Advice on Medical Bills & Insurance Claims

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

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

Your question touches on three possible sources of the main issue here:

• 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 / 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.

For example, if a doctor tells a patient before treatment, "My office will probably goof-up the billing. You want us to handle it for you?" The patient 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 they failed, and now demand you pay for their 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: they were put on notice of the deadline when they agreed to join the insurance provider’s network, and; the provider had the information necessary to make a claim.

See the Bills.com 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. However, if the insurance carrier denies a claim through no fault of the medical provider, the patient or insured party has liability for the debt.

Here, it sounds as if your previous insurance provider is refusing to pay these claims because they were filed outside of the time limits laid out in your policy. If, for example, the claim was filed timely but rejected, and then refilled after the deadlines, then the insurance company may be required to pay the claim as the delay would have been due, at least in part, to its improper rejection of the initial claim. However, if you or the provider simply failed to file the claims in a timely manner, then the insurer may be within its rights to refuse to pay these claims. 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.

Another issue may be what representations the provider made to you about your responsibilities in paying for its services. For example, if the provider told you repeatedly the debt was already paid by your insurance, and you therefore did not file a claim based on this representation, then the provider may be liable for all or a portion of the unpaid debt. However, if the provider sent you a bill in a timely manner and indicated the insurance company had not paid the bill, you would likely be responsible for making sure that any errors were corrected, and for paying the bill if the provider was still unable or unwilling to pay it on your behalf, then the lender’s attempts to collect on this debt and its placing the item on your credit reports are likely acceptable practices, and you will 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 Bills.com 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.

Best,

Bill

Bills.com