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Doctor office not wanting to file the claim???

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MPierce

Junior Member
What is the name of your state (only U.S. law)? California
Hi I went to sign my daughter up for an appointment with my son's pediatrician (she has never been seen there) And they informed me that I owed them $181 form 2 yrs ago when she was born I do not remember talking to any other pediatrician other then hers when she was born however I was covered by Blue Cross Blue Shield and they say that they filed claims with them at the time but they were denied. The insurance company has no record of this.

Turns out that the doctors office had my insurance number wrong, the insurance said they can file a claim and be denied due to the 180 day rule but they can then file an appeal stating that they had my insurance number wrong, I told the doctors office this and they told me it's not their responsibility anymore and that I have to pay it.

What are my rights? Do I still have to pay even though I had insurance at the time? I feel like it's not my fault they got the number wrong, it's like they don't want to do their job and go through the steps of filing a claim 2 yrs later with an appeal.What is the name of your state (only U.S. law)?What is the name of your state (only U.S. law)?
 


Zigner

Senior Member, Non-Attorney
Seems to me that, if you want to use this doctor, you're going to have to pony up the $181.
 

MPierce

Junior Member
Well I'm not going to use the doctor now if this is the way they are going to treat me however this is on my credit and I don't think I should pay 181 for their clerical mistake...
 

Isis1

Senior Member
Well I'm not going to use the doctor now if this is the way they are going to treat me however this is on my credit and I don't think I should pay 181 for their clerical mistake...
you know, i'm not being smart arsed about this at all, but you should have been proactive to make sure all payments are made. you are responsible for any monies not paid by the insurance company. it says so on the contract you filled out when you signed the authorization to treat. you should have been proactive as you are the one holding the policy.

so, yeah, this will stay on your credit until you pay it. sorry.
 

ecmst12

Senior Member
If the doctor is contracted with your insurance company, they MUST bill the insurance company first. This is not your fault and I would not give them a dime. They need to file the claim and the proper appeals to try to get the timely filing accepted. You should only be responsible for your copay and any percentage that is patient responsibility.
 

swalsh411

Senior Member
you know, i'm not being smart arsed about this at all, but you should have been proactive to make sure all payments are made. you are responsible for any monies not paid by the insurance company.
What planet do you live on? This is not practical advice for people in the real world. For example, let's say I go to the dentist and have several things done at once. But I'm not a dentist so I don't know exactly what they call it or what codes they use when they bill insurance. I review my explanation of benefits and there are several things listed, most of which sound vaguely familiar. But low and behold the dentist tells me a year later that they should have billed for 6 procedures but only billed for 5 and that I owe them. Do you really think I should be responsible for this? I mean short of spending substantial time studying dental billing codes to ensure that everything was properly billed, how could I have prevented this?

edit: And let's say I have a kid with medical issues.... Should I be expected to take a day off work to review the EOB every time he goes to the doctor?
 
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lealea1005

Senior Member
Should I be expected to take a day off work to review the EOB every time he goes to the doctor?
Actually, IMHO (and most patient/insurance agreement small print), the patient is responsible for reviewing their EOBs, even if it's just to confirm the amount you're being billed is the same amount listed on the EOB as your portion to pay. Taking a day off work is a little dramatic.

Well I'm not going to use the doctor now if this is the way they are going to treat me however this is on my credit and I don't think I should pay 181 for their clerical mistake...

Well, that's certainly your perogative, however, it doesn't change the fact that you may owe the amount.

Is this Physician contracted/in network with your insurance plan? IF they did submit the claim with the incorrect member ID#, they would have received a rejection from their electronic clearinghouse. Normally, that rejection would lead them to contact you for a copy of your current insurance card so they could resubmit the claim.
Did you not get any bill/notification/phone call/mail from this office prior to your showing up for your child's appointment?
 

