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:
- They were put on notice of the deadline when they agreed to join the insurance provider’s network
- 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 remove 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|
|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.
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.
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.
I hope that the information I have provided helps you Find. Learn. Save.