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Medical Provider Failed to Pre-certify

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JLfromNC

Junior Member
What is the name of your state (only U.S. law)? North Carolina

Precertied for preventive procedure through Urologist--an in-network provider. Dr. performed the procedure at several medical facilities--and I chose based on day of the week that he'd be performing the procedures at the facility. The facility itself is out of network. At intake I provided my insurance card and signed the financial agreement form--that itemizes several terms. The first "I agree to pay for all medical services provided." As well, I assign fiduciary responsibility to the provider, "Please apply for any health insurance coverage that may be available to me." "I appoint (Medical provider) as my 'authorized representative' to act for me in getting payment for services provided." My insurance card states, "Provider must call (number) to obtain pre-authorization." Following the procedure I received a bill from the medical provider for around $5000. I appealed to insurance. Insurance company ruled the claim to be a "post-procedure claim." I noticed it did not refer to it as an out-of-network provider. I also confirmed with my insurance that the medical provider did not call to get the procedure pre-authorized--but the Dr. performing the procedure did. During my appeals process with the medical provider customer service manager I was told my bill would not be sent to debt collector until my complaint was reviewed. I received a voice message from customer service executive--but no info about the decision. I left a message with the executive and waited to receive follow up. Instead within a few days I received notice from a debt collector. I have filled HIPPA complaint due to transfer of info to debt collector. But I'm wondering if I would have a case against the medical facility for failing to pre-certify?
 


ecmst12

Senior Member
It's not the job of the facility to pre-certify, and they wouldn't be able to anyway. It's the physician's job to obtain precert, and your job to make sure precert is in place before consenting to undergo the procedure. The facility doesn't need separate precert, but it's your job to make sure that the facility is in network before agreeing to receive care there. This is nobody's fault but yours - you didn't even ask the facility if they were in the network!

Also, your HIPAA complaint is 100% inappropriate, as explained. And even if a violation did occur, it wouldn't get you out of the bill.
 

JLfromNC

Junior Member
Clarify

It's not the job of the facility to pre-certify, and they wouldn't be able to anyway. It's the physician's job to obtain precert, and your job to make sure precert is in place before consenting to undergo the procedure. The facility doesn't need separate precert, but it's your job to make sure that the facility is in network before agreeing to receive care there. This is nobody's fault but yours - you didn't even ask the facility if they were in the network!

Also, your HIPAA complaint is 100% inappropriate, as explained. And even if a violation did occur, it wouldn't get you out of the bill.
Thank you for taking the time to respond. Not sure if following clarification matters:

I did the paperwork through my urologist. I've done this 2 prior times and was not billed by the location where the urologist performed the procedure. I assumed the hospital billed the urologist. So that would explain why I didn't ask the facility. The facility is a hospital. If the hospital is a provider and MEDCOST card that the hospital copied--states that provider must call--then what the heck does the card matter? And I respectfully disagree about the HIPPA violation. I was not as of yet in default of payment because I was working through appeals process--and was told to wait until the customer service executive notified me of the result of their investigation. I wasn't given the chance to pay before the bill was sent. Also, if it's as cut and dry as your response conveys, then why didn't my insurance state "out of network" instead of "post procedure claim?" Don't mean to come across ungrateful for your response--and the lesson of course is learned.
 

Zigner

Senior Member, Non-Attorney
And I respectfully disagree about the HIPPA violation. I was not as of yet in default of payment...
The law doesn't require you to be in default. The law specifically allows for the transfer of PHI for the purposes of collecting the debt.


ETA: Read this page and maybe you'll understand why you're wrong: http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-treatment-payment-health-care-operations/index.html
 

ecmst12

Senior Member
It may or may not have been CORRECT for you to have been sent to collections while the claim is still being appealed or pursued. Either way, it was definitely NOT a violation of HIPAA.
 

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