Doctor billed insurance too late. Am I liable?

[LAHFL]

lkc, thank you for this information. I do have 60 days from receipt of denial to appeal. I received the denial around September 25; therefore, I am within that time frame. The provider's office manager is also appealing via telephone, but I will insure that something IN WRITING will go somewhere before deadline. This is one of the good insurance companies that is usually very responsive and very good about doing the "right" thing. My credit is perfect and, if it meant paying the full bill, I would do so to ensure it remains perfect; however, I don't think it will come to that. The provider is not claiming any overdue amounts; according to them the account is current. Nor are they asking me, at this point, to pay anything. I will request on Monday that she get me written documentation from their billing company that the claim was previously denied because of lack of coverage. As you said, I never received those denials. Unfortunately, had they just called me when the claim was first denied (last November), this thread wouldn't exist.

Thanks for your input.

 

[lkc15507]

You are very welcome LAHFL. I want you to be aware that depending on your type of plan -- fully insured, self-insured or ERISA vs. non-ERISA, you may have up to 180 days to appeal the decision. If you can determine that for sure, a well prepared appeal is very preferable to one submitted under the gun.

ERISA laws extending the appeal time frame are fairly recent. Your SPD may still show the 60-day time frame that was common before these new regulations. Yet your plan should have sent an "amendment" or "rider" explaining the newer time frames if they would apply. I. E. I am only suggesting that IF your time frame is as much as 180 days, you should use it to prepare a well thought out appeal. If your time frame is truly 60 days, appeal both timely filing and non-participant decisions now.

As I said earlier, you can win this one. Just DO NOT be too trusting on phone / verbal communicaiton. Written communication is imperitive.

Best to you,
lkc15507

 

[lkc15507]

PS, keep us informed on this. I am truly interested in the outcome. If something goes amiss, cbg, beth3, myself, or some others can help. Your story is one that many face daily. I'm big on education, I think this is a marvelous example of how to utilize one's coverage appropriately.
lkc15507

 

[LAHFL]

I will definitely keep you informed. I will also research the ERISA laws. Any riders or other information are sent to my husband at work and he isn't always good at bringing those things home. The contract I do have is the original, which is several years old. If the provider can produce written confirmation that the claim was filed in time, but denied erroneously, I'll be in the clear.

I understand the financial agreements we sign when receiving services. These are necessary to insure that providers receive payment for copays and/or denials not the fault of the provider. I do have a problem with being obligated to pay a claim that was denied due to the negligence of a provider. Yes, services were received; but, if the provider insisted on billing, or was contractually obligated to submit the claim but didn't do so properly, I don't understand why the patient is penalized and forced to pay. Then the patient is paying for insurance AND services. And, afterall, the provider has a whole year to get it right.

 

[JETX]

"I do have a problem with being obligated to pay a claim that was denied due to the negligence of a provider."
*** With all due respect, your concerns have little, if anything, to do with this issue. LEGALLY (after all, that IS what this site is) you are obligated to pay this debt. If you don't, the medical office can simply file a lawsuit against you, show the bill and show your signature saying that YOU are responsible for paying all bills incurred.

 

[LAHFL]

Point taken, JETX; and, if it does come to that, I will pay the bill -- long before it ever gets to collection or lawsuits. As I always say, "We don't have to like the rules, but we do have to follow them." Perhaps in the future, I will add a clause to the financial agreement stating, "not liable for any denial of claim due to negligence of provider to submit said claim properly or completely." If they don't want to treat me, I'll find someone else.

 

[lkc15507]

LAHFL:

As long as you keep what you posted in mind--the rules are the rules--I will say I agree with you in principle. I have posted on these boards before that I believe even an implied (must less contractural as you have said is the case here) obligation by the provider to properly and timely bill the payer should be binding for them and release the patient from obligation if / when they clearly fail. But as I said when I posted it, I can be an idealist. However, I do find this a problem of managed healthcare. It takes the patient out of the loop yet leaves them in the lurch.

lkc15507

 

[LAHFL]

Resolution

I filed an official appeal to the denial based on the fact that the provider had billed several times with the year and had been erroneously denied payment. I also pointed out that the last submission, which WAS denied, was entered into their system on August 28 (one day after the deadline), but was mailed on August 21. There is no way it would take an entire week to get from here to their PO box. The provider appealed as well. I received a letter yesterday from the insurer that the claim is being paid. I just spoke with the provider's office and they already have the check. Chalk up one for the little guy!

Thank you so much to all of you who were so helpful and supportive. I hope you have a wonderful holiday season.

PS to JetX -- Now that my brain is not addled by too much anesthesia from two open heart surgeries done 7 weeks apart, I can once again monitor claims and payments. In September I found something from June that I had never heard anything about, so I called the provider and learned that they had never sent a bill because of computer complications. I called again in November and got the same story -- still hadn't been billed. The lady was very nice and told me that they had to bill within the time limits or I was not responsibile. Of course, when I asked her if she could please put that in writing and send it to me, she said she couldn't. Anyway, after "bugging" them several times, I got a call this morning that the bill has finally been submitted -- well within the time allotted.

 

[lkc15507]

LAHFL:

Good for you! Great! Knew you could win this! Thank you for posting the outcome. I am truly glad as you were within the provisions of your plan. I only hope that many others will read this and know that being familiar with their plans and following those guidelines is the best way to have claims covered.

God bless and take care.

lkc15507

 

[LAHFL]

lkc, et all, thank you again for your advice and suppport. Yes, I agree that two things are essential for dealing with an issue such as this:

1. You must arm yourself with as much information as possible, which includes reading your policy and researching your state laws. If I hadn't read my policy and acted immediately, I would have been 'shut out' of formally appealing by another deadline.

2. You must face the problem immediately and deal with it. I think too many people bury their heads in the sand and hope it will just "go away" or become defensive and attack the provider. Before they know it, collection agencies are calling and their credit is ruined. By contacting the office manager and working with her, I established a good rapport with her. We celebrated our victory together. There were actually three charges on the bill, but the insurer only paid for two (I have no idea why). Because of the 'bond' between us (ie, she like me because I was working WITH her), she told me to forget about it, zeroed that charge out, and my account is closed and paid.

I wish you all a wonderful holiday season.