member
    Join Date
    Feb 2006
    Location
    Philadelphia, PA
    Posts
    35,403
    Since customer service at UHC has not been helpful, that is why I suggested contacting your local medicaid office for help.
  12. #12
    moburkes is offline Senior Member
    Join Date
    Nov 2005
    Location
    South Cackalacky
    Posts
    15,365
    Simply becuase the paper that you signed, and that can be presented to a judge, will outweigh any oral information that you received. However, I can't imagine that every single receptionist told you this.
  13. #13
    badadjective is offline Junior Member
    Join Date
    Mar 2007
    Posts
    15
    Thank you for all your replies. I will take up this matter with Medicaid and the New York State Insurance Department.
  14. #14
    lealea1005 is offline Senior Member
    Join Date
    Jul 2006
    Location
    supratentorial region
    Posts
    2,603
    Good luck, but don't get your hopes up.
  15. #15
    ecmst12 is offline Senior Member
    Join Date
    Feb 2006
    Location
    Philadelphia, PA
    Posts
    35,403
    Accepting your copay means nothing. Your copay is printed on your card, that's all they were going by. Verifying with the insurance company just means that they verified you were covered, not that they participate. Payment is never guaranteed until the bill is received and processed by the insurance company.

    But it is not your fault that customer service has not been helping you, I will give you that. You have been trying to do everything right. UHC works for the Medicaid office in this case, so (again) that is why I suggested appealing to their bosses. The department of insurance may also be able to help. I don't understand what kind of insurance plan, even a Medicaid one, can't even tell you whether a doctor participates when you call. That's like, the most basic of basic information you can ask for.

Similar Threads

  1. Breach of Contract, mailicious Prosecution? and Illegal Act from an illegal repo
    By NeedSomeJustice in forum Consumer Contracts, Guarantees and Warranties
    Replies: 0
    Last Post: 09-14-2007, 11:26 AM
  2. ala carte medical billing, billing type notification.
    By Altairah in forum Medical and Health Care Malpractice
    Replies: 2
    Last Post: 07-27-2007, 09:13 PM
  3. My HC provider is billing me 4 the cost of billing the Ins Co.
    By Blue Colnago in forum Health Insurance and HMO Plans
    Replies: 5
    Last Post: 09-11-2006, 03:40 PM
  4. Illegal sale of home/illegal transfer of deed
    By scoonbug1951 in forum Buying & Selling a Home
    Replies: 5
    Last Post: 09-17-2004, 08:22 AM
  5. Is this illegal? Double billing....
    By randocommando in forum Debt Collections
    Replies: 1
    Last Post: 08-02-2004, 06:12 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  

© 1995-2012 Advice Company, All Rights Reserved

FreeAdvice® has been providing millions of consumers with outstanding advice, free, since 1995. While not a substitute for personal advice from a licensed professional, it is available AS IS, subject to our Disclaimer and Terms & Conditions Of Use.