Serious HELP NEEDED!!!

If the doctor was in the network on the date of the operation, your insurance has to cover it. I would contact the doctor, via mail, and explain to him the situation. Have him pull it back from the lawyer, and have him re-bill your insurance.

Keep in mind, this would only work if the operation was done while he was in the network.

 

Seems like you are delving into the legal realm now, which is not my area.

I assume the week before he changed practices, he had other patients. How did he bill those other patients?

There has to be a resolution to this. Unfortunately, you may need legal advice on this one, since nobody you have contacted is helping.

 

The doctor, and the old group he was part of, were under contract to the insurance company to provide your services at agreed rates. The services were provided while under that contract. The original practice should have billed for their payment, and under that contract, they were probably required to bill for it in a timely manner.

If this doctor then left, then it is a separate matter between his old group practice and him to get payment from the old practice for services performed while he was with them, which they should have billed for. For him to bill separately for services he was contracted to bill through the old group practice is a breach of his contract thru the group practice with the insurance company.

The insurance company should enforce its contract with the old practice. The old practice is obligated to submit the claim to the insurance company for payment, whether he is now there or not.

The doctor's filing of a claim outside of the practice under which he was under contract with the insurance company for services performed while he was there is a breach of that contract. His claim is against the old practice.

The arbitrary passing of time after the occurrence of events (provision of services) that are covered by the insurance contract does not change the obligations of the various parties.

This is my view. I am not an attorney.

 

That is just what I was thinking after reading the post, that the Dr. has breached his contract

 

You might start by contacting your insurance company, and have them put pressure on the first group to submit the bill, since they are allowing a doctor that had been in their group to separately bill out of network for work done while he was in network. He is breaching their contract.

Contact the first group, in writing, and notify them that their doctor had submitted an erroneous claim outside of network for work done when he was with their group. Notify them that this is a breach of their insurance contract, and that your are notifying your insurance company.

In the mean time, notify the attorney for the doctor, in writing, that the bill he is attempting to collect is fraudulent, due to the doctor's billing of your insurance company directly, as out of network, instead of through the group he was under contract with when the services were provided. Suggest he collect from the original group, who may also have a claim for the services provided.

Follow up all calls with letters to memorialize the call, clarifying your position. If you run into more problems, file a complaint with your insurance commissioner.

 

Is the attorney, as a CA, the one posting the TL on your reports?

Dispute in writing with the 3 CRAs, as paid in full before collection, submitted in error. They will request verification from the CA, who should remove after confirming with the doctor. Make sure the attorney/CA is already aware of the insurance payment to the original practice, so they don't just blindly parrot back what they already have. Also demand from the attorney/CA that the entire TL be removed promptly from all CRAs, since this account was already paid in full by your insurance. If you get any hassle from the attorney about just marking the account as "paid collection", you may need to go after the doctor for damages. The CA is quite capable of telling the CRAs the TL is an error and should be completely removed.

You want to establish a big paper trail that this was already paid and sent to collection erroneously, and force all parties to acknowledge that and remove. Otherwise erroneous negative reports, or accounts have a way of reappearing.

 

Also, always keep your complete paperwork for disputes like this, way beyond the SOL. If people have messed up once, you can't depend on their records to straighten things out if they mess up again in the future. Your records must be better than theirs.

 

Also, insist that the CA remove not only their TL from all CRAs, but that they notify the CRAs that they pulled your reports in error, and their inquiries should be cloaked from dislosure to other users.

 

Is this accurate:
1) The original practice billed for the procedure, and was PAID 100% by insurance.
2) The doctor separately billed for the SAME procedure, and was PAID the out of network percentage by insurance.

If so, the insurance company wants its overpayment back, no doubt.

 

They probably would not bill you, since their payment was not made directly to you. But they would probably want the money back from the doctor, since they already paid the bill from the first practice. Errors happen, but they should be corrected.

Yes, I would let them know, since the whole mess should be straightened out to what it should be. But I would first want in hand a copy of the billing statement from the first practice showing billing for the doctors services, which was the basis for the claim made by the first practice to your insurance. Make sure you have your documentation, on both what was being billed for, and what was paid.

You should always get a full itemized bill from each medical provider, showing what they are billing for, regardless of whether they also bill insurance, and get paid by insurance. You need a copy of the statement from the first practice, showing billing for services by this particular doctor, to show that that is what your insurance paid for.

 

You also want an Explanation of Benefits statement from your insurance. This should match up with the billing statement from the first practice, and should show no amount payable by you if insurance paid the claim 100%.