Advice on Medical Bills & Insurance Claims

Upon reviewing my credit report I found numerous negative medical bills, turns out that the claims were not filed correctly.

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Medical Office Insurance Card | Medical Debt
Bill's Answer: Answered by Mark Cappel

Insurance questions are difficult to resolve because they involve three parties, including the:

  • Insurance company or claims administrator
  • Medical service provider
  • Patient or insured party

Your question touches on three possible problems:

  • The insurance company denied the claim(s) in error
  • The provider submitted the claim(s) incorrectly or after the deadline
  • The service provided was one not included in your insurance coverage

Here, it appears the medical provider filed the claims incorrectly. This is frustrating for patients because medical providers almost always require a patient or insured party to sign a waiver stating the patient will pay the bill if the insurance provider denies the claim. That seems an unfair and one-sided contract.

If a doctor tells you, “My office will probably goof-up the billing. Want us to handle it for you?” You would probably say, “No, thanks, I’ll do it myself or find a doctor who hires competent billing people.”

Your expectation was the medical provider would, once it agreed to handle the insurance forms, take reasonable care in processing your insurance claim. But it failed, and now demand you pay for its incompetence. You mentioned resubmitting the claim to the insurance company. The insurance company rejected the claim based on a failure to meet a deadline. A cynic would view insurance deadlines as arbitrary, and intended to accomplish exactly what you described in your question — an excuse to deny a claim. However, the medical provider is still to blame when they miss a deadline for two reasons:

  1. They were put on notice of the deadline when they agreed to join the insurance provider’s network
  2. The provider had the information necessary to make a claim.

See the article Health Insurance Claims to learn more about how health insurance companies process claims.

Credit Report & Delinquent Medical Debt

You have no legal right to require the consumer credit reporting agencies or the medical providers to removed the delinquent accounts from your credit reports. The medical provider will claim you have liability for the debts. Regardless of any issues you may have had with your insurance, the waiver you probably signed gives the medical provider an argument you owe the debt, even if the provider submitted the insurance claim in an incompetent manner. The medical provider may claim you were responsible for notifying the provider of the new insurance information, or you should have paid the bill and filed the insurance claims yourself.

How to Handle Medical Debt

No law requires a medical provider to file an insurance claim on a patient’s behalf. Providers do so as a courtesy to patients, and to help ensure the provider is paid in a timely manner. Review the following table to learn how to handle common medical claim problems.

Medical Bills & Medical Insurance Claims
Insurance Claim Problem Patient Liability & What To Do
How to handle common medical insurance claim problems. Source:
Claim for covered service denied through no fault of the medical provider Patient or insured party has liability to provider for debt, and potential cause of action against insurance provider
Claim denied because it was filed outside of the policy's time limits due to medical provider's negligence Insurer may be within its right to deny claim. Consult with a lawyer to learn if you have liability for debt, or cause of action against medical provider for failing to file claim in timely manner
Claim for covered service filed in a timely manner but rejected, then re-filed after deadline Insurance company required to pay the claim as the delay would have been due, at least in part, to its improper rejection of the initial claim
Medical provider tells you services were paid by insurance company, but later says they were not paid Medical provider may be liable for all or large portion of unpaid debt
Medical provider tells you covered services were not paid by insurance company Patient or insured party must file claim with insurance company
Medical provider tells patient its service is covered by patient's insurance, which later denies claim Ask medical provider to resubmit claim using proper or different coding. Consult lawyer if you believe medical provider's statement about your coverage had fraudulent intent

Regardless of the reason given by the insurance company for its denial, you have the right to appeal the decision if you feel that the claim should have been paid under the terms of your policy. To read more about the insurance appeals process, and various other insurance related topics, visit the Medical Billing Advocates of America Web site to find a local medical advocate who may be able to help you.

Tip Talk to a debt resolution partner about your options to free yourself from medical debt. The advice is free, and comes without obligation.

In situations where the medical provider sends you a bill in a timely manner and indicates the insurance company did not paid its claim, you are likely responsible for paying the bill and making sure any errors in the insurance claim are corrected. In situations like these, the medical provider’s attempts to collect on this debt and it placing the item on your credit reports are likely acceptable practices. You need to negotiate a resolution with the medical provider if you want these items removed from your credit reports.

For more information about credit, credit reports, and credit scoring, visit the credit resources page. I wish you the best of luck in your efforts to resolve this debt, and hope that the information I have provided helps you Find. Learn. Save.



