Doctor never submitted bills to insurance...

[sbrennan007]

Illinois-
Starting back in September of 2001 I started seeing a specialist, whom I was approved by my insurance and referred to by my primary doctor.

I started seeing this specialist on a regular basis and every visit paid my $15.00 co-payment. About 3 years after my first visit (yes, 3 years) I received a statement from this specialist's office stating that I owed $770.00. When I contacted them about this (I spoke with both the office staff and the specialist) they told me that their previous office staff was never on top of billing the insurance companies in a timely manor, and that since so much time had gone by the insurance would no longer accept the billings from the specialists office, hence telling me that I would now have to pay these charges.

I indicated to them that this was the first time I've ever received any notification of this and that as they could see my co-payments had always been paid. I told them I didn't see how it was my fault that their office never submitted the correct documentation to the insurance company (I have been with the same company for 12 years and have always received pre-approved insurance coverage for this specialist as required by the insurance company).

They then proceded to tell me that the insurance refused payment of these charges, so I asked them for detailed records of each time the bills were submitted to the insurance company and to identify what visits each billing to the insurance company was for. I have asked for this information now 3 seperate times, all requests for this information were sent via certified mail to the specialists office.

Today, now almost 5 years later I receive a letter from a collections agency stating that this account was turned over to them for collection. I contacted the collections agency and explained the entire situation and let them know that I have copies of certified letters and conversations with this office, non of which were ever returned.

Over the past 5 years now, in trying to get to the bottom of this and in requesting the above documentation, I have had several of the office staff tell me that this is nothing new for them and that the previous office staff was just horrible and never followed up with anything. They have notations on my account there of receiving all certified letters, but still to date have never sent me the information I asked for.

Am I responsible for this $770.00? As I mentioned above, I have had full insurance for more than 12 years now with the same company and always followed the correct procedure for obtaining referrals and approvals from the doctors and insurance companies..

What can I do here?
Thank you in advance for any assistance!
Sean

 

[wayne-o]

This is not the answer you probably want to hear, but**************.you will most likely be responsible. Most drs note that they are filing insurance as a courtesy, but are not required to.

 

[sbrennan007]

I'ts not that I don't want to take responsibility for something here, it's that I paid what I was responsible for and never heard anything from either the Dr.'s office or insurance company for over 3 years.

The Dr.'s office has even admitted over the phone that they did not bill or follow up with the insurance company as they should have, but they really don't care at this point.

Even the primary girl who their billing now in the office said this should be removed, but the doctor says he doesn't care what was or wasn't done right by his staff in the past.

From what I understand, there are a large number of similar issues like mine taking place at the same office.

I've sent 3 certified letters now asking for detailed billing information from their office to the insurance company and have never received a response. When I call the insurance company to discuss it, they tell me I'm covered, but they have nothing to go off of either as they haven't received anything as well...?

 

[Ladynred]

I'ts not that I don't want to take responsibility for something here, it's that I paid what I was responsible for and never heard anything from either the Dr.'s office or insurance company for over 3 years.

What you are RESPONSIBLE for is the services rendered - ALL of it, not JUST the co-pay. Every single medical provider I've even been in has a notice posted in clear view that says payment is due when services are rendered. Providers file insurance AS A COURTESY but YOU are ultimately responsible for the entire bill. If the insurance doesn't pay, for whatever reason, you're on the hook.

Rather than battling wth an inept staff, you need to be talking to your insurance company. Per agreements, claims must be timely filed and the limit on filing claims as usually 2 years. Some insurances do have provisions that if the provider - per their agreement with the insurance company - fails to file a timely claim that you are not responsible for the balance. However, if they REJECTED charges, that is something else. IF claims WERE filed, even if rejected, YOU should have received an Explanation of Benefits (EOB) with reasons for the rejections clearly noted.

I suggest you stop sending letters asking for this information from the dr's office and GO to the office and don't leave until you get the records you have repeatedly requested. Ask for the Practice Manager and deal with him/her until you get what you need.

Bottom line though, you DO have to pay this bill, despite their ineptitude.

 

[justalayman]

What you are RESPONSIBLE for is the services rendered - ALL of it, not JUST the co-pay. Every single medical provider I've even been in has a notice posted in clear view that says payment is due when services are rendered. Providers file insurance AS A COURTESY but YOU are ultimately responsible for the entire bill. If the insurance doesn't pay, for whatever reason, you're on the hook.
.

LNR: I respectfully disagree with you here. In my personal situation, the provider is required by their agreement with the insurance company (if they are "in network providers") to file the necessary forms with the insurance company. They are required to not bill me until an EOB has been issued as well. The provider is contactrually obligated to accept the ins. co's. EOB and can bill me for only the portion the ins. co states as my responsibility. Of course they can appeal the EOB as incorrect but that then becomes a situation between the ins. co. and the provider to settle. In effect, the provider may not be able to attempt to collect from the OP due to a agreement with the ins. provider. Worth checking out.



So with that lengthy bit said, I would suggest the OP contact their ins. co. and speak with them as to any agreement the provider had with the ins. co. at the time of rendered services. Other than that, this may be a time barred collection, if the OP wishes to go that way. I generally do not advocate dumping your responsibilities by using the SOL but if the doc doesn't want to play fair, the why should the OP.