Liability for unsubmitted charges after a certain amount of time

[ender-1]

What is the name of your state?State: Indiana

I am writing on behalf of my wife, who has some problems with a medical facility.

In June 2003 she was required to get an MRI by our primary care physician. She went to the Radiology Dept of the medical care facility in question and they made a copy of her insurance card, she had a employer-sponsored Anthem Blue Cross Blue Shield PPO plan and the MRI was a covered item.

The medical care facility failed to submit the charges to the insurance company and at the same time messed up my wife's profile so she is listed twice, one with wrong information. Several calls to the facility failed to get them to remove the second wrong profile.

They started sending payment notices (~$280) indicating that we were responsible for the procedure. We talked to them and determined they did not submit the charges to the insurance company. We called the insurance company and they said as long as it was submitted within 15 months of the procedure they would pay out for it. We were given a fax number with the rep's name to put on the ATTN: line and gave this info the medical care facility.

Again, they failed to contact the Insurance Company. Now it's past the 15 month deadline and they are continuing to harass us with payment notices. They haven't sent the account off to collections (yet) but we are worried they will cause harm to her credit rating or that in the end we'll be forced to pay for this procedure because of their incompetence.

We'd like to threaten legal action but I am having a heck of a time searching on Google, et al, for situations such as this. What is the law regarding this? Can they really sit on a claim for almost 2 years and then go after us when the insurance company won't pay because it's been too long?? What can we tell these people to get them off our back?

Thanks for your help!!

 

[somarco]

I see this situation quite often . . .

When your wife was treated by the facility she most likely signed a financial responsibility form. In essence, treatment was rendered and the facility is entitled to their fees, REGARDLESS of who pays.

The carrier has a contractual agreement with the employer and that agreement states, among other things, it has the right to refuse claims not filed on a timely basis.

So you have two contracts in play here. One between the provider and your wife; the other between your wifes employer and the carrier.

Did the provider drop the ball and fail to file the claim properly and on a timely basis? Sure.

Did the carrier rightly deny the claim under their contract? Sure.

Do either of these situations relieve you (or your wife) of the responsibility for paying the bill? No.

You can pay the bill then pursue reimbursement from the carrier on appeal.

You can ignore the bill and hope it will resolve itself. It wont.

You can appeal to the carrier to reconsider, and to the provider to forgo collection remedies and see what happens.

Your provider has a moral obligation to file the claim timely and properly, but they do not have any legal obligation to do so. If you really want to risk damage to your credit over a $280 bill that is your prerogative.

 

[ablessin]

I would call your carrier because some policies stand behind the member in that the facility/provider can't bill the patient if the insurance denies (depending on the reason, of course)...if they denied because your policy was not in effect on DOS - facility/provider can bill.

BUT - timely filing may be different - it's a policy specific thing so you'll have to make a call to your insurance carrier and ask them.

I see this often, what with working in a hospital and sometimes we'll call the insurer and theywill tell us you can't bill the insured, or that we can (again, depending on what the denial was for)

good luck