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Comments (64)

Dan H.
Louisville, KY  |  February 05, 2014
In August of 2012 I visited my cardiologist for my annual checkup. The claim was not filed with my insurance until May of 2013. Insurance denied the claim and sent me an EOB explaining that the time limit for filing the claim had expired. The doctor's billing service started sending me bills and I provided them (twice) with copies of the EOB. I even sent them a letter explaining why I didn't feel I was responsible for this bill. It is not my fault they didn't file the claim in time. They have now turned it over to a collection agency. Am I wrong? Am I responsible because they didn't do their job on time?
February 06, 2014
This is a highly frustrating situation because you pay for your health insurance with the expectation it will provide coverage for procedures it promises to cover. It is also frustrating because the medical provider made an implied promise it would file a claim with your health insurance provider in a timely manner. It didn't, and now the insurance you're paying for is denying a claim it would have paid had the doctor filed the claim on time. Now, the doctor expects you to pay for its negligence.

What to do? Have a heart-to-heart with the doctor's office manager, and explain it's not fair for you to pay for both your insurance and the procedure that would have been covered had they not been negligent. Try to work out a compromise of some kind, especially if you have a good relationship with the doctor.
Tina L.
New York, NY  |  February 02, 2014
I am on Medicare. I had my annual pelvic exam in Dec. It is a covered service. Medicare denied the claim and I have a $200 bill. When I called, Medicare said it wasn't submitted as an annual pelvic exam, but as a general doctor visit with no other codes. I called the hospital billing office and explained. The man said he would email his supervisor to add the correct code. I've received a 2nd bill and called back again. Yesterday I received a collections notice. What do I do? This is covered by my insurance, but only if correctly coded.
February 03, 2014
It sounds like the collections notice you received is from the hospital, not from a collection agency. Call the hospital back and speak to them, again, about changing the code. Keep records of the time you called, the person with whom you speak, and what is said. I think you should also call Medicare again, at 1-800-MEDICARE (1-800-633-4227). You can also file a complaint with Medicare, using the form on this page.
Bo G.
Taylorville, IL  |  January 30, 2014
I was required by my college to carry insurance during my time there. I did not feel well for two years and regularly saw my doctor. I was sent to a couple specialists and finally a cardiologist. He found three blocked arteries and put in stents. The insurance company through the college is refusing to pay any medical bills because I did not see their nurse beforehand. Should the insurance be liable for my medical bills? And how long is the period to file a claim against the insurance company? Thank you
February 07, 2014
Ask the insurance carrier if it has an ombudsman's office or appeals process to help you work through this issue. In this case, the nurse referral satisfies a bureaucratic requirement, but seems ridiculous in light of your diagnosis. How many nurses, as wonderful as they are, would have diagnosed blocked arteries in an interview?

If the insurance company does not budge, then consider hiring an advocate, such as Medical Cost Advocate or Hospital Bill Review.
Narayanan P.
Warren, MA  |  January 30, 2014
I went to ana optometrist along who was covered under Cigna medical insurance but not under Cigna Vision. However the diagnosis was deemed to be purely vision related and so it was deemed to be out of network, I have a squint and a family history of eye problems including night blindness etc. Should I ask the doctor to resubmit the claim so it is covered?
February 07, 2014
Never hurts to talk to the office manager to learn if the office can resubmit a properly coded medical claim.
Jen V.
Mertztown, PA  |  January 29, 2014
My husband had brain surgery in 2006 and the one provider who was able to help him was out of network. He received approval to have the services with this provider as an exception and his insurance paid for all services at 100%. However, the insurance company would forward the payments to him and my husband would sign over these checks to the out-of-network provider. He continued to visit this doctor annually through 2009 and was told of no concerns or outstanding bills. Today, 8 years later, we received a collections letter for over $19,000 from this provider. How is this possible? We are trying to find out more details to see what the specific services are to discuss with this provider. The collections people can't tell us much. We can't even submit anything at this point, 8 years later, if it is missed??? Is this even legal at this point to come after him for payments that they have never asked about previous to now... 8 years later??
January 30, 2014
Step 1: Validate the debt immediately. If the medical provider or its collection agent has admitted to you it doesn't have much information on this account, it's unlikely it will be able to validate the debt. A debt that cannot be validated cannot be collected.

Step 2: If the medical provider or its collection agent can validate the debt, then learn your state's statute of limitations.

Step 3: If the statute of limitations clock on this debt has run out, then send whoever is trying to collect the debt a cease communications notice.

