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Doctor billed insurance too late. Am I liable?

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L

LAHFL

Guest
What is the name of your state? Florida

Had tests done Aug 2002 by private diagnostic company. I received notice from insurance company Sept 2003 that they had just received claim and denied because "claim has not been filed within the time limits specified in your contract (one year)." Just received bill from provider stating, "Ins Co advised us that you are not on the policy info." NOT TRUE and contadicts reason for denial on statement of benefits from insurance company. I have been covered under this policy for the past 4 years and still am. Have had 3 surgeries in the past year -- all paid by same insurance company. Am I responsible for the full amount ($1027.50) even though it was denied due to their negligence in billing too late? BTW, claim would have been paid at 100% due to having met my deductible during the year.

Thanks for any help you can provide.
 


Beth3

Senior Member
Over the course of the 13 months, are you saying you never received a single statement from the diagnostic provider showing that there was a balance due of $1027.50?
 
L

LAHFL

Guest
That is exactly what I am saying! They did not bill the insurance company until 13 months after service. Only after receiving a denial of claim did they bill me. The statement is dated 10/31/03 and shows .00 in all the late columns.
 
L

LAHFL

Guest
That is exactly what I am saying! They did not bill the insurance company until 13 months after service. Only after receiving a denial of claim did they bill me. The statement is dated 10/31/03 and shows .00 in all the late columns.
 

JETX

Senior Member
Doesn't matter. YOU have the responsibility of paying the bill, or making sure that YOUR insurance company handles it. Once you pay the bill, then you can go and try to get reimbursement from whoever (if anyone) may be at fault.
In the meantime, if you will remember the paperwork that you filled out in the doctors office (or hospital), you signed agreeing to be the responsible party.
 
L

LAHFL

Guest
JETX - Point taken; however, I do take exception when the provider insists on handling the billing and taking assignment, then doesn't bill in time, leaving the patient responsible for the entire bill. If they had billed in time and received payment from insurance, they would only have received 50%-60% of the total bill they now expect me to pay. Not a bad racket! This was a doctor who came to another doctor's office to do this test. I don't recall signing any papers taking responsibility for any amounts due to their negligence or otherwise. I guess I'll just have to fight. I don't intend to lie down and play dead--it's not my style when principle is involved.
 

JETX

Senior Member
And if YOU had monitored the bill for the services YOU received, this wouldn't be a problem now. Simply, you have a responsibility to make sure that the bill was paid.
 
L

LAHFL

Guest
Normally, I would have monitored the bill and noticed if I had not received anything indicating it was paid; however, nothing was normal about that time period. Within a few months after that test, I had 2 open heart surgeries and then, 4 months after the second one, had another surgery to correct a sternal infection caused by the incision. I had dozens of tests during that period and mountains of insurance claim forms. Besides being a little overwhelmed by this, the anesthesia makes the brain somewhat fuzzy. It's hard to keep track of it all when there's that much, especially when the providers don't send you anything until AFTER they hear from the insurance company. In this case, THEY sent the bill in too late; and, by the time I heard about it, it was too late to do anything. I guess I should be grateful that this is the only thing that slipped through the cracks.
 

Beth3

Senior Member
LAHFL, ultimately, you are responsible for payment of the bill, as you authorized and received the services. However, you don't have to let on to the provider that you are aware of that.

I'd contact them, explain your insurance company has rejected the claim because they didn't send the bill in until 13 months after services were rendered, and ask the provider what THEY are going to do about it? I'd be surprised if they offer to forgive the debt but you might be able to negotiate a decent discount.
 
L

LAHFL

Guest
Beth, thank you for the suggestion. I will certainly give that a try. I understand my responsibility for payment; however, I do not understand how providers can avoid their responsibility for compliance with an insurance company's provisions for billing when that provider agreed (actually insisted) to handle the billing. Are they not bound to supply the necessary information in a timely manner according to the insurance conract when they agree to handle the billing process?
 

cbg

I'm a Northern Girl
That depends upon whether they have a contract with the insurance carrier that REQUIRES them to handle the billing. In the event that they don't, they can choose to handle it themselves but do not have any contractual requirements.
 
L

LAHFL

Guest
They DO have a contract with the insurance company. It is a PPO and they are a PPO Provider. My contract with the insurance company states "Providers have agreed to file claims for the services they render;" therefore, I assume that the provider's contract also has provisions relating to filing claims.
 

cbg

I'm a Northern Girl
Fine, that's information you didn't provide before. However, since neither you nor we have read their contract with the company, we don't know what requirements they are held to.

What you CAN do (besides Beth's excellent suggestion) is notify the Provider Relations department of the insurance carrier as to what happened. They will be able to determine if the doctor has violated the contract, and, if so, whether you are due any relief because of it.
 
L

LAHFL

Guest
Thanks for the support. I just spoke with the office manager in the provider's office. Their billing service said they submitted the claim 3 times last year and it was rejected by the insurance company because I wasn't on the policy. The office manager contacted the insurance company and the insurance company rep confirmed that I WAS AND STILL AM on that policy and is taking it to her supervisor. So, maybe this will turn out to be an easy one.
 

lkc15507

Member
LAHFL:

I was pleased to see your last post as that was my suggestion--to confirm with the provider whether or not the claim HAD previously been filed as their explanation to you differed than the explanation from the insurer.

Now, my next suggestion is to grab your summary plan description (SPD) and read the section on filing an appeal. File that appeal with all speed as you may be approaching the deadline to do so as it is. You have a determination from the insurer based on timely filing. You now need to disprove that "adverse determination" in order to be able to keep the process alive. The provider should be able to provide documentation that the claim was previously filed--such as whatever documentation they received from the insurer indicating that you were not on the plan--thus their explanation of previous non-payment by the insurer. They should also be able to provide their own internal documentation of dates filed etc.

If you can successfully document that the claim was previously / timely filed, then you can address the insurer's original determination of ineligibility based on not being a member. If things are as you say, the provider is correct about having filed, and you act quickly and appropriately according to your SPD's appeals process--you can win this one.

Best to you,
lkc15507

PS I suggest that during the appeals process, if you pursue it, you communicate with the provider regarding payment arrangements as you are ultimately responsible for the bill. If your appeal is then successful, you can be reimbursed. That is much better than having your credit totally wrecked.

Editing again, I want to be clearer. Even though your verbal communication with the insurer implies their knowledge that you are / were on the plan, you should still make your appeal in writing, perhaps even RRR. Your lifeline to keeping this decision alive is a written appeal, just in case someone forgets to follow-up your phone calls. I will further try to stress this because if the insurer's system of operation were reliable, I doubt there would have been three denials of your claim in the first place. If something should go amiss with their records again, I would want that proof of having submitted a written appeal. My bet is that your time frame for appealing the decision overall will begin with your receipt of the timely filing adverse determination. If the earlier claims filings were denied based on not being a participant in the plan, in my opinion it is highly unlikely you received any "adversed determination" notice from the insurer at all--i.e. they had no record of you, therefore, with no "adverse determination" from the insurer, you had nothing to appeal. Now you do, the timely filing adverse determination. Do not rely on verbal communication with this entity to be reliable.

Again, best to you,
lkc15507
 
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