insurance question

[MMP987]

What is the name of your state? tx

my in- network doctor billed my hmo insurance company for services for a 2 month period. the insurance sent payment to the health organization that the doctor was associated with at the time that the bill was sent to the insurance. the doctor is no longer associated with the group and is billing me. he says that the insurance company paid the wrong person and he never received payment. when i call my insurance company, i am told that the claim was paid and sent to group that the doctor has in his paper work. I have a statement from the insurance stating that the doctor was paid in full and I owe nothing. i paid my copayment each time i had an appointment. my doctor's office is threatening to send the bill to a collection agency if the claim doesn't get paid. do i have to pay the claim?
MMP987

 

[hjc]

No, the doctor should not be able to bill you .. here's why ... the contract the provider signed to join the ins plan. These contracts state that if the provider doesn't comply with all of the stipulations laid out in the contract and as a results he loses monies, then he cannot "balance bill" the patient. That's the medical providers problem for not understanding their contractual responsibilities.

The clause that would apply here is the one that requires a medical provider give ample notification of change in practice locales. I.E. the doctor should have notified the HMO that he was leaving a particular group, where he was going, what the new TIN would be and the effective date of that change.

Call the ins co -you need to verify if the doctor notified them of his change in location. Verify if this is a requirement in their contract. You may need to speak with someone in provider relations. Tell them you want to file a complaint about the doctor.

And if i'm right, tell the doctor that he cannot bill you, nor can he send this acct to collections. What he can do is grovel to the ins company and try to correct his provider file. But remember that's his problem not yours.

 

[MMP987]

thanks for the information. i really appreciate it.
mmp987

 

[CIAA]

hjc,

I don't know, but I would think that under the credit laws, you may be able to dispute the bill in writing within 30 days after receiving notice and they are required to investigate or evaluate your dispute. I would also think that the collection companies would not want to take one that is actively in dispute. Regardless, it would be wise to send the doctor written notice that you are disputing his bill, setting out the reasons why.