Situation: -4 authorized doctor's visits in Jan of 2004. -Insurance covers services, physician however does not accept insurance. -Physician's office bills the insurance (sent in all 4 claims) - 2 of the 4 services get paid for by the insurance - Physician's office accepts the payment. - Insurance company has lost one of the claims. - Insurance company has lost one of the checks. (Reissued 2x - haven't received them) Now... the OC and a CA for the OC have reported it to our CR. What, if anything, is the responsibility of the insurance company here? Granted, the OC stated that they wouldn't take our insurance, however how valid is that arguement when they billed and accepted payment from them. Worse case, I plan on doing a pay to delete letter (checks are coming to me this time). Shanyl
The insurance company is responsible for the covered medical expenses. But the doctors and hospitals have long ago discovered how difficult it can be to try to get anything out of an insurance company if they don't want to pay for some reason or just goof it up. So they make the patient or a relative of the patient sign a consent form which also says that in case of any problems with the insurance company the patient or relative will pay. That means that the insurance company is no longer the primary party responsible for payment of services provided by the hospital. So it is your financial future that is on the line if you don't pay them. You are the one that is going to get hurt, not the insurance company. You have to pay up first and then if you have some beef with the insurance company that is between you and them. Sadly enough, people pay good money for their insurance premiums and they expect to get good coverage and prompt payment out of the insurer in case of problems. Even if they have full coverage it often don't cover everything or there is something that the insurance company won't pay for so the patient is left holding the bag. Same thing with auto insurance. The insurance companies are ripping people off there too. The premiums are high and often unreasonably so. An example is a neighbor of mine who bought a new car and the very day he bought it some drunk hit him without insurance. Naturally he had full coverage. Or at least he thought he did. His new vehicle was totaled and he was injured and so was his wife although not badly. He fought with the insurance company for months and it still cost him a lot of money because they would not pay him what he paid for the vehicle. It cost him several thousand dollars in the end and the vehicle had less then 100 miles on it. He couldn't get anything out of the drunk either because he didn't have any money, didn't have a drivers license, no insurance and was driving an old beater that probably wasn't worth nothing but junk price after the wreck and they threw him in prison because he had a lot of DUI convictions on his record. Back on topic, you are the one that is responsible for the medical treatment.
But doesn't their intent show otherwise once they not only chose on their own to submit to an insurance company that they claimed not to accept and accepted payment from them?
You could make that claim but I'm sure the doctor could claim he just tried to do you a favor a couple of times but since it didn't work out you are responsible for the bill. I'm sure he would figure out some way to wiggle out of any claims you might make. They usually do.
The doctor's office is not obligated to bill the insurance company unless they are under contract with the insurance company. Any time you receive healthcare services, billing the insurance company is a courtesy to you. Ultimately you are responsible for the bill.
NEW MEMBERS READ THIS. http://consumers.creditnet.com/straighttalk/board/showthread.php?s=&postid=410243#post410243 ************************************************************ Any time you receive healthcare services, billing the insurance company is a courtesy to you CaliGirl ********************** So how does the insurance Co. pay if they are not billed?
If a physician or hospital is not under contract with the insurance company, they are not required to bill the insurance. If they do, when they are not contractually obligated to do so, then they are doing so as a courtesy. One of the first things you sign when receiving medical services is a form that states you are responsible for the bill. This poster will probably have to pay herself, then seek reimbursement from the insurance company - but that will probably be at the usual and customary prices for those services in her geographical area.
Re: Re: Legal Recourse? Thanks for the above reply;but it still did not answer the following question. Originally posted by lbrown59 So how does the insurance Co. pay if they are not billed? [/B]
Re: Re: Legal Recourse? NEW MEMBERS READ THIS. http://consumers.creditnet.com/straighttalk/board/showthread.php?s=&postid=410243#post410243 ************************************************************ quote:Originally posted by CaliGirl -------------------------------------------------------------------------------- 1* This poster will probably have to pay herself, 2*then seek reimbursement from the insurance company -------------------------------------------------------------------------------- 1*Most people have insurance because they don't have the money to pay it themselves. If one has the finincial resources to pay the bill themself then why do they need the insurance? 2*Again I have to ask how can you seek reimbursement if no bill is presented.
Re: Re: Re: Legal Recourse? 1. That is true, I am not arguing that fact. There are numerous examples of when people that do indeed have insurance seek medical care without authorization from their insurance. There are also many times when patients choose to go "out of network" because maybe their choice physician is not contracted with the insurance company, so they decide to pay for it themselves. 2. You can present an itemized statement of services to your insurance company for the services that were provided to you. While it may not be a claim submitted on a HCFA1500 or a UB92 (the universal claim forms used by almost all insurance companies) it will contain the appropriate information that is needed for the insurance company to be able to make adjudication. This happens all the time. I am too cheap myself to go out of network, but it does happen all the time.
Well we weren't out of network by choice. This physician is the only one within 2 hour drive that provides this care - so we had special authorization. I know one thing, I HATE the insurance... but that will change in Nov. Until then, I've fought this for 4 months and it's looking like I have another 2 months to go before (30 days to make sure my lost check is lost, 10 days to stop payment, another 2-4 weeks to process, just to see if they can loose it again.) And my CR awaits..... unfortunately, it was very expensive procedures that's not an easy out of bank expense. Shanyl
Shanyl, The only judgement I made in my post, was a judgment on myself. Not on you, or why you would do something related to your medical care. I was simply answering a question lb posed to me. I hope you are successful in getting this taken care of, and since you had authorization for the medical care, I would push the insurance company to let you know if they had a special arrangement with the physician for a one time only visit. It could be that there was some sort of contract between them under these circumstances, only pertaining to you as a patient. If that is the case, you may have some recourse there. You may be able to put more pressure on the physician at that point. A lot of this will depend on the wording in the authorization you received.
