Dr Office Exceeded Time Limit

[bellasmom]

Pennsylvania

My husband has an eye condition called keratoconus. In March of 2004 he had a cornea transplant in one eye. We received lots of EOBs from the insurance company, and we paid all the 'patient responsibility' balances off long ago.

I received a letter from our insurance company today saying that a claim filed by the eye doctor has been denied because its submittal was outside of the time limit of 12 months. The claim information is correct, and the date of service is the day that my husband had the surgery. The amount denied is $3522.75.

My husband needs ongoing follow-up visits. I have contacted the eye doctor several times because we have not been receiving EOBs for every visit. The eye doctor claims that they are submitting everything to the insurance company. I have kind of dropped the ball on this one, I know I should have immediately contacted the insurance company to find out why I wasn't getting an EOB if the Dr. office was submitting it, but I didn't. In the mean time, we have been paying the entire bill for all of his follow up visits for the past 2 years.
We will pay what we owe, but insurance is expensive, and this Dr office needs to submit the claims so we are actually using it. Even if they won't pay part of it, it gets added to our deductible & out of pocket expenses (we have a max. out of pocket expense per year).

1. Will we be liable to pay the $3522.75 that was just now submitted to the insurance company?

2. The eye doctor says they are submitting the follow up visit claims. If I'm not getting an EOB, how can they be? If I tell them we won't pay the bill until we get the EOB for the visit, can we be reported to the credit bureau?

3. Are we the eye doctors cash cow?

 

[LJ2006]

To Bellasmom

Sounds like your doctor's office is losing a lot of money by hiring people who don't know what they're doing. They need to hire some good people to take care of their business! (I might know some people in that area who can help them.)

I don't know your insurance company, and I'm in Texas - but this is how things usually go all around the USA:

Your insurance company not only has a contract between you and them, they also have a contract with the doctor (usually). If the doctor is what's called a "participating provider", he has to stick to the contract, and in most cases, it includes filing the claims for the patients within a specified amount of time.

The contracts usually state that if they don't file within those time limits, the patient is not to be held financially responsible - UNLESS the patient fails to live up to their part of the contract with the insurance company by not giving the required ID, not following through on referrals if they're needed, and/or not providing the doctor with information they need to file that claim right.

So, you may not be responsible for ANY amounts aside from your regular copayment amounts per all the contracts above. You have no control over what the office staff does with that information once you leave there and you've fulfilled your part of the contract that you have.

How do you find out if you're responsible? Great question.

1.) Contact your insurance company & find out if your doctor is a "participating provider". If he is, then he's bound by certain terms in his contract.

1A.) If the answer is no, and he isn't in network or isn't a provider, he can charge you whatever the going rate is, and you're responsible for payment whether or not he files the claims on time.

1B) If he IS a participating provider, find out what's in his contract regarding the timely filing limits (sounds like you already have an idea) and if you are responsible for payment if those limits aren't met. (my guess is, that you aren't).

2.) Ask your insurance company to put in WRITING that you are NOT financially responsible - and send a copy of that information to your doctor's office and at your next office visit, hand the physician another copy personally.

The reason you want to do this, is the doctor may not realize that he has a billing problem. I've met many doctors who aren't aware that they're losing money until they're near bankruptcy. If you like the man, you can help him by showing him the letter. The money he gets or doesn't get, seriously affects his own livelihood, so he'll want to be involved - presuming he knows!!

They should NOT deny your husband any medical care based on their own mistakes. If that happens, a nice long talk with the office and/or billing manager & doctor should help clear up these problems. Remember to always be nice & courteous. You can be angry & passionate about what you know, but you don't need to be mean & nasty.

If all else fails, you COULD pay the bill & send your own claims to the insurance company yourself, but I warn you, you'll still need help from the billing dept. to get those claims paid, and you'll get less $$ back than you paid. The question here is: is it worth it?

To be honest, I'd go somewhere else first & let the office deal with their own problems if I couldn't get things resolved with them..

Good luck.

 

[kNOwtheLAW]

LJ2006 provides excellent steps to persue the matter from your end.

However, you asked the following:

1. Will we be liable to pay the $3522.75 that was just now submitted to the insurance company?

You can always request an appeal of the insurer's initial decision. The process to follow is outlined in your policy benefit booklet. If there are extenuating circumstances the appeal may be successful. By appealing you are asking that a real person get involved with the claim. Many claim systems are automated today, providing for ways that will automatically allow the insurer to pay the claim. A bad date could cause an automatic denial. If the 'doc' is at fault it will be difficult for him to hold the patient responsible.

2. The eye doctor says they are submitting the follow up visit claims. If I'm not getting an EOB, how can they be? If I tell them we won't pay the bill until we get the EOB for the visit, can we be reported to the credit bureau?

Many docs use 3rd party billing services. It sounds as if this is where the problem lies, but who knows. If your insurance is valid, and in force, in either a 'managed care' or 'indemnity' scenario, the only way you will know your actual patient responsibility is for the claims to be adjudicated by the insurance company. If you are remitting payment before these claims are adjudicated you are most likely over paying.

While not always the case, in a 'managed care' policy format, contracts between the insurer and the doc may not permit 'balance billing'. The doc may be required to accept what is adjudicated and paid by the insurer. That is unless you chose to use a doc who is a non participating provider. In that case the policy will likely pay a reduced benefit and you will have to pay the balance. However, if you have an indemnity policy, the doc is within his right to balance bill. If, when you read the policy booklet, it talks about 'participating providers' you will know you have a 'managed care' policy format. An indemnity plan allows you to go to any doc, it allows the insurer to pay the claims at the usual and customary (U&C), or reasonable and customary (R&C) rates for service provided in your geographic area of the country. U&C and R&C are synonymous terms.

In light of this mess, if I were you, I would also insist on a complete 'audit' of the services and charges provided by the doc from the beginning of the surgery. Do all this in writing and keep copies for yourself. Send everything CRRR (certified return receipt requested).

Prior to being reported to the credit bureau you need to be notified of any payment deficiencies by the doc's office, or his agent. Immediately, upon receipt of such notices, respond in writing, with your statement of proof what you and your insurance company have paid to date. Reiterate that you have requested an audit of the charges and services provided, and you are contesting the amount. Send a copy of all correspondence to the insurance carrier and keep them involved.

3. Are we the eye doctors cash cow?

It would seem so. . . Stop!

However, the doc is probably unaware of all this. A personal discussion with him (no one else) apprising him of the situation may resolve the entire issue. Please keep posting to this thread if you have follow up questions, or to update us on the status of your situation as it progresses.

KTL

 

[bellasmom]

I called the insurance company. They said that the claim submitted was for a 'facility charge', and that the provider is a participating provider, and because the provider did not submit the claim within the required time period (12 months), my husband is not liable for the $3522.

So, I guess that's the end of it than. We're thankful not to have to pay the bill, of course, and thanks to those who responded.