Just about the first thing we all do when visiting a doctor’s office is to provide them with a copy of our insurance card. It is generally understood that the medical office will submit a claim for whatever treatment we received and that you will then pay the amount insurance does not cover.

But what if the doctor’s office fails to file the insurance claim?  What if the doctor files the claim after the normal 90-day insurance claim deadline?  Do I still owe the doctor for services that would have been covered under insurance but, due to the negligence of the doctor’s office, are now unpaid?  What about claims that are filed incorrectly because the doctor used the wrong medical code?

The other day I met with a client who owed $25,000 of medical debts that would have been covered had the doctor’s office timely filed the claim. The client was being sued by a collection company that was assigned the debt by the very doctor who failed to file a claim! Gosh, that seems so unfair.

If a bill collector sues you for a medical debt where a claim should have been filed by the doctor with your medical insurance, take the following actions:

  • File a written response to the lawsuit ASAP.  If you fail to respond in writing to the Clerk of the Court within 30 days of receiving a court summons the bill collection will obtain a Default Judgment and begin garnishment proceedings.  Always, always, always file a written response to a lawsuit with the clerk of the court.  Always.
  • Obtain a copy of the Provider Agreement between your doctor and the insurance company.  Your insurance company should provide a copy.  Some provider agreements require the doctor to file a claim in a timely manner using the correct billing codes and that if a doctor does not do this they prohibit the doctor from billing the patient.
  • If the Provider Agreement requires the doctor to file a medical claim correctly, provide a copy of that agreement to the court.
  • File a medical claim with your health insurer, even if the claim is late.  If they deny coverage because the claim is untimely, appeal the coverage denial.  In life, the squeaky wheel gets the oil.  Start squeaking.
  • Negotiate the Debt.  If the doctor negligently failed to file a medical claim, make that an issue and demand that the bill collector discount the fee due to this error.
  • Obtain a copy of the late claim filed with the insurance company and a copy of the coverage denial letter.  The court will be interested in seeing a letter denying an untimely claim submitted by the very doctor who assigned the debt to a bill collector.

We assume professionals will act carefully to ensure that medical claims are filed in a timely manner.  Unfortunately, a great many medical claims do not get filed correctly or not at all.  Beware of your deadlines to submit health claims (typically 90 days) and circle your calendar to ensure they get filed.  If you do not receive an Explanation of Benefits within 60 days of seeing a doctor, assume something is wrong and contact your insurer and the doctor’s office.

Image courtesy of Flickr and David Syzzek.