MPierce

Junior Member
It was 2 yrs ago and I think it would have been a red flag if I was being billed by a pediatrician I never heard of with my first newborn child I do however know for sure I never met this doctor before until I had my second child. And I know I received no phone calls from this doctors office as far as billing I told them to send me every document they have for proof they billed me.


In any case I think they should take the opportunity to file a claim with the insurance even if they have to file an appeal afterwards because the insurance will pay them they just don't want to have to do the work to get the insurance to pay.
 

tranquility

Senior Member
Actually, IMHO (and most patient/insurance agreement small print), the patient is responsible for reviewing their EOBs, even if it's just to confirm the amount you're being billed is the same amount listed on the EOB as your portion to pay. Taking a day off work is a little dramatic.
Obviously, you've never had a person in your life who needed a lot of medical care. I agree with swalsh411, there is no way to connect the dots at a certain point.

Personal example.

Dr. A does emergency brain surgery on wife at hospital A which is a participating provider. Dr. A was on call at the emergency room. (There was no prior relationship between Dr. A and patient.) Later problems develop and a shunt is implanted by Dr. A at hospital A. Wife visits mother when shunt extrudes from the body and I pick her up and take her to hospital B for emergency surgery to remove the shunt. Hospital B is a participating provider and was chosen by Dr. A because that is where he usually practices (And, is a much larger hospital.) in consultation with ER doc B. Dr. A does not attend surgery to remove the shunt but Dr. C (doctor in Dr. A's group) does.

Insurance pays over a ton of money and I pay over a large amount. (Out of pocket max for year.)

Dr. A's group agrees that we hired him on through the ER and he is constrained to accept the contracted amount with insurance company for the first two surgeries as our "hiring" of him was through the participating provider. HOWEVER, he claims that because he was hired for the third surgery directly, and not through hospital A, that provider contract is not applicable and charges me the difference because Dr. C was not a part of that occurrence. (Hospital B, where the surgery takes place, is also a participating provider.)

Now, see if you can spend a WEEK on the inches thick pile of EOB and billings and see if you can come up with some theory of what was paid for or not. I couldn't, and I'm pretty good at making numbers match up.

That's just one doctor (But omits all the support time he spent, like hospital visits or ICU items). Do you know how many OTHERs were billing at that time?

After you match up the numbers, then go to college or vocational school to learn that "surgery" can mean the process of inserting an IV along with all the other medical codes and meanings.

After that, easy peasy.
 

ajkroy

Member
OP, is it possible that this pediatrician saw your daughter in the hospital when she was born? That could account for the bill without you "knowing" them first.

If that is the case, find out as much about the visit as possible. As for a copy of the office note or just the date of service from the staff. If it was while she was on your insurance during her first 30 days of life, then yes, this could very well be your responsibility, depending on your insurance rules, because she likely received her own insurance ID number after that. It was up to you to keep track of everyone who needed that number.

If it was another visit and it just slipped your mind, speak to BCBS and get them involved. If they were the insurer at the time and they did not receive a bill during the timely filing period, they can put pressure on the office to negate the bill.

I strongly suspect it was the first situation, though. It seems odd that a parent would forget that they took their child to a doctor and then not deal with the subsequent bills for an insured child. Then again, I can't figure out why you were taking both of your kids to different pediatricians in the first place.
 

lealea1005

Senior Member
Obviously, you've never had a person in your life who needed a lot of medical care. I agree with swalsh411, there is no way to connect the dots at a certain point.
Sorry it took so long for me to see this....I actually was 1000 miles away from home visiting the person in my life who currently receives medical care for a condition requiring several different specialists. Maybe it's because her father and I do this for a living, but as sick as she is, she and her husband are well aware of the necessity to keep track of their EOBs, and whether her multiple Physicians/the hospital/the facilities are being properly compensated for their services.
 
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part of the costs is for administrative reasons .. I would ask for 1/2 the bill to be abated 'cause they charged you for a service they did not provide.
 

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