Step 4: If the statute of limitations clock on this debt has not run out, then negotiate a settlement for this debt.
Kelly S.
Albuquerque, NM  |  January 28, 2014
I have a billing question. Say my primary insurance doesn't pay anything and leaves it to my deductible then my secondary pays some am I liable for the difference from my primary balance that my secondary didn't pay? For ex: my primary paid $0 but left $269.33 to my deductible. So then the dr office sent it to my secondary and they paid $135.55 and left me a $40 copay. Do I have to pay the $40 and $133.78? Or do I just pay the $40
January 29, 2014
I believe that you still need to pay the $133.78. Check with your doctor's office to be sure, so that it receives all that it needs to record the account as being at $0.
Marco Bellini B.
Los Angeles, CA  |  January 28, 2014
I received a bill on 09/2013 resulting from a MRI scan that took place on 10/2009 for an Auto Personal Injury case. I was told by my attorney few yrs back when we settled that all claims have been paid. After speaking with the attorney who handled my case, I then quickly informed the MRI facility that he needs to re-submit their claim and that the file needs to be brought back from the law firm storage which might take few weeks or months even, since over 4 years have gone by without having the MRI facility to check or follow up with our attorney or me regarding their invoice. Two months later, the original MRI invoice dated 10/2013 was reported to a collection agency precisely 4 years after the MRI invoice date. The collection agency added their own interest of $620 to the original MRI invoice of $1500 My attorney wrote the collection agency a letter informing them in details that he is working on resubmitting the claim to the insurance agency and that payment date will depend on the process of the Insurance agency. On January 1st at 7 AM, I received a notification via text and email from my credit report (Experian and Equifax) that a collection item has been place on my report , resulting in a decrease of my score Who should I sue or even blame here. Both of the credit agencies above rejected my request to remove the collection acct.
February 07, 2014
Consult with your lawyer about your credit report issue, and any possible causes of action you may have.

Also review the Fair Debt Collection Practices Act and the possibly illegal interest the collection agent added to your account.
Martha C.
Chicago, IL  |  January 27, 2014
I recently went to the doctor for an annual pap smear that is covered by my pink card... While i was there since my pink card wasn't pink but white i was told that i had full coverage and they suggested I would get blood work done. I asked if it was for certain my insurance covered it the receptionist said yes, later the doctor asked her the same question since i told her i couldn't afford it if it wasn't covered. They did the test and two weeks later i came in for pink eye. The receptionist then told me she was wrong about my insurance coverage and that i would have to pay out of pocket for the blood tests. They said another company would later bill me. What can i do about my current situation.
January 29, 2014
This is a tricky situation, especially if you wish to continue seeing your doctor. The first step I recommend is to send a polite letter to the doctor's office stating the facts you presented. It is clear that you only had the procedure done after receiving assurance that you were covered. Request that the doctor cover the charges. As the doctor also asked if you were covered and was told that you were, s/he should agree that it is not your responsibility. If your polite letter does not get a positive response, send a second letter that asks them to meet you halfway.
Morgen C.
Altamonte Springs, FL  |  January 26, 2014
I was set to deliver my son at my midwife's birthing center. I had paid the required deductible up front ( it hasn't been met yet). Complications arose, and I had to be transferred to the hospital. Later, when I received my hospital bill, I found out it was for my outstanding deductible. My midwife had failed to tell my insurance company about the deductible. I have proof, but she won't take any responsibility. I have posted negative reviews to which she demanded I remove them, and I even reported her to the BBB. I don't have the money to pay a second deductible( nor do I think I should have to) and attorneys are expensive. What are my other options to try and recoup my deductible so I can apply it to my hospital bills. Is this technically insurance fraud?
January 29, 2014
Speak with your insurance company and supply them the proof that you paid the midwife and that it should, in your view, go towards your deductible. Get a clear answer from your insurer whether the midwife payment would count, as there can be policies where the hospital coverage is under a separate deductible. I don't believe that what the midwife did, though improper, meets a standard for insurance fraud, which is usually filing false claims to receive payment.
James S.
Vanceburg, KY  |  January 16, 2014
Can I the client be held liable for errors in the billing of the hospital? The reason being the insurance company wouldn't pay them. It's been almost two years and I just got a letter from a law firm about collecting this debt. When I called the insurance company a year ago to inform them the hospital was attempting to hold me liable on this debt, the insurance company told me the bill was rejected because the hospital did not use proper billing codes. If this isn't my fault why am I liable? It's a workers comp case the hospital submitted the claim to.
January 23, 2014
Talk to your employer's workman's comp representative about this issue. Perhaps the hospital can resubmit the claim with the correct billing codes. If their insurance carrier refuses to process the new claim, then consult with a lawyer discuss the hospital's negligence in submitting a defective claim. It is unjust for the hospital to put all of the burden for screwing up insurance billing on a patient.
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